Reducing Health Inequities in the United States: Insights and Recommendations from the National Heart, Lung, and Blood Institute’s Health Inequities Think Tank Meeting

Background

Inequities in health have their roots in the structure of society and reflect the unequal life chances experienced by people of different social classes, racial/ethnic backgrounds, and other dimensions of social stratification (e.g., sex and geography). Many decades of surveillance and research in the United States and across the globe have shown that an excess burden of disease falls on disadvantaged population groups (1). The persistence of inequities across the full spectrum of health outcomes, access to health care, adoption of health-promoting behaviors, and exposure to health-promoting environments are amply documented in recent reports (2). The National Healthcare Quality and Disparities Report (QDR) provides a comprehensive overview of the quality of health care received by the general U.S. population, and inequities in care experienced by different racial, ethnic, and socioeconomic groups. The 2014 QDR demonstrates that, despite evidence of progress, there are many persistent challenges to improving quality and reducing inequities (2).

Although the variation in state performance on quality and inequities may suggest the need for tailored approaches for improvement, the systemic nature of inequities across multiple indicators (mortality, morbidity, risk factors, access to care, and quality of care) suggests that innovative ways of addressing these structural determinants of inequities are needed. Health inequities lead to loss of lives, health, productivity, and increased health care costs, which collectively have profound economic consequences. This perspective is amply affirmed by the National Research Council (NRC) and Institute of Medicine (IOM) report that compares the current U.S. health disadvantage to peer high-income countries (3), and the report from the Joint Center for Political and Economic Studies on the economic burden of health inequities in the United States (4). In tackling this challenge, the National Heart, Lung, and Blood Institute (NHLBI) convened a Think Tank meeting to obtain advice regarding the objectives and design of the next generation of research that will address health inequities in the United States. The Think Tank was convened to both identify underpinnings of health inequities and inform the NHLBI’s implementation (T4 translation) research initiatives, which, by definition, focus on strategies for broad implementation of evidence-based interventions in “real world” settings to reduce the burden of disease across at-risk populations. Implementation research is still a developing field; therefore, bringing it to maturity will require development of new design and analysis tools, as well as advances in the mechanics of collaborative research. Such efforts should have broad focus by considering factors both within and beyond the health care system systematically and objectively to reduce the differences (gap) in health outcomes between populations, and especially to improve health in underserved populations at the greatest risk for poor health outcomes.

Charge to the Think Tank Panel

Given the investments by the NHLBI in observational and clinical science, the Think Tank was charged to consider the objectives and design of the next generation of research targeting health inequities. In particular, NHLBI’s newly formed Center for Translation Research and Implementation Science (CTRIS) (5) has as its mission to advance late-stage or T4 translation research, which implies identifying effective methods for disseminating and implementing evidence-based interventions known to improve the health of the population. A prominent aspect of late-stage (T4) translation research (focused on dissemination and implementation) is attention to reducing health inequities, which are driven by social and economic factors, with additional contributions from challenges in access, quality, and affordability of health care, and the availability and delivery of public health services. To this end, the Think Tank group was charged with advising the NHLBI on how best to: develop methods for testing and implementing evidence-based interventions that will reduce health inequities in at-risk population subgroups; develop infrastructure for research on health inequities, including (but not limited to) capacity for T4 translation research, and collaboration with other entities, such as community stakeholders, health care systems, and governmental agencies (in particular public health agencies and public funders of medical care); increase involvement of medically-disadvantaged populations in research; utilize contemporary changes in health care as potential natural experiments for understanding changes in health inequities; and educate and mentor the next generation of health inequities researchers, prepared in the full range of biological, behavioral, social, and systems sciences necessary for effective advancement of knowledge on the dissemination and implementation of interventions that will eliminate health inequities. A major focus of this effort is to transform health inequities research from simply the study of the problem to the study of interventions to eradicate them. In the context of this charge, the Think Tank was asked to identify the highest priorities among its recommendations. A different pair of panel members, who were tasked ahead of time with this responsibility, moderated each meeting session. In this context, session moderators were asked to consider in depth the key discussion topics for their assigned session, and to present a summary of the issues, as well as make recommendations to the Think Tank as a whole. During each session, all panel members were called upon in sequence to weigh in on the issues presented by the session moderators, to stimulate dialogue and eventual consensus on the priority recommendations.

