Addressing the Impact of Structural Racism and Discrimination on Minority Health and Health Disparities (R01 - Clinical Trial Optional)

Funding Opportunity Description Key Definitions for the FOA: Discrimination: A socially structured action that is unfair or unjustified and harms individuals and groups. Discrimination can be attributed to social interactions that occur to protect more powerful and privileged groups or institutions at the detriment of other groups. Racism refers to discrimination based on race or ethnicity. Structural discrimination refers to macro-level conditions (e.g., residential segregation) that limit opportunities, resources, and well-being of less privileged groups (Healthy People 2020, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/discrimination). Structural racism and discrimination (SRD): For the purposes of this FOA, SRD refers to structural racism and discrimination on the basis of race/ethnicity and/or other statuses, including but not limited to gender, sexual orientation, gender identity, disability status, social class or socioeconomic status, religion, national origin, immigration status, limited English proficiency, or physical characteristics or health conditions. NIH-designated Populations with Health Disparities: Racial and ethnic minorities, socioeconomically disadvantaged populations, underserved rural populations, and sexual and gender minorities in the U.S. (see https://www.nimhd.nih.gov/about/overview/). Background There is increasing recognition that racism and discrimination contribute to poorer health outcomes for racial/ethnic minorities and other populations that experience health disparities. In fact, all populations with health disparities experience increased exposure to racism and/or other forms of discrimination over the life course. There is also a growing societal recognition that racism and discrimination extend beyond the behavior of individuals to include SRD, which is embedded in historical societal, institutional, organizational and governmental structures through formal and informal processes, procedures, and practices that limit both opportunities and resources to segments of the population. SRD is supported by the power structures that exist in society and in the institutions that are most likely to influence health outcomes. Despite this enhanced awareness, racism and discrimination are not routinely included as determinants of health in biomedical research. Health research on racism and discrimination to date has largely focused on interpersonal interactions, and to a lesser extent, one specific form of SRD, residential segregation. Typically, such research focuses on the adverse health consequences of SRD exposures. Less research has explored the resilience among populations exposed to SRD or community strategies to resist or mitigate historic or contemporary SRD exposures. Additionally, intervention research has rarely emphasized reduction of SRD as a strategy to improve health and reduce disparities. Research on mitigation of SRD is needed to inform health care and social policies at all levels. Health research and interventions need to routinely incorporate constructs and measurement of SRD across multiple socioecological domains and levels of influence in order to improve minority health, promote health equity, and eliminate health disparities (see the NIMHD Research Framework for more information: https://www.nimhd.nih.gov/about/overview/research-framework.html). Examples of domains in which SRD may occur include, but are not limited to, the following: Organizational/Institutional: Organizational-level climate; workplace hiring, promotion, or disciplinary practices; academic tracking, stigmatization, school disciplinary and admission practices; tolerance of abuse/harassment; health care system practices. Neighborhood/Community: Housing or lending practices and property value assessments; zoning laws; neighborhood distribution of public transportation, green spaces, grocery stores, hospitals and emergency departments, and ambulatory health clinics; resource allocation for schools through local tax base; location of cellular towers for mobile access, highways and major thoroughfares, and industrial or waste sites; criminal justice profiling; police-involved violence;targeted social marketing of harmful or ineffective products; hate crimes. Societal: Criminal justice policies and sentencing practices, land/water use rights, self-governance or political representation for tribal communities and U.S. territories, immigration and asylum policies and procedures, gerrymandering, voter suppression laws or practices, religious and cultural discrimination, depiction or representation in national media and social media. Research Objectives This initiative will support intervention research to address the impact of SRD on minority health and health disparities. Research projects must address SRD in one or more NIH-designated populations with health disparities in the U.S. and should address documented disparities in health outcomes. Applications are expected to provide a justification for why the specific types of SRD included constitute SRD, such as how the racism or discrimination is structural rather than reflecting individual-level behavior and how the SRD