• “Insights” on Simulation Modeling and Systems Science, New Research Funding Opportunity

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    By Xinzhi Zhang, M.D., Ph.D.
    Program Director, Division of Scientific Programs
    National Institute on Minority Health and Health Disparities

    There are many contributing factors to health, such as race, ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location. To help close health gaps, the National Institute on Minority Health and Health Disparities (NIMHD) spearheads scientific research at the National Institutes of Health (NIH) to improve minority health and reduce health disparities.

    NIMHD is leading a new Funding Opportunity Announcement (FOA): Simulation Modeling and Systems Science (SMSS) to Address Health Disparities. To learn more about SMSS and this new funding opportunity, NIMHD Program Officer Dr. Xinzhi Zhang addresses a few questions for the Insights blog.

    Dr. Xinzhi Zhang

    What is simulation modeling and systems science?

    Systems science considers different components within complex systems across multiple levels to help understand their interactions and influences. The dynamic relationship that unfolds when considering the many factors that contribute to health inequities, such as segregation, food insecurity, and neighborhood safety, to name a few, cannot be fully captured with currently available data and analytic methods. Simulation modeling and systems science (SMSS) is a tool that tests plausible scenarios and helps us understand the magnitude of intended and unintended consequences of specific interventions. It also provides options to adjust and/or refine simulated intervention designs prior to actual implementation testing in the real world.

    In what ways can SMSS help us better understand minority health and health disparities?

    Although we know simulation models cannot replace real-world settings or scenarios, many simulation models are becoming indispensable for decision making, such as in national or local pandemic planning. SMSS can also have a profound impact on health policies relevant to minority health and health disparities.

    In a variety of fields, SMSS approaches have been used to guide interventions in clinical preventive care and disaster planning as well as analyze national health reform strategies. SMSS has also been used to model potential public health outcomes in cases where it is not feasible to test various intervention strategies on real populations, particularly where interventions may involve factors far upstream from health outcomes, such as societal causes embedded in political, legal, economic, and cultural factors.

    How will NIMHD support SMSS research?

    NIMHD is interested in several research priorities that could have significant impact on our knowledge of minority health and health disparities research. Specific examples of research topics can be found in the Simulation Modeling and Systems Science to Address Health Disparities FOA.

    Will any other NIH Institutes or Centers participate in this funding opportunity?

    Yes. In addition to NIMHD, nine other NIH Institutes, Centers, and Offices are participating in the Simulation Modeling and Systems Science to Address Health Disparities FOA:

    • National Cancer Institute (NCI)
    • National Heart, Lung, and Blood Institute (NHLBI)
    • National Institute on Aging (NIA)
    • National Institute on Deafness and Other Communication Disorders (NIDCD)
    • National Institute on Drug Abuse (NIDA)
    • National Institute of Mental Health (NIMH)
    • National Library of Medicine (NLM)
    • Division of Program Coordination, Planning, and Strategic Initiatives (DPCPSI), Office of Disease Prevention (ODP)
    • Office of Behavioral and Social Sciences Research (OBSSR)

    The due date for the first round of applications is January 7, 2018. Applicants are encouraged to read the entire Simulation Modeling and Systems Science to Address Health Disparities funding opportunity announcement at https://grants.nih.gov/grants/guide/pa-files/PAR-18-331.html to get additional information about the application process.

  • NIMHD Loan Repayment Programs

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    By Dorothy M. Castille, Ph.D.

    Health Scientist Administrator, Division of Scientific Programs
    National Institute on Minority Health and Health Disparities

    The National Institute on Minority Health and Health Disparities (NIMHD) invites qualified health professionals who contractually agree to engage in NIH mission–relevant research to apply for the 2018 extramural NIMHD Loan Repayment Programs (LRP) for an average of at least 20 hours per week for at least two years. Descriptions of the NIMHD LRP follow:

    The objectives of these congressionally established and designed programs are to recruit and retain qualified health professionals into research careers that focus on minority health disparities or other health disparities or to recruit and retain qualified health professionals from disadvantaged backgrounds into clinical research careers. The Extramural LRPs repay up to $35,000 of a researcher’s qualified educational debt annually, in return for a commitment to engage in NIMHD mission–relevant research at a domestic, nonprofit, or government entity. Educational eligibility criteria require that applicants possess a doctoral-level degree from an accredited institution.

    All applications must be completely submitted, including all recommenders’ letters, via the applicant’s eRA Commons account by 8:00 PM EST on November 15, 2017.

    In conjunction with this program, NIMHD hosted a Technical Assistance Webinar on Thursday, October 5, 2017. The purpose of the webinar was to discuss the program’s goal, the application process (including recent revisions to it), components of an application that are competitive and responsive to the funding opportunity announcements, criteria for review of applications, and the financial vetting process.

    To learn more about NIMHD’s Loan Repayment Program, visit https://www.nimhd.nih.gov/programs/extramural/loan-repayment.html.

    To view information from NIMHD’s LRP Technical Assistance Webinar, visit https://www.nimhd.nih.gov/programs/extramural/loan-repayment.html.

    For more information about the program or to get feedback on a previous application, please contact:

    Dorothy M. Castille, Ph.D.

    Adelaida Rosario, Ph.D.
    Former NIMHD Program Officer

    Vincent Thomas, M.S.W., M.P.A.
    Former NIMHD Staffer

  • Breastfeeding Disparities in African American Women

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    By Regina Smith James, M.D.

    Director, Clinical and Health Services Research
    National Institute on Minority Health and Health Disparities

    Some say the best things in life are free…but are they really? Well, when it comes to providing our babies with the best nutrition ever, breastfeeding is not only economical, but it has positive health effects for both baby and mom. Did you know that breast milk is uniquely suited to your baby’s nutritional needs, with immunologic and anti-inflammatory properties? Yes, it’s true! And the American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months, with gradual introduction of solid foods after 6 months while continuing to breastfeed up to 1 year.

