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Goal F: Understand health disparities related to aging and develop strategies to improve the health status of older adults in diverse populations

Health Disparities are differences in any health-related factor — disease burden, diagnosis, response to treatment, quality of life, health behaviors and access to care, to name only a few — that exist among population groups. Health disparities are associated with a broad, complex, and interrelated array of factors, and may reflect:

  • Age
  • Race
  • Ethnicity
  • Socioeconomic status
  • Disability status
  • Identity and expression* (e.g.,gender, racial, ethnic)
  • Geographic location (e.g., rural or urban environment)
  • Education
  • Health care (e.g.,access, quality)
  • Culture (e.g.,norms, traditions, collective responses)
  • Health behaviors (e.g.,smoking, violence, substance abuse)
  • Biological (e.g., sex, chronic inflammation, telomere attrition, cellular senescence)
  • …Or a combination of these

In 2015, NIA developed and adopted its new “NIA Health Disparities Research Framework”) to stimulate the study of environmental, sociocultural, behavioral, and biological factors that influence health disparities related to aging. Many of these factors are broad, complex, and interrelated.

To address the contribution of these factors to health disparities related to aging, NIA has supported research, for example, that found Alzheimer’s disease to be more prevalent among African Americans and Hispanics than among other ethnic groups in the U.S. Other studies have found that lower socioeconomic status is associated with poorer health and reduced lifespan in the U.S. Scientists have also observed sex differences in health and longevity. For example, overall women live longer than men, but are more likely to develop osteoporosis or depressive symptoms or to report functional limitations as they age; men, on the other hand, are more likely to develop heart disease, cancer, or diabetes.

Social environmental factors such as residential segregation, discrimination, immigration, social mobility, work, retirement, education, income, and wealth can also have a serious impact on health and well-being. Economic circumstances can determine whether an individual can afford quality health care and proper nutrition from early life into old age. Individual and family financial resources and health insurance often determine whether an older adult enters an assisted living facility or nursing home or stays at home to be cared for by family members.

The causes of health disparities are dynamic and multidimensional, and to address them adequately, NIA will consider environmental, social cultural, behavioral, and biological factors. For this reason, NIA will use an integrative approach to motivating health disparities research related to aging.

Goal F objectives:

Approach

F-1: Identify and understand environmental, social, cultural, behavioral, and biological factors that create and sustain health disparities among older adults.

Many complex and interacting factors can affect the health and quality of life of older adults. For example:

  • Environmental factors related to income, education, occupation, retirement, and wealth may have a serious impact on key determinants of health over the life course and ultimately the health and well-being of older adults.

  • Social factors such as individual and structural forms of discrimination and bias can shape the everyday experience of individuals from minority or vulnerable populations.

  • Cultural factors can have a tremendous influence on approaches for managing stress, diet and food preferences, attitudes toward physical activity, and other critical health/coping behaviors.

  • Behavioral factors and psychological processes represent major pathways by which environmental and social factors affect health. Optimism, pessimism, and sense of control serve as risk or resilience factors for impacting health, while chronic stress exposure can enhance vulnerability.

  • Biological factors that are influenced by environmental and sociocultural factors — and transduced through behavioral processes — may alter the course, severity and acceleration of disease and disability.

All these factors and their interconnections must be understood to develop and implement effective interventions to address health disparities among various population groups. NIA will support and conduct research across diverse population groups to:

  • Gather data to further distinguish patterns of health disparities and causes.
    • Gather and analyze data on burdens and costs of illness, healthy life expectancy, longevity, and mortality trajectories. Determining the health burden and other costs of specific illnesses has always been difficult due to the lack of adequate data on incidence and prevalence as well as inconsistencies in calculating health and monetary costs. These difficulties are compounded across populations by differences in use of formal medical care and informal family caregiving. Projections of future healthy life expectancy, longevity, and mortality depend on assumptions about how groups of individuals will change over time, particularly as recent immigrants become culturally assimilated. This research will be archived in the best interest of all populations and will provide valuable information for projecting the specific needs for health care services within various population groups.
    • Support the development and wide sharing of data resources that are needed to conduct health disparities research related to aging. Research to understand health disparities requires that data from multiple sources be accessible in standard formats to researchers on a national level. NIA will continue to support and expand surveys of health disparity populations in order to provide the data needed by researchers and public policy makers, including cross-national, comparative, and historic research. We will provide access to these and related data for use in health disparities research and to inform policy development.
    • Develop comparable databases — including cross-national databases — on health outcomes, risk factors, and determinants of health disparities. Although many of the disparities in adult health and life expectancy across national, racial/ethnic, and social class boundaries are well documented, causal mechanisms are less well understood. Research to understand these differences will be critical to the development of behavioral and public health interventions.
    • Use ongoing data collection programs to oversample health disparities populations. These data will provide important information on socioeconomic factors, health care needs, collective cultural responses, social network characteristics, perceptions of stress and resilience, risk/coping behaviors, genetic stability, and other important factors.
       
