National Institutes of Health Minority Health and Health

National Institutes of Health
Minority Health and Health Disparities Strategic Plan 2021–2025
Taking the Next Steps

STRATEGIC PLAN 2021–2025
Table of Contents
NIH Director’s Foreword............................................................................................................ 3 Introduction ............................................................................................................................... 4 Minority Health and Health Disparities: Definitions and Parameters...................................... 6 NIH and HHS Commitment ....................................................................................................... 8 Foundation for Planning............................................................................................................ 9 Structure of This Plan................................................................................................................ 10 Strategic Plan Categories ......................................................................................................... 11
Scientific Research............................................................................................................. 11 Research Sustaining........................................................................................................... 11 Outreach, Collaboration, and Dissemination...................................................................... 12 Leap Forward Research Challenge .................................................................................... 12 Summary of Categories and Goals........................................................................................... 13 Scientific Research Goals and Strategies .......................................................................... 13 Research-Sustaining Activities: Goals and Strategies ....................................................... 14 Outreach, Collaboration, and Dissemination Goals and Strategies................................... 14 Details of Categories and Goals ............................................................................................... 16 Scientific Goals, Research Strategies, and Priority Areas.................................................. 16 Research-Sustaining Activities: Goals, Strategies, and Priority Areas............................... 23 Outreach, Collaboration, and Dissemination: Goals and Strategies.................................. 28 Leap Forward Research Challenge .......................................................................................... 32 Minority Health and Health Disparities Research............................................................... 33 Research-Sustaining Goals................................................................................................ 35 Future Plans............................................................................................................................... 37
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NIH Director’s Foreword
“Advancing the science of understanding the causes of health disparities and of developing effective interventions to reduce health disparities and improve minority health is one of my personal priorities. NIH has a major role in identifying interventions and causes of health disparities. If we can chip away at health disparities, everyone can experience the better health they deserve. Using the tools of research and our creativity to address our task, we have a moral responsibility to address health disparities. What a privilege to be engaged in this noble enterprise that has real promise to give every person the opportunity to have better health.” — Francis S. Collins, M.D., Ph.D., Director of NIH
“As health disparities remain a potentially preventable burden, public health is impacted unnecessarily.” — Eliseo J. Pérez-Stable, M.D., Director of the National Institute on Minority Health and Health Disparities, NIH

The publication of the Institute of Medicine report on unequal treatment, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, summarized a legacy of unequal health care and differential health outcomes for most leading causes of disability and death in the United States among African Americans compared with Whites, with selected available data on other racial and ethnic minority groups. Since then, sources of data dramatically have improved while scientific advances in basic mechanisms have strengthened our understanding of etiological pathways and potential intervention points to improve minority health, reduce health disparities, and promote health equity. The need for rigorous scientific approaches to minority health and health disparities—building on decades of studies addressing social inequality and health, behavioral epidemiology, and access to quality health care—is now increasingly being met by an expanding array of biological and data science tools that help us understand health and disease mechanisms.
The Office of Minority Health Research was founded at NIH in 1990 to provide a focus for research questions that

addressed racial/ethnic minority populations. Through congressional legislation, the Office was upgraded to the National Center on Minority Health and Health Disparities in 2000 and to the National Institute on Minority Health and Health Disparities (NIMHD) in 2010. NIMHD is charged with coordinating and leading NIH’s vision and programs on minority health and health disparities research. The topics are broad and include health determinants pertaining to the entire life course, including all populations, diseases, prevention, and health care. Research that advances understanding and improvement of health and disease in minority racial/ethnic groups in the United States requires a basic understanding of the construct of race and ethnicity, incorporating the social determinants of health in the context of science. Research to understand the causes of and define mechanisms leading to interventions to reduce health disparities is a parallel mandate, incorporating socioeconomic, geographic, and cultural factors to address conditions with negative outcomes in specific populations. NIMHD envisions an America in which all populations will have an equal opportunity to live long, healthy, and productive lives. 