    What are some of the health benefits of breastfeeding? Breast milk not only offers a nutritionally balanced meal, but some studies suggest that breastfeeding may even reduce the risk for certain allergic diseases, asthma, and obesity in your baby, as well as type 2 diabetes in moms. Also, breastfeeding creates a close bond between mother and child. And from a financial standpoint, breastfeeding is economical. The United States Breastfeeding Committee noted that families who followed optimal breastfeeding practices could save approximately $1,500 that would have gone toward infant formula in the first year alone. Imagine what you could do with those extra dollars!

    Despite the many benefits of breastfeeding, African American mothers have the lowest rate of breastfeeding initiation and duration. The Centers for Disease Control and Prevention (CDC) noted that from 2011 to 2015, the percentage of women who initiated breastfeeding was 64.3 percent for African Americans, 81.5 percent for Whites, and 81.9 percent for Hispanics. And while 79.2 percent of infants began breastfeeding, only 20 percent breastfed exclusively for 6 months, and 27.8 percent met the recommended breastfeeding duration of 12 months. The Surgeon General’s Call to Action to Support Breastfeeding noted that even while researchers control for family’s income or education level, breastfeeding rates for African American infants are lower than for White infants at birth, 6 months, and 12 months.

    Why do these racial disparities persist? Here is what some research is showing us: (1) African American women tend to return to work earlier after childbirth and are more likely to work in environments that do not support breastfeeding; (2) healthcare settings that provide supplemental feeding to healthy full-term breastfed babies during the postpartum stay decrease the likelihood of exclusive breastfeeding; (3) healthcare settings that separate mothers from babies during their hospital stay; (4) lack of knowledge about the benefits of breastfeeding and the risks of not breastfeeding; (5) perceived inconvenience—a breastfeeding mother may have to give up too many habits of her lifestyle; (6) the mistaken belief that “big is healthy,” leading moms to introduce formula early; (7) the cultural belief that the use of cereal in a bottle will prolong the infant’s sleep; and (8) embarrassment—fearful of being stigmatized when they breastfeed in public.

    How can we begin to address these challenges? The National Institutes of Health are taking action by supporting high-quality research on breastfeeding. For example, Community Partnership for Breastfeeding Promotion and Support; Novel Intervention to Increase Lactation Practices by African American Women; and Breastfeeding Support and Weight Management for Black Women: A Dual Intervention are just a few projects currently being conducted. In addition to research efforts, there are a number of resources available for new mothers to support breastfeeding. Here are a few to get you started:

    As noted earlier, breastfeeding may reduce the risk for certain diseases, like obesity and type 2 diabetes; both are major causes of morbidity and mortality in adults in the United States, particularly for African Americans. Could it be that early life experiences, like breastfeeding, somehow have a protective effect against such diseases later in life? If we approach this question with a “life course perspective,” we might think about intervening as early as preconception or pregnancy to address these disparities before they develop. According to the U.S. Preventive Services Task Force (USPSTF), we should actually initiate our efforts early by providing interventions during pregnancy and after birth to support breastfeeding.

    August is National Breastfeeding Month, so let’s galvanize our efforts and raise more awareness about the importance of breastfeeding and the positive health effects it can have for both baby and mom.

    Related Posts
    Can Paid Maternity Leave Help Address Disparities in Maternal Mortality?

    1. Anstey, E., Chen, J., Elam-Evans, L. and Perrine, C. (2017). Racial and Geographic Differences in Breastfeeding — United States, 2011–2015. Morbidity and Mortality Weekly Report, 66(27), 723–727.

    2. Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Davidson, K. W., Epling, J. W., García, F. A., . . . Pignone, M. P. (2016). Primary Care Interventions to Support Breastfeeding: US Preventive Services Task Force Recommendation Statement. JAMA, 316(16), 1688–1693.

    3. Johnson, A., Kirk, R., Rosenblum, K. L., Muzik, M. (2015). Enhancing Breastfeeding Rates Among African American Women: A Systematic Review of Current Psychosocial Interventions. Breastfeeding Medicine, 10(1), 45–62.

    4. American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–41.

    5. U.S. Department of Health and Human Services. (2011). The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General. Available at http://www.surgeongeneral.gov/library/calls/breastfeeding/index.html.

    6. CDC. Racial and Socioeconomic Disparities in Breastfeeding — United States, 2004. (2006). Morbidity and Mortality Weekly Report, 55(12), 335–339.

    7. Centers for Disease Control and Prevention. (2002). National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2000. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

  • Minorities and Mental Health: Moving Beyond Stigma

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    By Courtney Ferrell Aklin, Ph.D.
    Former Chief of Staff, National Institute on Minority Health and Health Disparities

    By Marcia M. Gómez, M.D.
    Health Science Policy Analyst, National Institute on Minority Health and Health Disparities

    Dr. Courtney Ferrell Aklin

    Demographic trends in the United States have continued to change rapidly. Projections indicate that within the next 30 years, the majority of the United States will be non-White.1Among the racial and ethnic groups that will make up the majority, there is significant heterogeneity, making healthcare delivery even more challenging.

