F R O M C E L L S T O S E L V E S

Health Disparities

Bridging the Gap

U.S. Department of Health and Human Services

National Institutes of Health

Eunice Kennedy Shriver National Institute of Child Health and Human Development
Acknowledgement 

The National Institute of Child Health and Human Development would like to thank William Coupon 

of Coupon Worldwide, Inc., New York, New York, for the donation of the cover photographs. 
Health Disparities
 

Bridging the Gap
 
TABLE OF CONTENTS 

The NICHD Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
 

NICHD—Building Scientific Bridges to Health . . . . . . . .3
 

The NICHD Health Disparities Plan . . . . . . . . . . . . . . . . . .4
 

Building by Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
 

Scientific Areas of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
 

Important Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
 

The NICHD’s Unique 


Perspectives in Health Disparities . . . . . . . . . . . . . . . . . . .7 


INFANT AND MATERNAL MORTALITY AND MORBIDITY . . . . . . . . . 7
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
 

REPRODUCTIVE HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
 

Current Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
 

HIV/AIDS—TARGETING WOMEN AND TEENS . . . . . . . . . . . . . 15
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .16
 

EARLY ANTECEDENTS OF 


DISPARITIES IN DISEASE AND GROWTH . . . . . . . . . . . . . . . . . . .19
 

PART 1: UNDERSTANDING THE FETAL
 

MECHANISMS LEADING TO HEALTH DISPARITIES . . . . . . . . . . . . . . . . . . .19
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .20
 

PART 2: UNDERSTANDING DISPARITIES IN GROWTH
 

AND DEVELOPMENT—OBESITY AND NUTRITION . . . . . . . . . . . . . . . . . . 20
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .21
 

EARLY ANTECEDENTS OF CHILD 


WELL-BEING AND ADVERSE BEHAVIORS . . . . . . . . . . . . . . . . . .23
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .24
 

i 
TABLE OF CONTENTS continued 

SCHOOL READINESS, COGNITIVE 


AND BEHAVIORAL DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . . .27
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .28
 

RESTORING FUNCTION AND PREVENTING DISABILITY . . . . . . . .31
 

PART 1: PHYSICAL DISABILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .32
 

PART 2: DEVELOPMENTAL DISABILITIES IN CHILDREN . . . . . . . . . . . . . . . .32
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
 

Current Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
 

TRAINING AND CAREER DEVELOPMENT . . . . . . . . . . . . . . . . . .35
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
 

Current Training/Career Development Programs . . . . . . . . . . .36
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .36
 

PART 1: TRAINING AND CAREER DEVELOPMENT PROGRAMS . . . . . . . . . . .36
 

PART 2: OTHER ACTIVITIES TO ENHANCE PROFESSIONAL DEVELOPMENT . . . .37
 

OUTREACH TO COMMUNITIES AND THEIR INSTITUTIONS . . . . . .39
 

PART 1: ENHANCING PARTICIPATION OF
 

MINORITY COMMUNITIES IN THE DESIGN OF CLINICAL TRIALS . . . . . . . . . . .39
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
 

Current Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .40
 

PART 2: OUTREACH TO MINORITY
 

COMMUNITIES, YOUTH, AND THEIR INSTITUTIONS . . . . . . . . . . . . . . . . . .41
 

The Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
 

Current Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
 

Future Goals/Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . .41
 

Appendix—Roster of Advisors . . . . . . . . . . . . . . . . . . . . .43
 

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FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

The NICHD Mission
 

Since its inception in 1962, the National Institute of 

Child Health and Human Development (NICHD) has 

dedicated its research to understanding the dynamic 

biological, behavioral, and social processes that dictate 

physical, emotional, and cognitive growth. NICHD 

research starts early, from before conception through the 

transitions of infancy, childhood, and adolescence, 

which set the foundation for conditions, diseases, and 

behaviors that last a lifetime. The Institute creates the 

knowledge to understand the complex interplay of 

processes that transform cells into healthy functioning 

individuals, free of disease and disabilities. When this 

goal is not achieved, or achieved unequally by different 

groups, the NICHD mission is to understand why, and to 

develop remedies to ensure the healthy functioning of all 

infants, children, youth, and families. 

The NICHD mandate also includes addressing: 1) the 

biological, physical, social, individual, and community 

forces affecting population dynamics and human 

reproduction—many of these forces contribute to the 

earliest beginnings of health disparities; and 2) the 

science to help persons with physical disabilities restore, 

replace, enhance, and prevent decline in function. 