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Introduction
Medical advances and new technologies have allowed Americans to live longer and healthier lives for the past century. These advances, however, have not helped all Americans equally, and health disparities persist, disproportionately affecting racial and ethnic minority populations, individuals of less privileged socioeconomic status (SES), underserved rural residents, sexual and gender minorities (SGMs),1 and any subpopulations that can be characterized by two or more of these descriptions. In October 2016, SGMs were formally designated as a health disparity population for research purposes.
In the 35 years since the Heckler report was published,2 pioneering researchers studying health disparities and minority health have worked to reduce the burden of premature illness and death experienced by many people from minority racial and ethnic backgrounds, SGMs, rural residents, and individuals of less privileged SES. For example, thanks to the efforts of researchers, advocates, and other stakeholders, the gap in mortality between Blacks and Whites was reduced by about half from 1999 to 2015, narrowing from 33 percent to 16 percent.3 Not all health outcomes are worse for disparity populations; in selected conditions, racial and ethnic minorities of less privileged SES have better health.4 However, the individuals comprising these groups still face considerable health disparities in most conditions. These disparities include shorter life expectancy; higher rates of cardiovascular disease, cancer, diabetes, infant mortality, stroke, cognitive impairment, asthma, sexually transmitted infections, and dental diseases; and differences in prevalence and outcomes of mental illness.
1 Sexual & Gender Minority Research Office (SGMRO). Strategic Plan to Advance Research on the Health and Well-being of Sexual & Gender Minorities: Fiscal Years 2021–2025.
2 Heckler MM. Report of the Secretary’s Task Force on Black and Minority Health. U.S. Department of Health and Human Services.
3 Cunningham TJ, Croft JB, Liu Y, Lu H, Eke PI, Giles WH. Vital Signs: Racial Disparities in Age-Specific Mortality Among Blacks or African Americans — United States, 1999–2015. MMWR Morb Mortal Wkly Rep 2017;66:444–456.
4 Franzini L, Ribble JC, Keddie AM. Understanding the Hispanic Paradox. Ethn Dis. 2001;11(3):496-518.

Health disparities are the result of differences in and interplay among numerous determinants of health, including biological factors, the environment, health behaviors, sociocultural factors, and the way health care systems interact through complex multilevel pathways. These dynamic and complex interactions lead to poor health outcomes and challenge researchers to identify mechanistic pathways to develop interventions that may lead to reductions in health disparities and improvements in minority health that promote health equity with a systematic applied approach.
Section 10334 of P.L. 111-148 tasks NIMHD with coordinating NIH’s research related to minority health and health disparities: “The Director of the Institute, as the primary Federal official with responsibility for coordinating all research and activities conducted or supported by the National Institutes of Health on minority health and health disparities, shall plan, coordinate, review, and evaluate research and other activities conducted or supported by the Institutes and Centers of the National Institutes of Health.” In addition, Section 2038 of P.L. 114-255 (21st Century Cures Act) tasks NIMHD with fostering partnerships and collaborative projects relating to minority health and health disparities: “The Director of the Institute may foster partnerships between the national research institutes and national centers and may encourage the funding of collaborative research projects to achieve the goals of the National Institutes of Health that are related to minority health and health disparities.” As part of all strategic planning processes across NIH, Institutes and Centers (ICs) are tasked with coordinating with the Directors of NIMHD and the Office for Research on Women’s Health to ensure that the plans account for the unique perspectives, strengths, and challenges facing minorities and women, as described in Section 2031 of P.L. 114-255. Furthermore, section 404N of the Public Health Service Act encourages increased research with SGM populations as a response to the mounting evidence of the health disparities experienced by SGM populations, as well as an acknowledgment of unique