    Mental illness is one of the most prevalent health problems in the United States and one of the most taxing on the healthcare system. In addition, mental illness carries the highest disease burden among all diseases, with devastating effects on daily functioning; personal, social, and occupational impairment; and premature death if left untreated.2 One in 10 children and one in five adults are affected by mental illness.3

    Mental illness does not discriminate. It occurs in all racial, ethnic, and socioeconomic groups and is the leading cause of disability in the United States. However, two thirds of individuals with a diagnosable mental health disorder do not seek treatment.4 Most ethnic minorities have similar prevalence rates of mental health issues to those of Whites, but they have less access to mental health services, are less likely to seek and receive needed care, and, when they do receive it, are more likely to get poorer-quality care. This combination of disparities leads to racial and ethnic minorities having a higher proportion of unmet mental healthcare needs compared with majority populations.5

    In 1999, health disparities in mental health were highlighted in the Surgeon General’s report on mental health. Dr. David Satcher, former U.S. Surgeon General, called on all Americans to educate themselves and challenge the stigma, attitudes, fear, and misunderstanding that remain barriers to truly addressing mental illness.6 In 2008, in an effort to sustain dialogue on mental health in minority populations, the U.S. House of Representatives established July as National Minority Mental Health Awareness Month.

    Brother, You’re on My Mind, created as a partnership between Omega Psi Phi Fraternity, Inc., and the National Institute on Minority Health and Health Disparities (NIMHD), is an example of an initiative designed to increase awareness about mental health among African American men. The focus of the initiative is on starting a conversation to dispel the myths associated with mental health problems and assert the importance of seeking treatment. Expectations that men be “tough,” coupled with poor access to mental health services, leave men of color who struggle with mental illness especially susceptible to substance abuse, homelessness, incarceration, and homicide.7

    Particularly for populations of color, existing stigmas and the lack of discussion on mental health are major barriers to individuals seeking proper treatment. It is important to remember that mental health is fundamental to overall health and well-being at every stage of life.8 NIMHD is committed to envisioning an America in which all populations have an equal opportunity to live long, healthy, and productive lives. Therefore, we must continue to encourage discussion, awareness, and research about mental health.

    More research is needed to examine:

    • The best approaches to mental healthcare.
    • The best ways to increase communication between patients and mental healthcare providers.
    • The increased risk of mental illness among people who are poor, homeless, or incarcerated or who have substance abuse issues and how to address them.
    • Cultural aspects relating to mental health and how to integrate resources within communities.



    National Institute of Mental Health (NIMH)

    Substance Abuse and Mental Health Services Administration (SAMHSA)

    National Alliance on Mental Illness


    1. Colby, S. L., & Ortman, J. M. (2015). Projections of the Size and Composition of the U.S. Population: 2014 to 2060. Washington, D.C.: U.S. Census Bureau.

    2. Reeves, W. C., Strine, T. W., Pratt, L. A., Thompson, W., Ahluwalia, I., Dhingra, S. S., . . . Safran, M. A. (2011). Mental illness surveillance among adults in the United States. Morbidity and Mortality Weekly Report, 60(03), 1–32.

    3. U.S. Department of Health and Human Services. (n.d.). Any Disorder Among Children; and U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

    4. Mental Health America. (2017). The State of Mental Health in America. Alexandria, VA: Mental Health America.

    5. U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; and Wahowiak, L. (2015). Addressing stigma, disparities in minority mental health: Access to care among barriers. The Nation’s Health, 45(1), 1–20.

    6. U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

    7. National Institute on Minority Health and Health Disparities. (2017). Brother, You’re on My Mind.

    8. U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

  • Improving the Health Status of African American Males

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    By Wayne T. Harris, Ph.D.
    Project Director and Contact Principal Investigator
    Hampton University Minority Men’s Health Initiative

    It gives me great pleasure to contribute to the National Institute on Minority Health and Health Disparities (NIMHD) blog, NIMHD Insights. While the health status of all groups in the United States has improved over the past century, significant gaps remain between the health status of African Americans and other minority groups, and that of the general population. For example, in 1950,1 the life expectancy of an African American male at birth was 59, while that of a Caucasian male was 68. In 2014,1 the life expectancy at birth for an African American male increased to 72.0 while that for a Caucasian male increased to 76.5. Similar gaps exist in the health status and health outcomes of minority populations using a variety of measures, and clearly more work needs to be done.

    The Hampton University Minority Men’s Health Initiative (MMHI) exists to contribute to the achievement of one of the overarching goals of Healthy People 2020: “to achieve health equity, eliminate disparities, and improve the health of all groups.” Research has consistently shown that disease management and prevention efforts related to chronic diseases such as diabetes, cardiovascular diseases, cancer, and asthma lead to long-term improvement in outcomes.2 But these research findings have not been translated into sustainable, community-based programs. Furthermore, violence prevention efforts are clearly needed to reduce the significant loss of life due to homicide – the eighth leading cause of death among African Americans in 2014, and the fifth leading cause of death among African American males in 2014.1 MMHI is a program based on collaboration between selected regional Historically Black Colleges and Universities (HBCUs) to leverage resources in order to increase research into the causes and solutions for health disparities, increase community outreach and education, and promote effective prevention and/or treatment activities. As part of the National Institutes of Health and NIMHD’s efforts to advance engaged and transdisciplinary research, MMHI serves as a Transdisciplinary Collaborative Center (TCC) for research on minority men’s health.

    Through this collaboration, and using the expertise of faculty, administration, staff, and community partners, MMHI supports ongoing research projects in cancer, cardiovascular disease (CVD) risk reduction, diabetes, and violence prevention. MMHI also supports 1-year research seed projects and 2-year research pilot projects aimed at improving health outcomes among minority males. Two specific examples of activities conducted by MMHI are the Promis Program, which is focused on violence prevention, and the Heart Strong Program, which focuses on CVD risk reduction in African American men in rural southern Virginia.

    In 2016 and 2017, 49 young men ages 12 to 18 were enrolled in the Promis Program. This program provides meetings and workshop sessions facilitated by male volunteers who serve as mentors. MMHI provides training for workshop facilitators, co-facilitators, and peer mentors, and conducts ongoing evaluation using mentor, retention, and engagement surveys.