  • Track and analyze reduced life expectancy and disease prevalence in diverse older adult populations.

    • Identify the determinants of disparities in the prevalence of diseases and conditions such as heart disease, obesity, hypertension, frailty, diabetes, comorbidities, and certain types of cancer. Researchers will explore the influence of contextual factors such as residential segregation, stress, education, language, and access to health care and how these may link with genetic, molecular, and cellular mechanisms to sustain differences across populations.

    • Determine the reasons for variation in the prevalence of cognitive decline and AD/ADRD across population groups. NIA will support research to better understand the differences in the prevalence of AD and related dementias among African Americans, Asians, and Hispanics compared to non-Hispanic whites. We will continue to examine a range of possible causes of these disparities, including the impact of comorbidities such as hypertension, cardiovascular disease, and diabetes; health behaviors; and disease processes. This research will draw on culturally appropriate and standardized measures to better understand these differences and to suggest culturally appropriate interventions.

  • Understand differences in aging processes across diverse populations. We will characterize normal and accelerated processes of aging in diverse populations to increase our understanding of the course of disease and disability and to identify similarities and differences.

  • Understand how environmental, sociocultural, behavioral, and biological factors lead to disparities in health at older ages and develop interventions to reduce those disparities. Health disparities persist within and across diverse racial, ethnic, and socioeconomic groups. Research is needed to understand the causes of these disparities and how they relate to relevant factors. Examination of cross-national research opportunities has the potential to provide increased knowledge of natural experiments in divergent aging experiences and aging policy developments that would inform a more general understanding in aging societies.

  • Explore mechanisms through which the effects of environmental and sociocultural factors manifest themselves, as well as critical periods for reversing such effects and/or the optimal timing of intervention. Specific groups of the U.S. population experience chronic socioeconomic disadvantage throughout their lives or for extended periods in life that generate persistent, chronic stress. The patterns of stress reactivity appear to hasten the progression of disease. It is therefore important to invest in research on the effects of discrimination, bias, stigma, and stereotypes, particularly the mechanisms through which these environmental and sociocultural factors become biologically embedded to influence health disparities.

  • Determine how environmental, sociocultural, behavioral, and biological determinants interact to increase risk of disease and disability. Environment, socioeconomic factors, and risk behaviors can all interact to influence biological influences and accelerate aging as well as the development, progression, and outcome of disease in populations groups. NIA will support research to learn more about risk factors for disease and preventive factors contributing to good health by researching these influences individually and in concert. We will place a special emphasis on longitudinal data to untangle the multitude of factors that affect health and well-being.

  • Determine the effects of early-life factors on health disparities among older adults. Differences in childhood socioeconomic status, stress exposure, risk/coping behaviors, disease incidence, environmental exposure, and health care in fetal development and early life can affect disease and disability in later life. NIA will support research to identify these early-life factors, as well as the mechanisms through which they influence health in later life. These findings can then be used to inform clinical and even policy interventions to reverse the effects of childhood disadvantage among older adults.

F-2: Develop strategies to promote active life expectancy and improve the health status of older adults in diverse populations.

Life expectancy has increased among all population groups; however, notable disparities remain. For example, African American men have the lowest life expectancy of all racial/gender population groups in the U.S. In addition, more adults are living with one or multiple chronic conditions that may not affect length of life but may dramatically affect quality of life, and significant disparities have been observed in this area, as well. For example, African Americans suffer disproportionately from hypertension and prostate cancer, and Hispanics suffer more from diabetes. NIA will continue to:

F-3: Develop and implement strategies to increase inclusion of underrepresented populations in aging research.