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health challenges faced by SGM individuals who may be affected by a socially disadvantaged position. The plan will guide NIH in setting scientific goals, such as advancing the scientific understanding of health disparities, and research-related activity goals, such as strengthening the national research capacity to address minority health and health disparities.
Research supported by NIH has worked to reduce these disparities and improve minority health across all diseases, disorders, and conditions. As a result, all ICs contribute to the science and support activities. NIH also supports training, workforce development, capacity building, and other activities that work to reduce health disparities. This NIH strategic plan demonstrates ICs’ commitment to research that improves minority health and reduces health disparities and to activities like training and capacity building that enhance the ability to reveal the new scientific knowledge needed to improve health for all Americans.
The scientific information discovered in basic research proposes to move along a continuum through clinical sciences until a practice or procedure that improves individual and population health can be implemented. Minority health and health disparities research can be viewed in a similar framework. Information about a racial or ethnic minority group—such as behavioral, biological, sociocultural, socio-ecological, and environmental

characteristics and attributes—placed within a health care or public health setting provides the basis for understanding minority health. Once these basic factors are identified, similarities and differences between population groups may become apparent. These population differences may or may not constitute a health disparity, since the outcome for some conditions may be better for the population presumed to be disadvantaged, such as in the Hispanic Paradox.5
Understanding why a racial or ethnic minority group has a specific health outcome is at the core of minority health science. Minority health research intends to identify factors contributing to health conditions, independent of whether a health disparity exists or is identified. When investigations of differences in health between diverse groups exist, where the disadvantaged population group has a worse health outcome, this defines one aspect of health disparity research. Health disparity research then strives to understand mechanisms as to why a racial or ethnic minority group has a worse health outcome compared to a reference group.
Clarifying the difference between minority health and health disparities research prompted NIMHD to develop revised definitions for the biomedical research field. These distinct definitions provide justification for a new approach for the next generation of knowledge discovery to improve minority health and reduce health disparities.

5 Ruiz JM, Steffen P, Smith TB. Hispanic mortality paradox: a systematic review and meta-analysis of the longitudinal literature. Am J Public Health. 2013;103(3):e52‐e60.
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Minority Health and Health Disparities: Definitions and Parameters

Definitions of the terms “minority health” and “health disparities” have evolved as the research fields have grown and interacted with the full spectrum of scientists. Initially, the definitions were intertwined, as the researchers doing this important work have bridged both fields, and the assumption was made that minority populations always had health disparities. For NIH, this plan underscores the need to separate the science of minority health, which focuses on the health of racial and ethnic minority communities, and the science of health disparities, which focuses on differences in health outcomes for defined disadvantaged populations that are worse than the White reference population. There is clear overlap, since for many conditions, minority populations have well-defined health disparities compared with the White population in the United States. However, creating some separation of these disciplines may prove beneficial in enabling each field to make greater independent strides. Over the course of fiscal years (FYs) 2015 and 2016, NIMHD undertook a process across NIH to revise the definitions for minority health and health disparities.6
Minority Health Definition
Minority health (MH) refers to the distinctive health characteristics and attributes of racial and/or ethnic minority groups, as defined by the U.S. Office of Management and Budget (OMB), that can be socially disadvantaged due in part to being subject to potential discriminatory acts.
Minority Health Populations
NIH uses the racial and ethnic group classifications determined by OMB in the Revisions to Directive 15, titled Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity. The minority racial and ethnic groups defined by OMB are American Indian or Alaska Native, Asian, Black or African American, and
6 AJPH Supplement: New Perspectives to Advance Minority Health and Health Disparities Research. Am J Public Health. 2019;109(S1).

Native Hawaiian or other Pacific Islander. The ethnicity used is Latino or Hispanic.
Although these five categories are minimally required, the mixed or multiple race category should be considered in analyses and reporting, when available.
Other NIH efforts that support Tribal Nations can be found in the NIH Strategic Plan for Tribal Health Research FY 2019–2023.
Self-identification is the preferred means of obtaining race and ethnic identity.
Minority Health Research
Minority health research is the scientific investigation of distinctive health characteristics and attributes of minority racial and/or ethnic groups who are usually underrepresented in biomedical research to understand health outcomes in these populations.
Health Disparity Definition
A health disparity (HD) is a health difference that adversely affects disadvantaged populations, based on one or more of the following health outcomes:
ƒ Higher incidence and/or prevalence and earlier onset of disease
ƒ Higher prevalence of risk factors, unhealthy behaviors, or clinical measures in the causal pathway of a disease outcome
ƒ Higher rates of condition-specific symptoms, reduced global daily functioning, or self-reported health-related quality of life using standardized measures
ƒ Premature and/or excessive mortality from diseases where population rates differ
ƒ Greater global burden of disease using a standardized metric