    The Heart Strong Program uses a community-based, participatory research approach to design and test a behavioral intervention to reduce cardiovascular disease (CVD) risk. Secondarily, the project seeks to understand barriers and facilitators to healthy lifestyle (e.g., physical activity and diet) and to develop a culturally, contextually, and gender-sensitive intervention to improve healthy eating and physical activity. In 2017, 40 African American men ages 21 to 74 from the Brunswick and Greensville/Emporia areas were enrolled in the program. As part of the program, the men receive monthly memberships at local exercise facilities; weekly personal training; nutrition and cooking health classes; and CVD health education in a large group setting. Individuals can also participate in smaller social support groups.

    The results of these and other MMHI activities will be used to develop future long-term and expanded research studies, inform health policy decisions, and initiate sustainable community-based activities aimed at reducing and ultimately eliminating health disparities.


    1. National Center for Health Statistics. (2016). Health, United States, 2015: With special feature on racial and ethnic health disparities. Hyattsville, MD: U.S. Department of Health and Human Services.

    2. Parekh, A. K., Goodman, R. A., Gordon, C., Koh, H. K., & The HHS Interagency Workgroup on Multiple Chronic Conditions. (2011). Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life. Public Health Reports, 126(4), 460–471.

  • Stroke Ready: Partnering to Increase Acute Stroke Treatment Rates in Flint, Michigan

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    By Lesli Skolarus, M.D., M.S.
    Associate Professor, Neurology, University of Michigan

    Sarah Bailey, M.A.
    Executive Director, Bridges into the Future, Flint, MI

    Dr. Leslie Skolarus (left) and Elder Sarah Bailey (right)May is Stroke Awareness Month, and we would like to share some information about stroke and our research with you. Each year, about 800,000 people in the United States have a stroke. Disability is the greatest challenge facing survivors and their families. About two thirds of stroke survivors are left with a disability.

    Post-stroke disability is substantially reduced by acute stroke treatments, which include intravenous tissue plasminogen activator (tPA) and intra-arterial treatment. Unfortunately, these treatments are underutilized—administered to less than 5 percent of U.S. stroke patients. Treatment with tPA must be given in the emergency department (ED) within 4.5 hours of the start of stroke symptoms. 1 The main reason stroke patients do not receive tPA is that they wait too long to call 911. 2 Think of tPA like Drano® for your brain: We want to get the plugged pipe—in the case of stroke, the plugged artery—open as soon as possible. The less time the artery is plugged, the lower the chance of brain damage, so it is extremely important that a person who is experiencing stroke symptoms calls 911 right away.

    Compared with non-Hispanic Whites, African Americans are less likely to receive acute stroke treatment, largely due to their greater delays in seeking medical attention 3-7 Thus, the ability to recognize stroke symptoms and respond immediately by calling 911 is crucial to reducing racial disparities in post-stroke disability. 8 In Flint, Michigan, a predominantly African American community, the rate of acute stroke treatment is half the national rate. 9 In fact, Flint has the lowest treatment rate of any region of its size in the country.

    Dr. Lesli Skolarus and Elder Sarah Bailey distributing water

    For the past 7 years, neurologists and health behavior and health education experts from the University of Michigan have partnered with Bridges into the Future, a faith-based community organization dedicated to improving Flint’s health, to increase stroke preparedness. During our pilot study, “Stroke Ready,” which was funded by the National Institute of Neurological Disorders and Stroke, we learned through local focus groups that it would be important to address factors such as outcome expectations (i.e., the belief that strokes can be treated) and cost and anxiety barriers when developing stroke preparedness interventions for the Flint community. Using a community-based participatory research (CBPR) approach, we developed and tested a faith-based, theory-driven, peer-led behavioral intervention that increased stroke preparedness among youth and adults in three predominantly African American churches. 10-11 With support from the National Institute on Minority Health and Health Disparities, we are now testing a multilevel intervention to optimize acute stroke care in the ED and to improve community stroke preparedness, with the primary goal of increasing acute stroke treatment city-wide.

    African Americans experience significantly worse post-acute stroke outcomes. Our goal is to reduce this disparity by developing accessible, effective stroke preparedness programs with the communities that are most in need. By combining theory-based public health approaches to address neurological disease, we hope to provide neurologists and community partners with a framework for approaching neurological disease and, ultimately, improving the lives of our patients.


    1. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768-74.
    2. Kleindorfer D, Kissela B, Schneider A, et al. Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: a population-based study. Stroke. 2004;35:e27-29.
    3. Schwamm LH, Reeves MJ, Pan W, et al. Race/ethnicity, quality of care, and outcomes in ischemic stroke. Circulation. 2010;121:1492-501.
    4. Johnston SC, Fung LH, Gillum LA, et al. Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: the influence of ethnicity. Stroke. 2001;32:1061-8.
    5. Hsia AW, Edwards DF, Morgenstern LB, et al. Racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study. Stroke. 2011;42:2217-21.
    6. Lichtman JH, Watanabe E, Allen NB, Jones SB, Dostal J, Goldstein LB. Hospital arrival time and intravenous t-PA use in US Academic Medical Centers, 2001-2004. Stroke. 2009;40:3845-50.
    7. Messé SR, Khatri P, Reeves MJ, et al. Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry. Neurology. 2016;87:1565-74.
    8. Burke JF, Freedman VA, Lisabeth LD, Brown DL, Haggins A, Skolarus LE. Racial differences in disability after stroke: results from a nationwide study. Neurology. 2014;83:390-7.
    9. Skolarus LE, Meurer WJ, Shanmugasundaram K, Adelman EE, Scott PA, Burke JF. Marked Regional Variation in Acute Stroke Treatment Among Medicare Beneficiaries. Stroke. 2015;46:1890-6.
    10. Skolarus LE, Zimmerman MA, Murphy J, et al. Community-based participatory research: a new approach to engaging community members to rapidly call 911 for stroke. Stroke. 2011;42:1862-6.
    11. Skolarus LE, Zimmerman MA, Bailey S, et al. Stroke ready intervention: community engagement to decrease prehospital delay. Journal of the American Heart Association. 2016;5:e003331.
  • Contradicting the Myth of the Model Minority Through a Population Health Equity Approach