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F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

NICHD—Building Scientific Bridges to Health
 

Building Bridges . . . 

Building bridges to bring communities together takes 

conscious, dedicated, and collaborative effort. It 

requires a great understanding of the natural and 

manmade forces that interact over time. Construction 

must be thoughtfully and carefully designed, with 

foundations rooted in science, but firmly grounded in the 

communities to be served. 

In some ways, bridging, and more importantly 

eliminating, the gap in health disparities takes the same 

dedicated effort. Health disparities do not "just occur"; 

they develop over time as natural biological and 

behavioral forces interact with such factors as poverty 

and discrimination, and are modified by a variety of 

community, social, and economic forces. Closing the 

health disparity gap demands an indepth understanding 

of these processes and mechanisms as they interact over 

lifespans. Finally, it requires the conscientious design of 

interventions, rooted in science, but implemented through 

acts of individuals and communities working together. 

. . . That Span Generations 

Scientists believe that the best time to eliminate 

disparities may start well before birth and extend 

through the first decade of life. Although genetics and 

related biological factors may provide initial blueprints, 

numerous events and experiences from conception 

onward—be they biological, developmental, or social— 

interact with this "programming." How and when these 

factors interact may determine whether or not individuals 

start life on a healthy and fully functional path. No 

matter which path is taken, however, the cumulative 

effects of these events can last a lifetime or, as scientists 

now believe, can be passed down to future generations. 

Building on this premise, scientists, including many 

supported by the National Institute of Child Health and 

Human Development (NICHD), are poised to conduct 

basic and applied research that can help to eliminate 

health disparities. This is particularly true for eliminating 

some of our Nation’s most persistent health disparities, 

starting with infant and maternal mortality. As noted, 

the Institute’s mission combines a unique developmental 

perspective with critical partnerships to further the 

science underlying health disparities. 

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Health Disparities: Bridging the Gap 

The NICHD Health Disparities Plan
 

Building by Design 

To build the NICHD strategic plan concerning health 

disparities, the Institute drew from its existing, 

distinguished, and strong research portfolio aimed at 

eliminating health disparities. Reflecting the Institute’s 

mission, the unifying concept of the plan is development, 

starting before conception and continuing throughout the 

lifespan and across generations. The Institute’s long 

experience investigating the complex biological and 

environmental interactions that drive developmental 

processes is invaluable when clarifying the causes of 

racial and ethnic, and even community-based, 

disparities. By focusing and coordinating research on 

gestation and the early years of life, including the 

transitions into and out of adolescence and young 

adulthood, the NICHD can address not only the 

development, but the critical timing of preventive and 

therapeutic strategies. 

To build the strategic plan organizationally, the NICHD 

drew upon a vast array of professional and public input. 

Within the Institute, a working group that included more 

than 30 scientific, planning, and policy staff drew upon 

ongoing planning efforts; recent forums, workshops, 

conferences, and research findings; as well as 

discussions with researchers across the country to 

suggest initial goals and objectives. These were 

consolidated into a draft plan that was shared with 

executive staff within the NICHD and the National 

Institutes of Health (NIH). 

In addition, the draft plan was posted on the NICHD 

Web site to encourage broad public comment; it was 

also shared with our Council members and the Friends 

of the NICHD. At the same time, the Director of the 

NICHD sought input and guidance from a panel of 10 

national experts (see Appendix), representing a broad 

array of scientific and policy disciplines, as well as 

individuals who are authorities on, and have personal 

experience working with, health disparity issues. 

Panel members not only reviewed the content of the plan 

but suggested priorities among the many goals and 

initiatives, noting that the plan builds on the Institute’s 

strengths. This includes targeting research to the two 

most vulnerable stages of human development: 1) very 

early development, with a focus on perinatal outcomes 

and infant mortality, and 2) the transition from 

adolescence to adulthood, a period where youth may 

miss important developmental milestones due to a 

complicated mix of biological, behavioral, and social 

factors. The members also endorsed the blending of 

scientific approaches, ranging from those used in 

biology and clinical medicine to those used in the 

behavioral and social sciences. 

After all comments were consolidated and reviewed, the 

plan was revised and finalized. Although in printed 

format, this plan is a flexible blueprint that will guide 

new and ongoing activities, and one that will be 

continuously reviewed in light of scientific findings, 

advances, and resources. 