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Health Disparity Populations
NIH defines health disparity populations as racial and ethnic minority populations (see above OMB directive), less privileged socioeconomic status (SES) populations, underserved rural populations, sexual and gender minorities (SGM), and any subpopulations that can be characterized by two or more of these descriptions.
Other NIH efforts that support SGMs can be found in the NIH FY 2016–2020 Strategic Plan to Advance Research on the Health and Well-being of Sexual and Gender Minorities.
Health Determinants
There are many factors that impact an individual’s health and the risk of experiencing health disparities. These domains of influence have been expanded into “health

determinants” in order to capture areas that go beyond the social determinants and that include factors, such as individual behaviors, lifestyles, and social responses to stress; biological processes, genetics, and epigenetics; the physical environment; the sociocultural environment; social determinants; and clinical events and interactions with the health care and other systems. Each of these health determinants plays an important role in health disparities and interacts in complex ways to affect an individual’s health. For example, African American/Black women and Latinas experience lower survival rates from triple-negative breast cancer than White women with the same disease—even with similar access to care, screening mammography, and insurance coverage—due to the lack of specialized screening and lack of viable treatment options available for this form of breast cancer.7

7 Ko NY, Hong S, Winn RA, Calip GS. Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer. JAMA Oncol. 2020;6(3):385–392.
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NIH and HHS Commitment
Healthy People 2020 envisions a society in which all people live long, healthy lives. The U.S. Department of Health and Human Services (HHS) aims to enhance the health and well-being of all Americans by providing effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services. In April 2011, HHS released the HHS Action Plan to Reduce Racial and Ethnic Health Disparities (HHS Disparities Action Plan), a comprehensive national strategy to reduce health disparities. The HHS Disparities Action Plan sets out five goals to help achieve the vision of a nation free of disparities in health and health care.
The mission of NIH, as part of HHS, is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability. In 2015, NIH released the NIH-Wide Strategic Plan, Fiscal Years 2016–2020, outlining a vision for biomedical research that capitalizes on new opportunities for scientific exploration and addresses new challenges for human health. The NIH Minority Health and Health Disparities Strategic Plan also aligns with the health promotion and disease prevention objective of the NIH-Wide Strategic Plan by advancing opportunities in biomedical research through evidence-based reduction of health disparities.

The NIH Minority Health and Health Disparities Strategic Plan follows the missions and goals outlined in these plans and addresses the current insufficient progress in improving MH and reducing HDs in the United States. The plan integrates NIMHD’s vision of an America in which all populations have equal opportunity to live long, healthy, and productive lives with NIH’s mission to seek fundamental knowledge of the nature and behavior of living systems and apply new knowledge to enhance health, lengthen life, and reduce illness and disability.
The NIH Minority Health and Health Disparities Strategic Plan represents a commitment by NIH to support research aimed at addressing the risk and protective factors that operate and interact on multiple levels to impact the well-being of HD populations. NIH is also committed to supporting research-sustaining activities— such as research capacity building, workforce development, outreach, and inclusion of minorities in clinical trials—that improve MH and reduce HDs, as well as activities that promote collaboration and dissemination in different fields.
The NIH Minority Health and Health Disparities Strategic Plan aligns NIH’s efforts to address MH and HDs with advancing scientific knowledge and innovation in the HHS Disparities Action Plan.