    Diabetes management class participants perform group exercises

    By Chau Trinh-Shevrin, DrPH
    Principal Investigator, NYU Center for the Study of Asian American Health
    Associate Professor, Departments of Population Health and Medicine
    Vice Chair for Research, Department of Population Health
    Director, Section for Health Equity
    NYU School of Medicine

    Asian Americans do not need an apple a day to keep the doctor away. Research suggests that doctors are less likely to follow evidence-based guidelines and meet standards of care with their Asian American patients compared with other racial groups in preventing and managing chronic conditions.1,2Asian Americans, however, face just as many health challenges, including an increasing rate of diabetes and certain cancers.

    This neglect seems to be linked to the “model minority” stereotype of Asian Americans, promoted in American culture and media, which portrays them as uniformly hardworking, affluent, and healthy. Yet, Asian Americans are not all alike: There are substantial differences in language, migration, and social experiences across Asian subgroups whose ancestral heritages hail from East, South, and Southeast Asia, and health concerns and risks vary across and within these communities.3

    The model minority myth systemically influences how health care is provided to Asian Americans. In fact, the evidence suggests the following:

    • Aggregated data mask important differences—such as diet and health risks—that may affect health outcomes among more than 30 Asian ethnic subgroups.
    • Diabetes rates are strikingly high for South Asians and Filipinos.4
    • Suicide is one of the leading causes of death among Korean American males,5 suggesting difficulties in accessing and seeking mental health services.

    For these reasons, the Center for the Study of Asian American Health at NYU School of Medicine’s Department of Population Health was established in 2003 and is the only National Institute on Minority Health and Health Disparities Center of Excellence devoted to Asian American health in the United States. Our center seeks to counter the model minority stereotype by employing a population health framework to advance the health of Asian Americans in New York City and nationally.6–8 We have focused on three key development areas:

    • Data Disaggregation: We have led data collection and analyses efforts to support the disaggregation of data on Asian Americans into subgroup to better understand the nature and prevalence of certain health conditions.9
    • Community and Clinical Linkages: Our studies prioritize patient-centered care that aims to bridge communities with poor access to care to doctors and clinics. The DREAM (Diabetes Research, Education, and Action for Minorities) Project, a culturally tailored intervention for Bangladeshi Americans with uncontrolled type 2 diabetes, has demonstrated efficacy in reducing HbA1c and increasing physical activity.10 Community health workers (CHW) lead sessions on diabetes management in Bengali and work with community members to overcome a range of barriers, such as how to use the subway to get to doctor’s appointments and how to ask the right questions. One study participant said, “I only knew [previously] that if I was feeling bad, I should go to the doctor. Now, I have my own doctor—myself.”
    • Multi-level Strategies: We are developing multi-level strategies that integrate health information technology as well as policy, systems, and environmental changes to address major disparities that Asian Americans experience. One focus area of our work is on developing culturally adapted interventions with CHWs and electronic health records in safety net clinical settings to improve adherence to preventive treatments against stomach cancer in high-risk Asian American communities.

    Korean American community screening event at a church in Queens.

    As we celebrate Asian American and Pacific Islander Heritage Month, health care systems increasingly face the challenges of ensuring culturally and linguistically relevant care. We hope more resources will be dedicated to the health of Asian Americans—the fastest growing minority population in the United States11—and meaningful evidence-based strategies will inform policy and practice. As patients and medical professionals, we must mindfully approach Asian Americans as we would any other population—with the intention of addressing complex health challenges and risks experienced by all Americans.


    1. Tung, E.L., Baig, A.A., Huang, E.S., Laiteerapong, N., & Chua, K.P. (2017). Racial and ethnic disparities in diabetes screening between Asian Americans and other adults: BRFSS 2012–2014. Journal of General Internal Medicine 32(4), 423–429. doi: 10.1007/s11606-016-3913-x

    2. Islam, N.S., Kwon, S.C., Wyatt, L.C., Ruddock, C., Horowitz, C.R., Devia, C., & Trinh-Shevrin, C. (2015). Disparities in diabetes management in Asian Americans in New York City compared with other racial/ethnic minority groups. American Journal of Public Health, 105(Suppl. 3), S443–S446. doi: 10.2105/AJPH.2014.302523

    3. Yi, S.S., Kwon, S.C., Sacks, R., & Trinh-Shevrin, C. (2016). Commentary: Persistence and health-related consequences of the model minority stereotype for Asian Americans. Ethnicity and Disease, 26(1), 133–138. doi: 10.18865/ed.26.1.133

    4. King, G.L., McNeely, M.J., Thorpe, L.E., Mau, M.L., Ko, J., Liu, L.L., . . . Chow, E.A. (2012). Understanding and addressing unique needs of diabetes in Asian Americans, native Hawaiians, and Pacific Islanders. Diabetes Care, 35(5), 1181–1188. doi: 10.2337/dc12-0210

    5. Hastings, K.G., Jose, P.O., Kapphahn, K.I., Frank, A.T., Goldstein, B.A., Thompson, C.A., . . . Palaniappan, L.P. (2015). Leading causes of death among Asian American subgroups (2003–2011). PLoS One, 10(4), e0124341. doi: 10.1371/journal.pone.0124341

    6. Trinh-Shevrin, C., Sacks, R., Ahn, J., & Yi, S.S. (2017). Opportunities and challenges in precision medicine: Improving cancer prevention and treatment for Asian Americans. Journal of Racial and Ethnic Health Disparities. Advance online publication. doi:10.1007/s40615-016-0334-9