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Health Disparities: Bridging the Gap 

Scientific Areas of Interest 

For purposes of this strategic plan, the NICHD defines 

"health disparities" as including significant differences in 

health and developmental outcomes, particularly 

between and among racial and ethnic groups. 

For the NICHD, emphasis is placed on differences in 

health and developmental outcomes whose origins may 

start before pregnancy and extend into early adulthood, 

or that result directly from a range of physical 

disabilities, no matter when they occurred. Our goal is 

to understand the mechanisms by which these racial and 

ethnic differences occur in light of the complex 

interactions between basic biological processes and such 

factors as poverty, education, and "community" with its 

distinct geographic, environmental, and cultural realities. 

These differences can be both positive and negative. 

While much of the plan targets reducing or eliminating 

many of the negative differences, the NICHD recognizes 

the importance of understanding how and why some 

minority and ethnic populations have better health 

outcomes than others, especially given the many adverse 

situations in which they may live. This "paradox" is 

particularly apparent in some immigrant communities 

where, for example, data have shown that recent 

immigrant women may have better pregnancy outcomes 

on average than women who are the first generation of 

their families to be born in the United States. By 

understanding the mechanisms that contribute to this 

paradox, scientists can identify "protective" factors, both 

biological and otherwise, that lead to resiliency and 

provide the foundation for successfully bridging the gaps. 

As evident from the descriptions below, the scientific 

areas that form the plan’s framework are not only key to 

our mission, but represent significant disparities 

requiring immediate attention: 

A— INFANT AND MATERNAL MORTALITY AND 

MORBIDITY is a critical research area for the 

Institute. Eliminating health disparities in 

infant/maternal health is also a prime objective of 

our Nation’s public health policy. 

B— REPRODUCTIVE HEALTH, another area that is key 

to our mission, addresses biological and behavioral 

mechanisms that compromise the reproductive wellbeing of men and women, including many minority 

groups. It also includes issues affecting family 

planning and sexually transmitted disease, which 

are covered in Healthy People 2010, the update of 

the Nation’s health objectives developed by the U.S. 

Department of Health and Human Services (DHHS). 

C— HIV/AIDS—TARGETING WOMEN AND TEENS 

is a key NICHD research area from both a 

biological and behavioral perspective. Related to 

issues of reproductive health, this plan addresses 

the high impact of these conditions on women and 

youth of color in the United States. 

D— EARLY ANTECEDENTS OF DISPARITIES IN DISEASE 

AND GROWTH addresses the most important roots 

of health disparities (e.g., diabetes, heart disease, 

obesity) that start with prenatal and gestational 

mechanisms. It also addresses how early nutrition 

contributes to these differences. 

E— EARLY ANTECEDENTS OF CHILD WELL-BEING 

AND ADVERSE BEHAVIORS addresses how the 

development and well-being of children are affected 

by poverty, and other family and community 

factors, which in turn contribute to poor health 

outcomes and the disproportionate incidence of 

injuries and violence in many minority communities. 

F— SCHOOL READINESS, COGNITIVE AND 

BEHAVIORAL DEVELOPMENT addresses differences 

in acquiring basic cognitive and learning skills that 

keep minority youth from breaking the disparity 

cycle. Research in this area has attracted 

significant public interest and support. 

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FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

G— RESTORING FUNCTION AND PREVENTING 

DISABILITY is a unique, yet overlooked area that 

recognizes the special needs of minority families 

in overcoming the burden of physical or 

developmental disabilities. 

H— TRAINING AND CAREER DEVELOPMENT in all 

areas of research, particularly for minority 

researchers, scientists, and clinicians, will provide 

the critical human resources needed to improve the 

health of minority communities. 

I— OUTREACH TO COMMUNITIES AND THEIR 

INSTITUTIONS involves translating scientific findings 

concerning health disparities into a common 

language that enables communities to act upon 

them. It also implies participating, giving back to 

communities, and encouraging partnerships so that 

the Nation gets the best return on its research 

investments. 

Important Themes 

Although the following themes and issues may not be 

stated explicitly or repeated throughout the plan, the 

NICHD recognizes their importance when conducting 

research concerning health disparities. 