The ability to recruit and retain research participants that are representative of the total U.S. population is essential to the conduct of rigorous health disparities research related to aging. However, specific racial, ethnic and socioeconomic population groups have been underrepresented in health-related research, including clinical trials and population-based research. NIA will:

F-4: Support research on women’s health, including studies of how sex and gender influence aging processes and outcomes.

Older women outnumber older men in the U.S., and the proportion of the population that is female increases with age. In 2014, women accounted for 56% of the population ages 65 and older and for 66% of the population ages 85 and older. Despite living longer, however, older women are more likely to report depressive symptoms or limitations in physical function, are more likely to live alone (a potential indicator or risk factor for isolation, lack of caregivers, or lack of support), and live in poverty at a disproportionately high rate. American women also lag significantly behind their counterparts in other higher-income nations in terms of longevity, and since 1980, the pace of gains in life expectancy of older U.S. women has slowed markedly compared to that in other industrialized countries.

NIA supports a diverse portfolio of research on older women’s health, including studies on sex differences in the basic biology of aging; hormonal influences on cognitive health; women’s health across the life course, with a particular emphasis on the menopausal transition; sex and gender-related demographic disparities in older age; economic implications of sex and gender at older ages; and age-related diseases and conditions that are unique to or more common in women, such as osteoporosis, breast and ovarian cancer, and urinary tract dysfunction. In addition, we support initiatives to ensure that women are fully represented in NIH-supported research, including the Sex as a Biological Variable (SABV) and Inclusion Across the Lifespan policies. As part of our commitment to supporting research on women’s health, NIA will:

  • Support research to better understand effective strategies for communicating health messages that are appropriate in diverse populations. Because of language, educational, and cultural differences, disproportionately affected populations do not always receive important information about healthy behaviors. Research on communication with specific audiences will assist the development of appropriate health messages and dissemination channels; we will continue to communicate with diverse audiences in various ways.

  • Develop appropriate strategies for disease, illness, and disability prevention and healthy aging among the underserved. Aging Americans need understandable, culturally appropriate tools they can use to maintain and improve their well-being. For example, diet and physical activity recommendations may need to be adjusted to take into account religious, ethnic, and cultural sensitivities. To address these concerns, researchers will:

    • Develop and promote culturally appropriate interventions to improve healthy behaviors along with strategies to increase the likelihood that these interventions will be initiated and maintained.
       
    • Design and promote interventions appropriate for older adults in diverse populations to more effectively prevent, diagnose, or reduce the effects of disease.
       
    • Design and promote evidence-based and culturally appropriate strategies for self-management of chronic diseases.
       
    • Investigate the factors affecting medication misuse and culturally appropriate strategies for enhancing proper use and compliance with medication regimens.
       
  • Develop and disseminate interventions to improve culturally appropriate health care delivery. NIA will promote better access to appropriate preventive care and clinical treatment, earlier diagnosis, improved outcomes, and reduced health care costs in diverse populations by supporting the development, usage, and clinical translation of research findings.
     
    • Develop interventions that build long-term and meaningful relationships among community leaders and members to create trust and to understand the cultural limitations of interventions.
       
    • Develop interventions to reduce health disparities and inequities associated with poor provider-patient interactions. Recent studies have revealed that how older adults are diagnosed and treated is as much a function of who they are, who is treating them, and where care is provided as it is a function of the symptoms they present. NIA will investigate ways to ensure that each individual is treated with appropriate evidence-based interventions regardless of race, ethnicity, sexual orientation/gender identity, place of birth, or cultural background.
     

    • Develop training programs to prepare culturally proficient researchers. We will facilitate training of researchers in the biomedical, behavioral, and social sciences working with older adults to help them better understand the medical implications of the growing diversity of our population. Training programs will help prepare the next generation of health professionals by incorporating new materials sensitive to these issues and preparing a cadre of culturally competent health care providers prepared to assist with patient decision making.