    7. Trinh-Shevrin, C., Islam, N.S., Nadkarni, S., Park, R., & Kwon, S.C. (2015). Defining an integrative approach for health promotion and disease prevention: A population health equity framework. Journal of Health Care for the Poor and Underserved, 26(Suppl. 2), 146–163. doi: 10.1353/hpu.2015.0067

    8. Trinh-Shevrin, C., Kwon, S.C., Park, R., Nadkarni, S.K., & Islam, N.S. (2015). Moving the dial to advance population health equity in New York City Asian American populations. American Journal of Public Health, 105(Suppl. 3), e16–e25. doi: 10.2105/AJPH.2015.302626

    9. Islam, N.S., Khan, S., Kwon, S., Jang, D., Ro, M., & Trinh-Shevrin, C. (2010). Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: Historical challenges and potential solutions. Journal of Health Care for the Poor and Underserved, 21(4), 1354–1381. doi: 10.1353/hpu.2010.0939

    10. Islam, N.S., Wyatt, L.C., Patel, S.D., Shapiro, E., Tandon, S.D., Mukherji, B.R., . . . Trinh-Shevrin, C. (2013). Evaluation of a community health worker pilot intervention to improve diabetes management in Bangladeshi immigrants with type 2 diabetes in New York City. Diabetes Educator, 39(4), 478–493. doi: 10.1177/0145721713491438

    11. Colby, S.L., & Ortman, J.M. (2014). Projections of the size and composition of the U.S. population: 2014 to 2060. Washington, DC: U.S. Census Bureau.

  • For the First Time, Healthy People Initiative Focuses on Social Determinants of Health

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    By Nancy Breen, Ph.D.
    Economist, Office of Strategic Planning, Analysis and Reporting, NIMHD and NIMHD Representative to the Healthy People Social Determinants of Health Workgroup

    Healthy People Background

    The Healthy People initiative is a federal program that provides “science-based, 10-year national objectives for improving the health of all Americans.” For the past 40 years, Healthy People has monitored the health of Americans and set benchmarks for how we can all be healthier. You can read more about Healthy People online at www.healthypeople.gov.

    Healthy People provides a national 10-year framework for health promotion and disease prevention, with measurable objectives and goals, and it invites states and localities to use the national framework and objectives for their own plans. While the focus has always been health promotion and disease prevention, the Healthy People 2020 agenda is the first to use social determinants of health (SDOH) to frame the conceptual understanding of health. For 2000, an overarching goal to “reduce health disparities” was introduced, partly in response to the 1985 Report of the Secretary’s Task Force Report on Black and Minority Health (often referred to as the “Heckler Report”).1 For 2010, that goal was strengthened to “eliminate health disparities.” For Healthy People 2020, one of the overarching goals is to “achieve health equity, eliminate disparities, and improve the health of all groups.”2 The graphic from Healthy People 2020 shows that the overarching goals emphasize the determinants of health.

    The mission of Healthy People 2020 includes identifying health improvement priorities; increasing public understanding of the determinants of health, disease, and disability; and engaging multiple sectors to identify opportunities for progress. Including health disparities in this framework improves the chances that federal interventions will be able to reduce health disparities and increase health equity for all Americans. The choice to highlight social determinants as a leading health indicator (LHI) is important, because LHIs are used to motivate action on high-priority health issues and challenges at the national, state, and community levels.3

    One of the Healthy People initiative’s key roles is to identify research, evaluation, and data needs. The National Center for Health Statistics conducts two assessments for each 10-year initiative. These midcourse and final reviews provide an opportunity to see the initiative’s impact along the way. The 5-year review for Healthy People 2020 was released in January 2017 and can be found on the CDC website, at https://www.cdc.gov/nchs/healthy_people/hp2020/hp2020_midcourse_review.htm.

    Healthy People 2020 Framework. Graphic from www.healthypeople.gov.

    Chapter 39 of the Midcourse Review focuses on SDOH, and some of the most important findings are described below. Healthy People 2020 defines SDOH as “conditions and the environment in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”4 The 33 SDOH objectives are organized into five domains:

    1. Economic stability (9 objectives)
    2. Education (5 objectives)
    3. Health and healthcare (6 objectives)
    4. Neighborhood and built environment (10 objectives)
    5. Social and community context (3 objectives)

    Highlights from the Midcourse Review

    Economic Stability

    How much money people spend on housing can have a meaningful impact on their well-being. Economic experts recommend that families spend no more than one third of their income on housing, so that adequate funds are available for other expenditures. Studies show that spending more than half of a family’s income on housing puts householders at high risk of losing their home. The Midcourse Review shows that more people are being affected on both measures, suggesting that, overall, Americans are not doing as well in terms of economic stability as they were 5 years before.

    • From 2007 to 2011, the proportion of households that spent more than 30 percent of their income on housing rose from 35 percent to 38 percent; in 2011, Hispanics/Latinos were the racial/ethnic group most at risk. Householders with less than a high school education, with low family income, with a disability, or who lived in metropolitan areas were also at higher risk.
    • From 2007 to 2011, the proportion of households that spent more than half of their income on housing increased from 16 percent to 18 percent. Householders who were African American had less than a high school education, were poor, or lived in nonmetropolitan areas were at higher risk.


    Today, having a college education is important for getting a job and staying employed. The Midcourse Review showed that, unfortunately, the percentage of young people going to college after completing high school is lower than it was a few years ago.

    • Individuals ages 16–24 who had completed high school and enrolled in college the following October decreased from 68 percent to 66 percent between 2010 and 2013. High school completers from low-income families were less likely than completers from high-income families to enroll in college right after high school graduation.