• A range of different types of research must be 

supported to address health disparities. This includes 

basic biomedical and behavioral studies to identify the 

primary mechanisms contributing to a particular 

health disparity, as well as any related clinical, 

intervention, and effectiveness studies. The Institute 

must also balance support of one-time-only projects 

with the need to support new, extensive, ongoing 

longitudinal studies that may help to explain the 

development of health disparities over time. Likewise, 

the NICHD must build upon successful existing 

research networks or projects in addition to 

developing initiatives that require investment in new 

research infrastructure. 

• The newest scientific breakthroughs, advances, and 

technologies, such as those stemming from genomics 

and from the newest imaging technologies, should be 

incorporated when appropriate and feasible in the 

design of health disparities research. 

• The heterogeneity of racial, ethnic, and other 

population groups characterized by poor health 

outcomes must be recognized and considered in 

designing research. Often these differences are linked 

to variations associated with cultural differences within 

a community, neighborhood, or geographic region. 

The most accurate indicators of successful 

interventions are likely to be those that can account 

for these differences. Often the disparities may reveal 

themselves in differences associated with various 

communities and their institutions, such as those found 

in a wide range of Native American and immigrant 

communities. The differences also may be found 

when comparing populations isolated by geography 

and resources. Similarly, family-based research and 

studies that span generations are useful in 

understanding health disparities, especially when 

examining the behavioral as well as genetic aspects of 

adverse health outcomes. 

• To be successful, support for health disparities 

research requires multidisciplinary and collaborative 

initiatives and partnerships, not only between other 

NIH institutes and offices that share our interests, but 

with other Federal agencies (e.g., Centers for Disease 

Control and Prevention, Health Resources and 

Services Administration, Agency for Healthcare 

Research and Quality, Indian Health Service, 

Department of Justice, Department of Education), 

nonprofit organizations, and advocacy groups. 

• In addition to the human and financial resources 

required to implement the plan successfully, the NICHD 

must set priorities guided by our unique strengths. 

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Health Disparities: Bridging the Gap 

The NICHD’s Unique Perspectives in Health Disparities 

A INFANT AND MATERNAL MORTALITY AND MORBIDITY 

The Facts 

• Infant mortality and related rates: 

◆ Despite a 16% overall decline in infant 

mortality over the last decade, the rate among 

African Americans remains more than twice 

that of Whites. 

◆ African American infants are more than twice 

as likely to be born low birth weight (LBW) and 

more than three times as likely to be born very 

low birth weight (VLBW) as White neonates. 

As a result, prematurity and LBW are the 

leading causes of death among African 

American infants, occurring at five times the 

rate of Whites. 

◆ By comparison, the overall rate of low birth 

weight for Hispanics, who have a slightly 

higher rate of poverty than African Americans, 

is about the same as it is for Whites. Overall, 

infants born to Asian mothers have the lowest 

infant mortality rates of any ethnic or racial 

group in the United States. 

◆ These overall rates vary broadly within racial 

and ethnic groups: Mothers of Puerto Rican 

origin were 57% more likely to have LBW 

infants than Mexican mothers; likewise, Filipino 

mothers were 67% more likely to have a LBW 

infant than Chinese mothers. 

• Causes of disparities/prematurity: 

◆ Researchers suggest that one-third of premature 

births could be due to infection/inflammation. 

◆ The prevalence of certain infections varies by 

race, e.g., the incidence of bacterial vaginosis 

is 2.5 times higher among African American 

women than among White women. 

◆ Infection resulting in preterm delivery is much 

more common at earlier gestational ages. 

◆ While the poverty rate in African Americans is 

more than twice the rate of Whites, studies show 

that differences in infant mortality and morbidity 

rates cannot be explained by inequalities in 

social or economic circumstances alone. 

• Maternal mortality/morbidity in the United States: 

◆ Although maternal mortality rates have 

decreased dramatically, maternal death is four 

times higher among African American women 

than among White women, and is often 

preventable. 

◆ Ectopic pregnancy and preeclampsia are the 

number one and number two leading causes of 

maternal mortality and the leading causes of 

maternal mortality in African American women. 

◆ The risk for pregnancy-related mortality is 

1.6 times higher for women of other races than 

for White women. 

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FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

• The NICHD supports an extensive portfolio of basic, 

clinical, and behavioral research targeting prenatal, 

perinatal, and postnatal events and processes that 

ultimately influence pregnancy and maternal health 

outcomes among minorities. 

• The NICHD supports the Maternal-Fetal Medicine Unit 

and the Neonatal Research Networks, with the 

ultimate goal of reducing disparities in infant/ 

maternal mortality rates. Many of the sites are 

located in inner cities serving predominately African 

American and Hispanic populations. 