Panel Summary Statements and Recommendations

Significant research has demonstrated that inequities in heart, lung, blood, and sleep (HLBS) disorders are driven by factors defined and operating at multiple levels, including social, economic, environmental, health care-related, behavioral, stress-related, and other personal characteristics (6). These factors are organized into complex causal chains, likely involving interactions and feedback loops, and often operating across the life course of individuals. Many of the fundamental drivers of health inequities are rooted in structural causes related to unequal access to resources, knowledge, and power. Understanding the drivers of health inequities and intervening to reduce or eliminate them will therefore require a multiplicity of approaches, ranging from societal strategies and policies to individual targeted approaches. This makes translation science to address inequities especially challenging, but also critically important. For example, geographical location can contribute to inequities through effects of social policy, safety, environmental pollution, places to be physically active, and access to recommended nutritional resources, such as fresh fruits and vegetables. Essentially, where we live, learn, work, and play has an impact on the likelihood of developing illness, the speed of deterioration, and the possibility of successful recovery/rehabilitation; and participation in faith-based activities, community safety and violence, poor nutrition, and the absence of clean indoor air laws also contribute to the burden of HLBS conditions (7,8). The Think Tank recognized both the urgency, and the complexity of the task at hand, and, especially, the need for novel, creative, interdisciplinary, trans-sectoral, and multilevel approaches. The key recommendations from the Think Tank are offered in the Central Illustration and are summarized below.

Discussion

Thus far, the NHLBI has pursued a broad approach to health inequities research, with one of the most inclusive minority enrollment policies at the NIH, requiring at least 25% to 30% of research participants to be from minority populations. This enables more robust analysis of clinical trial results and observational study data by minority status. In addition, the NHLBI has launched several epidemiological studies specifically targeting minority health issues, including the Jackson Heart Study, the Hispanic Community Health Study/Study of Latinos, the Strong Heart Study, the PATHWAYS clinical trial to reduce obesity in American Indian schoolchildren, and the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study (18–23). The Institute has issued the Guidelines Implementation Panel Report for Diagnosis and Management of Asthma, which targets inequities related to asthma. Most recently, and still underway, the NHLBI launched 5 Centers for Population Health and Health Disparities to study causes of health inequities and, most importantly, to evaluate interventions. Overall, the NHLBI research investments on health inequity have been productive, but the time has come to build on these investments by stimulating implementation research in an effort to address the challenge of health inequities.

On the issue, charting the course of the next generation of research aimed at reducing health inequities, the NHLBI Thank Tank Panel provided key recommendations centered on addressing broad research themes that embrace multilevel determinants, building research platforms for implementing multilevel intervention protocols, adopting system science approaches, developing networks of collaborators and stakeholders, launching transformative studies that serve as benchmarks, optimizing the use of new data sources, platforms, and natural experiments, and developing unique transdisciplinary training programs to build research capacity. Participants at the Think Tank also recognized that, despite the importance of health care, improved health services alone might be insufficient to address all health inequities. Behavioral, social, community, and policy interventions, in addition to environmental and policy changes for improving health and healthy life expectancy, deserve increased attention, as they may be much more potent than medical interventions (24). The failure of our research to reach full translation is due, at least in part, to the barriers that many patients face in adhering to provider recommendations because of the circumstances in which they live and the incentives within health care. Both sets of challenges will need to be improved if the health inequities that affect so many in our nation are to be addressed.

Conclusions

Let us be reminded of the words of Dr. Martin Luther King, Jr., that “of all forms of inequity, injustice in health is the most shocking and inhuman” (25). While broader sociopolitical interventions to eliminate health inequities may appear to lie outside the remit of our disciplines, as health scientists it is our obligation to provide evidence of how a broad range of strategies, policies, and interventions ranging from societal to genetic may impact health and health inequities. We must work to ensure that all Americans benefit from access to proven interventions, and that targeted efforts to eliminate health inequities in our communities continue to be made. We have the knowledge to improve overall population health and well-being of communities, but more efficient and effective implementation is needed. In this regard, novel approaches and research platforms can be leveraged to facilitate implementation research on disparity reduction especially community and behavioral interventions, which is paramount for advancing adherence to best practices for health promotion—diets rich in fruits and vegetables, physical activity, tobacco avoidance or smoking cessation—prevention, and treatment of cardinal risk factors like overweight and obesity, high blood pressure, dyslipidemia, and diabetes, which are central to HLBS conditions. Indeed, if we can optimally disseminate and implement existing evidence-based approaches, we will achieve substantial improvement in the social wellbeing and productivity of the U.S. population. However, we also need to understand why interventions have not worked to eliminate health inequities in the past as well as what other strategies might complement or enhance existing evidence-based interventions.

Our recommendations include the engagement of other disciplines, more transformative studies and platforms and development and participation in networks and organizations that have dissemination and improvement in equity at their core. The principal conclusion of this Think Tank is that, despite a highly successful research enterprise that has led to lower HLBS disease and mortality, there has been at best only modest progress in reducing disparity by race/ethnicity, socioeconomic status (SES), and geography. And these have to be addressed if the NHLBI is to succeed in its societal purpose. The NHLBI does not stand apart from the American society but rather it is embedded in it. The growing diversity of the U.S. population, the growing SES inequity more generally and in health specifically and the enormous cost of health care in the United States relative to other countries could contribute to questioning societal support for research if it is perceived to be preferentially available to select populations, for example, high SES, rather than helping all equally and more targeted to those with greater health need.