    Health and Healthcare

    Having health insurance is an important part of making sure that people can afford access to an ongoing source of healthcare when they get sick. The Midcourse Review showed that more people under the age of 65 have insurance now than they did in 2007 and that people of all ages are more likely to have a source of ongoing healthcare. In addition, more people than before say that they can understand their doctor or nurse’s instructions.

    • The proportion of people under age 65 with medical insurance increased from 83 percent in 2008 to 87 percent in 2014, and the proportion of people of all ages with a source of ongoing care increased from 86 percent in 2008 to 88 percent in 2014.
    • The proportion of people age 18 and over who reported that their healthcare providers’ instructions were easy to understand increased from 64 percent in 2011 to 66 percent in 2012.

    Neighborhood Context and the Built Environment

    Under the well-known “broken windows” theory, an orderly environment signals that an area is monitored and that criminal behavior is not tolerated: Neighborhoods with a strong sense of cohesion assert social responsibility and control by fixing broken windows and other small but visible problems. Air quality and lead levels are important indicators of a clean and safe environment, and crime rates are an indicator of social cohesion.

    • Between 2008 and 2012, there was a decrease in the rate of arrests of minors and young adults ages 10–24 for serious violent crimes (from 444 to 324 per 100,000 population) and serious property crimes (from 1,527 to 1,223 per 100,000 population).
    • Days when the Air Quality Index (AQI) exceeded 100 (weighted by population and AQI) decreased from 2.2 billion to 982 million between 2006–2008 and 2012–2014. Also, lead levels in blood samples among children ages 1–5 years in the 97.5 percentile decreased from 5.8 mcg/dL to 4.3 mcg/dL between 2005–2008 and 2009–2012.

    Social and Community Context

    Social support is especially critical for children and adolescents, who are in their formative years. New items that may be measured in the final review of Healthy People 2020 include civic participation, incarceration, and discrimination.

    • The proportion of adolescents ages 12–17 who reported having an adult in their lives with whom they could discuss serious problems rose slightly, from 76 percent in 2008 to 78 percent in 2013; however, it is striking that almost a quarter of adolescents did not report having such an adult in their lives.

    Overall, the Healthy People 2020 Midcourse Review underscores a basic fact: Improving the social determinants of health and mitigating their adverse impacts on population health is complicated. Even so, trends for 15 of the 25 objectives that have targets are moving toward or have met national targets. The Midcourse Review provides an opportunity to assess progress and identify remaining opportunities for interventions so that more can be accomplished by 2020. Addressing SDOH in localities, states, and the nation is an important step toward reducing health disparities. We have made some progress, especially in healthcare and family communication, but there is still work to be done.

    Learn more about NIMHD’s work to eliminate disparities and improve the health of all groups.


    1. National Center for Health Statistics. Chapter 4: Leading Health Indicators. Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B04-LHI.pdf

    2. National Center for Health Statistics. Chapter 39: Social Determinants of Health (SDOH). Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C39-SDOH.pdf

    3. U.S. Department of Health and Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Volume I: Executive Summary. Washington, DC. 1985.

    4. National Center for Health Statistics. Chapter 1: Introduction. Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B01-Introduction.pdf

  • Introducing the Language Access Portal

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    By Kelli Carrington, M.A.
    Director, Office of Communications and Public Liaison
    National Institute on Minority Health and Health Disparities

    Many of us know what it’s like to feel overwhelmed during a doctor’s visit by information about health conditions, medicines, and behavior recommendations. For patients who don’t speak or understand English fluently, the situation can be more than overwhelming—it can be dangerous. Patients with limited English proficiency (LEP) are nearly three times more likely to have an adverse medical outcome.1

    Language is one of the most significant barriers to health literacy, the ability to understand the basic health information needed to make good health decisions. Patients who lack health literacy are often unable to read or understand written health information or to speak with their healthcare providers about their symptoms or concerns. These patients are less likely to follow important health recommendations or be able to give informed consent.2

    According to the U.S. Census Bureau, more than 1 in 5 U.S. residents don’t speak English at home. Of that group, about 4 in 10, or 25 million people, have limited English proficiency.3 Many people with limited proficiency also live in households where no one speaks English well, meaning there isn’t a translator readily available to accompany them to doctor’s visits.

    The National Institute on Minority Health and Health Disparities (NIMHD) is committed to addressing these language barriers and to improving the health literacy and lives of everyone living in America. We’re excited to announce a new tool, the Language Access Portal, as a resource for the NIMHD research community, public and community health professionals, healthcare providers, and others who work with health disparity populations with LEP. The portal improves access to cross-cultural and linguistically appropriate health information produced by the National Institutes of Health (NIH), NIMHD, and other federal agencies.

    The Language Access Portal pulls together health resources from across NIH in selected languages, particularly those languages spoken by populations experiencing significant health disparities. As we launch, the portal includes information in Spanish, Hindi, Tagalog, Korean, Chinese, Japanese, and Vietnamese. The portal currently has language resources for the following areas where health disparities have been identified:

    The Language Access Portal is an important tool to help people working with LEP populations provide the information necessary for patients to make important health decisions. The portal will continue to evolve and incorporate new resources from NIMHD, NIH and other government agencies as they become available, so keep checking back. By working together and using tools like the Language Access Portal, we can begin to tackle these communication barriers and improve the health of every resident of this country.