results in differential treatment or outcomes for less advantaged individuals, groups or populations. For example, with a project examining discriminatory school disciplinary practices, documentation of different overall rates of student suspensions or expulsions by race/ethnicity would not be sufficient to label this pattern as SRD. However, different rates of student suspensions or expulsions by race/ethnicity for the same type of student behavior or violation could be evidence of SRD. Applications are also expected to provide a conceptual model identifying hypothesized pathways between the SRD and health outcomes. Potential health outcomes may reflect health status; health condition-specific or all-cause disability, quality of life, mortality and morbidity; biological measures that reflect cumulative exposures to and effects of SRD; health behaviors; or access to, utilization of, or quality of health care. It is also expected that projects will collect data on SRD beyond individual self-reported perceptions and experiences to include data at organizational, community or societal levels. Potential data sources for SRD may include but are not limited to U.S. Census data, birth and mortality records; health surveillance data; crime statistics; traditional and social media data, school-based or educational data; labor statistics; voting records; local, state, and Federal law and policies; home ownership covenants; and organizational/institutional mission statements, policy guidance, operating procedures, or other relevant documents. Projects are expected to involve collaborations with relevant organizations or groups or stakeholders, such as academic institutions, health service providers and systems, state and local public health agencies or other governmental agencies such as housing and transportation, criminal justice systems, school systems, patient or consumer advocacy groups, community-based organizations, and faith-based organizations. Multidisciplinary research teams, including researchers from areas outside of the health sciences, such as economics, education, history, criminology, law, and political science, are encouraged. Research projects may focus on health promotion, prevention services, and/or treatment of chronic condition. Interventions may focus primarily on addressing SRD to improve health outcomes, or SRD may be included as one of several determinants of health addressed to improve health outcomes. For both types of intervention approaches, interventions must directly address the cause or source of SRD, not just help individuals or populations to cope with SRD. To this end, it is expected that investigators will collaborate with leadership from organizations, agencies, or programs where the SRD is originating from or being sustained (e.g., a project addressing SRD in the workplace should involve organizational leaders, human resource managers, or other relevant personnel involved in establishing, maintaining, or enforcing workplace policies and practices rather than only involving employees within a workplace). It is also expected that interventions will involve other relevant personnel or individuals within the setting (e.g., teachers, clinicians, co-workers, bystanders) as appropriate to enact changes to SRD, not just those who are directly experiencing SRD. Research designs should allow for the assessment of mechanisms through which the intervention modifies SRD and how these changes result in improvement in the targeted health outcomes. Mechanisms of interest related to SRD include changes to behaviors, environments, or policies at the interpersonal, organizational, neighborhood/community, or societal level. Investigators who wish to evaluate the effect of an intervention on a health-related biomedical or behavioral outcome are strongly encouraged to use appropriate intervention study designs, such as a parallel group- or cluster-randomized trial, a stepped-wedge group- or cluster randomized trial, a rigorous quasi-experimental design such as a group- or cluster-level regression discontinuity design or an interrupted time-series design, or a rigorous alternative. Intervention designs that lack comparison conditions or sites (e.g., an intervention implemented in a single clinic or neighborhood) are strongly discouraged. Whenever participants are assigned to study arms in groups or clusters (e.g., families, clinics, schools, worksites, communities, counties, states) and observations taken on individual participants are analyzed for intervention effects, special methods are required for analysis and sample size. Methods consistent with plans for assignment of participants and delivery of interventions should be documented in the application. Additional information is available at ?https://researchmethodsresources.nih.gov/. Research designs comparing interventions with and without SRD components are encouraged. It is expected that the interventions will have potential for sustainability in the intervention setting after the project is over as well as scalability to be implemented in other settings. Applicants are strongly encouraged to assess social determinants of health using measures available in the Social Determinants of Health Collection of the PhenX Toolkit (www.phenxtoolkit.org), as appropriate.