    • Continue to support training for clinical and research staff in message development, recruitment strategies, and community and media outreach. NIA will explore effective ways to mitigate the difficulties associated with enrollment of health disparities populations in research studies and clinical trials. For example, Community Based Participatory Research methods may be used to address cultural and language barriers and encourage effective communication about the potential benefits of studies and trials that seek to address health disparities and improve public health in priority communities.

    • Investigate novel approaches for increasing recruitment and retention of underrepresented researchers pursuing careers in science, particularly health disparities research. NIA will work to identify the best strategies for training and attracting a diverse workforce of new, midcareer, and senior researchers. This may be important for evaluating important strategies — including those that account for cultural and geographic factors — to enhance the recruitment of underrepresented groups into aging research. We will continue programs to train high-quality researchers through flexible mechanisms that reflect the rapidly changing needs of science and provide cross-disciplinary training. NIA will also work to tap the talents of all groups of society by encouraging degree-granting institutions to establish and improve programs for identifying, recruiting, and training diverse groups of individuals for careers in biomedical science.

    • Engage broad segments of the U.S. population in research on Alzheimer’s disease and related dementias. As funding for AD/ADRD has increased, the need for more people to participate in relevant research has grown. In particular, an urgent need exists to engage underrepresented communities. Today’s participants in AD/ADRD research are mostly white, non-Hispanic, well-educated, heterosexual, and married, with a spouse study partner. However, studies point to significant differences between rates of AD in specific populations, for whom factors like diet, culture, genetic influences, geography, and medical conditions may play a role. Broadly diverse participation in both observational and clinical studies will help us to better define and address racial, ethnic, gender, and other differences so that interventions can be better tailored to communities and individuals. We will continue to provide resources and support to facilitate widespread engagement in our research studies.

    • Encourage research to understand sex and gender differences in health and disease at older ages.Sex differences in health, longevity, and response to various preventive and treatment interventions are well documented. For example, many of the compounds tested through the Interventions Testing Program demonstrate differential effects on male and female mice. We will accelerate research on the basic biology driving health differences between sexes. In addition, recent demographic and economic trends have gender-specific implications for health and well-being at older ages. Unmarried women, for example, are less likely than unmarried men to have accumulated assets and pension wealth for use in older age, and older men are less likely to form and maintain supportive social networks. We will support research to explain how these and other factors may contribute to the differences in life expectancy and disability rates among men and women at older ages.

    • Support research on sex and gender differences in cognitive decline and AD/ADRD etiology, presentation, prevention, and treatment. Recent estimates suggest that nearly two-thirds of individuals diagnosed with AD are female. At the same time, most studies conducted in the U.S. have not observed sex differences in the incidence of Alzheimer’s disease — that is, in the rate of developing the disease. This may be in part because women, on average, live longer than men. Other potential reasons for this are complex and may include differences in brain structure; possible differential effects of the APOE ε4 genotype, which is the most common genetic risk factor for late-onset disease; differences in education between men and women in the age cohorts currently at greatest risk; and effects of sex steroid hormones on the brain. NIA will continue to study possible AD/ADRD risk and protective factors in both men and women, the mechanisms through which estrogen and other sex hormones work on the brain, and the effects of different forms of menopausal hormone therapy on cognition.

    • Solicit and support research on topics that are uniquely relevant to the health of older women. Some age-related health issues — for example, menopause and certain types of cancer — are unique to women. Others, such as osteoporosis, are significantly more common in women than in men. We will support research designed to understand and address these conditions, with an additional focus, where appropriate, on how common diseases manifest and respond differently to treatment in women and men.

    • Support initiatives designed to ensure that women are fully represented in basic, translational, and clinical research. Data from the NIH Office of Research on Women’s Health suggests that women now account for roughly half of all participants in NIH-supported clinical research. However, basic and preclinical biomedical research frequently focuses on male animals and cells, which may obscure understanding of key sex influences on health processes and outcomes. NIH has adopted a stringent “Sex as a Biological Variable” policy stating that the organism’s sex will be factored into research designs, analyses, and reporting in vertebrate animal and human studies. NIA will continue to support this and other policies designed to ensure full representation of women in all levels of research.

    • Track, monitor, and report on participation of women in NIA-supported research, including adherence to the NIH SABV policy. We will continue to report on progress in this domain through programs currently active across the NIH.

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