    1. Divi, C., Koss, R.G., Schmaltz, S.P., Loeb, J.M. (2007) Language Proficiency and Adverse Events in US Hospitals: a pilot study. Int J Qual Health Care. 19 (2): 60-67.
    2. Lee, J.S., Pérez-Stable, E.J., Gregorich, S.E. et al. (2017). Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency. J GEN INTERN MED. doi:10.1007/s11606-017-3983-4
    3. U.S. Census Bureau. Table S1601: 2011-2015 American Community Survey 5-Year Estimates.
  • Addressing Mental Health in African Americans Through FAITH

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    February 21, 2017

    By Tiffany Haynes, Ph.D.
    Assistant Professor, Department of Health Behavior and Health Education
    Fay W. Boozman College of Public Health
    University of Arkansas for Medical Sciences, Little Rock, AR University of Arkansas for Medical Sciences

    Dr. Tiffany HaynesDr. Tiffany Haynes Rural African Americans are disproportionately exposed to numerous stressors, such as poverty, racism, and discrimination,1-5 that place them at risk for experiencing elevated levels of depressive symptoms.6 Elevated levels of depressive symptoms can lead to a host of negative outcomes, including poor management of chronic illnesses (e.g., hypertension, diabetes), poor social and occupational functioning, and development of clinical depression.7 Although effective treatments for decreasing depressive symptoms exist, structural barriers (e.g., lack of available services, transportation) and perceptual barriers (e.g., stigma, fear of misdiagnosis) impede the use of traditional mental health services within these communities, resulting in a significant unmet psychiatric need. Failure to develop culturally appropriate strategies to provide adequate, timely care to rural African Americans can result in a significant public health crisis.

    African American churches have been identified as potential venues for providing depression education and treatment for rural African Americans.8 Within the African American rural community, churches represent a key portal through which as much as 85% of the community can be reached.9 Churches have been used to address physical health outcomes in those communities, but few have focused primarily on addressing mental health outcomes10-11. Through the NIMHD-funded project entitled “Faith Academic Initiatives to Transform Health (FAITH) in the Delta,” our partnership, consisting of faith community leaders and University of Arkansas for Medical Science researchers, conducted formative work in the Arkansas Delta. Data suggested that community members consider elevated depressive symptoms to be a significant unmet need. Furthermore, community members suggested that attempts to improve depressive symptoms should do the following:

    1. Provide education about depressive symptoms. Recognizing when depressive symptoms become a clinical problem is the first step toward receiving adequate treatment. However, rural African Americans report difficulties in differentiating between normal sadness and clinically significant depressive symptoms. Providing education about depressive symptoms allows rural African Americans to make informed treatment decisions.
    2. Address the role that stress from social inequities plays in the development and maintenance of depressive symptoms. Rural African Americans correctly realize that prolonged exposure to stress caused by social inequities is a significant factor in the development and maintenance of depressive symptoms. Treatments that conceptualize depressive symptoms as normal reactions to stress are more culturally acceptable in rural African American communities.
    3. Find ways to increase social support for those experiencing depressive symptoms. Stigma is a significant concern in rural communities. Rural African Americans experiencing depressive symptoms tend to socially isolate themselves, which, in turn, can worsen depressive symptoms.
    4. Provide mental health interventions in community-based settings. Residents suggest that offering mental health services in community settings, such as churches, would allow residents to receive treatment in less stigmatizing places and improve access to mental health care.

    (From left to right): Pastor Johnny Smith, Community PI; Dr. Tiffany Haynes, Academic PI; Dr. Karen K. Yeary, Academic Co-PI; and Pastor Jerome Turner, Community PI.

    Using this data as a base, researchers worked closely with the faith community to culturally adapt an evidence-based behavioral activation intervention for use with rural African American churches. This eight-session behavioral activation intervention, REJOICE (Renewed and Empowered for the Journey to Overcome in Christ Everyday), was adapted to include faith-based themes, scripture, and other aspects of the rural African American faith culture (e.g., Bible studies, interweaving faith-based messages throughout the intervention materials).

    Currently, we are testing the effectiveness of REJOICE and obtaining pilot data about the best ways to implement this intervention in rural African American churches. Collecting data from this project is the first step in providing timely and appropriate care to high-need and underserved communities.


    1. Harris, R. P., & Worthen, D. (2003). African Americans in rural America. In D. L. Brown & L. E. Swanson (Eds.), Challenges for rural America in the twenty-first century (pp. 32-42). University Park, PA: The Pennsylvania State University Press.
    2. U.S. Department of Agriculture, Economic Research Service (2016). Rural Poverty and Well-Being: Geography of Poverty. Retrieved from https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/
    3. Fitchen, J. M. (1992). On the edge of homelessness: rural poverty and housing insecurity. Rural Sociology, 57, 173-193.
    4. Kusmin, L. (Ed.). (2012). Rural America at a glance, 2012 edition. Washington, DC: U.S. Department of Agriculture, Economic Research Service.
    5. Odom, E. C., & Vernon-Feagans, L. (2010). Buffers of racial discrimination: links with depression among rural African American mothers. Journal of Marriage and the Family, 72, 346-359.
    6. Kusmin, L. (Ed.). (2011). . Rural America at a glance, 2011 edition. Washington, DC: U.S. Department of Agriculture, Economic Research Service.
    7. Mays, V. M., Cochran, S. D., & Barnes, N. W. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology, 58, 201-225.
    8. Taylor RJ, Chatters LM, Levin J. Religion in the Lives of African Americans: Social, Psychological, and Health Perspectives. Thousand Oaks, CA: Sage Publications, 2004.
    9. Reeves RR, Adams CE, Dubbert PM, Hickson DA, Wyatt SB. Are Religiosity and Spirituality Associated with Obesity Among African Americans in the Southeastern United States (the Jackson Heart Study)? J Relig Health. 2011.
    10. DeHaven MJ, Hunter IB, Wilder L, Walton JW, Berry J. Health programs in faith-based organizations are they effective? Am J Public Health. 2004; 94(6): 1030-6. 1448385
    11. Hankerson, Sidney H., and Myrna M. Weissman. “Church-based health programs for mental disorders among African Americans: a review.” Psychiatric Services 63.3 (2012): 243-249.