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Foundation for Planning
This strategic plan was created with the input of several NIH working groups, including teams of staff and researchers. To ensure that stakeholders at multiple levels were involved in this strategic planning process, NIMHD gathered input from experts within and outside of NIH. A few of these foundational activities are described below.
ƒ In FY 2012, during the Science of Eliminating Health Disparities summit, NIMHD conducted town hall meetings to collect data on critical minority health and health disparity research issues.
ƒ In FY 2015, NIMHD led an analysis of NIH’s portfolio of minority health and health disparities research to survey the status of both fields, analyze investments, and gauge gaps in the science or supporting structures.
ƒ During FY 2015 and FY 2016, NIMHD undertook a science visioning process to produce recommendations for advancing the fields of minority health and health disparities. Participating NIH staff and outside stakeholders suggested 10 priority recommendations each in defining etiologies and mechanisms, developing and evaluating interventions, and identifying innovative

methods from a wide range of needs, to reduce disparities and improve minority health. After review by the National Advisory Council on Minority Health and Health Disparities (NACMHD), the relevant recommendations were woven into the current strategic planning efforts, which include strategies beyond the visioning process and the Minority Health and Health Disparities Research Framework. Details are available in the American Journal of Public Health (AJPH) supplement New Perspectives to Advance Minority Health and Health Disparities Research.
ƒ During FY 2018, NIMHD held three virtual sessions and four listening sessions across the country to collect community-level input for the NIH Minority Health and Health Disparities Strategic Plan.
These activities—in coordination with NIH working groups and input from a range of NIH Institutes, Centers, and Offices—were reviewed by the National Advisory Council on Minority Health and Health Disparities (NACMHD) and provide the foundation for the NIH Minority Health and Health Disparities Strategic Plan.

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Structure of This Plan
FIGURE 1: NIH MH and HD Research Strategic Plan Priority Areas Framework

SCIENTIFIC RESEARCH
RESEARCH SUSTAINING
OUTREACH, COLLABORATION, & DISSEMINATION

Starting Line
Activities that will span 5 years

Building Momentum
Actvities that will continue for the next
5-10 years

Leap Forward
Visionary activities that will take up to
20 years

The NIH Minority Health and Health Disparities Strategic Plan 2021–2025 has been designed with three categories to represent a long-term framework: scientific research; research-sustaining activities; and outreach, collaboration, and dissemination to encompass the range of NIH’s MH- and HD-related work. Embedded in each category are goals that encompass up to 10 years of expected research. There are four research goals; three research-sustaining activities goals; and two outreach, collaboration, and dissemination goals.
This plan describes scientific goals with related research strategies and priority areas that represent key opportunities and needs to advance MH and HD research. Rather than reflecting a comprehensive listing of all relevant NIH activities, this plan describes how NIH can best advance minority health and health disparities research. Each goal is divided into strategies that are intended to capture strategic ways in which NIH can advance the sciences of MH and HD or develop key supporting structures. The priority areas consist of Starting Line and Building Momentum research efforts and activities that encompass MH and HD efforts across NIH. This plan includes 48 Starting Line activities that will span 5 years and 56 Building Momentum activities that will continue for the next 5 to 10 years (see Figure 1).
Eliminating health disparities is an indefinite priority for NIH, and NIH’s efforts in this space will continue well into the future. This plan lays out a focused vision for the next

10 years, specifying short-, intermediate-, and long-range research strategies and activities that will facilitate progress toward long-term goals.
These priority areas are described below:
ƒ Starting Line priority areas represent concrete, current efforts and initiatives aimed at improving minority health and/or reducing health disparities that are underway at NIH or with NIH partners.
ƒ Building Momentum priority areas represent concepts and potential initiatives for advancing the sciences of minority health and health disparities. These concepts include early ideas and initiatives being developed and considered for potential implementation.
ƒ Leap Forward priorities represent trans-NIH visionary goals that can have a significant impact on improving minority health or reducing health disparities in disease and disorders.
The NIH Minority Health and Health Disparities Strategic Plan 2021–2025 includes performance tracking and evaluation components to meet federal requirements. Most importantly, the plan aims to advance the science of minority health and health disparities and produce meaningful, measurable improvements in minority health and reductions in health disparities through the dissemination and implementation of both existing and novel scientific breakthroughs over the duration of the strategic plan and beyond.  

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