Current Research 

• Much of the Institute’s current research in this area 

targets racial and ethnic minority populations, and 

addresses issues that can help to reduce these 

health disparities. 

Examples of many targeted efforts include: 

◆ Studies on antibiotic treatment for bacterial 

vaginosis in African American women. 

◆ The "Initiative to Reduce Infant Mortality in Minority 

Populations in the District of Columbia" (or, the 

"D.C. Initiative"), which is co-funded with the Office 

of Research on Minority Health and targets 

interventions to the District’s minority population. 

◆ The Sudden Infant Death Syndrome (SIDS) "Back to 

Sleep" campaign and activities with partner 

organizations from the African American 

community and other racial and ethnic groups. The 

goal is to develop culturally sensitive campaigns 

that can help to eliminate the disparity in the 

prevalence of back-sleeping for African American 

infants within 3 years of the new outreach program. 

◆ Studies that analyze the disparity in medical, 

behavioral, and external SIDS risk factors for 

African Americans and Native Americans. 

◆ "The Puerto Rico Maternal and Infant Health 

Project," which examines factors leading to health 

disparities in the Puerto Rican community, 

and projects targeting the Mexican American 

population to discern factors leading to favorable 

pregnancy outcomes. 

◆ The Maternal Lifestyles Study (MLS), which is 

examining the developmental outcomes of infants 

exposed to drugs in utero and conducting important 

comparative analyses by racial/ethnic group. 

◆ Various studies concerning maternal mortality that 

examine such topics as the impact of diabetes, 

hypertension, stress, nutrition, and partner violence 

on pregnancy outcomes; many of these studies 

target minority women. 

Future Goals/Objectives 

Goal 1: Build upon the NICHD’s extensive 

intramural and extramural research portfolio to answer 

critical questions on health disparities in infant and 

maternal health. 

• Develop a program to supplement grants most likely to 

yield immediate answers to critical biological and 

behavioral questions targeting differences in infant 

and maternal mortality and major morbidities. This 

will help to increase the representation of diverse 

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FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

racial and ethnic groups in ongoing studies, and
 

findings can be used to develop further targeted
 

research. This effort will include methodological
 

seminars and workshops. 


Goal 2: Better understand the etiology, 

pathophysiology, and related social and behavioral 

factors, specifically leading to preterm births and low 

birth weight. 

• Significantly expand the scope of current efforts in the 

NICHD’s intramural Perinatal Research Branch (PRB). 

This would allow the PRB to relocate to an area and 

institution that serves significantly large numbers of 

high-risk and minority patients, expand opportunities 

for minority clinical fellowships, and more quickly 

translate findings into immediate use. 

• Clarify the biologic and social etiologies of health 

disparity in preterm births and in adverse neonatal 

outcomes associated with infectious/inflammatory 

disease processes, through multidisciplinary, 

collaborative research, and by augmenting current 

Network protocols. Target biologic factors associated 

with the disease process that might be specific to 

African American women. 

• Develop and implement clinical trials to prevent 

preterm births and adverse neonatal outcomes 

associated with infectious/inflammatory disease 

processes in minority women. Test different 

treatment regimens, as well as preventive and 

counseling strategies. 

• Identify genetic factors that may predispose women 

and their infants to preterm birth and low birth 

weight, targeting racial/ethnic populations. Some 

areas of interest would include genetic markers or 

genetic differences that may influence implantation 

and fetal growth. 

• Expand the D.C. Initiative with new interventions, 

targeting African American and Hispanic teens 

that simultaneously address psychosocial and 

behavioral risk factors to prevent preterm births and 

low birth weight. 

• Increase research training opportunities concerning 

health disparities in the perinatal period through the 

Specialized Clinical Investigator Development Award, 

which is a mentored research program operating in 

the NICHD clinical networks. 

Goal 3: Eliminate the disparate prevalence of risk 

factors in the sleep environment that ultimately influence 

the significant disparity in SIDS rates between racial and 

ethnic groups. 

• Expand the intensive community-based outreach 

campaign with minority populations to reduce risks in 

the infant sleep environment. These risks include 

sleeping on the stomach, sleeping on soft mattresses 

or sofas, and using quilts and pillows. Continue 

related evaluation activities. 

Goal 4: Create unique research infrastructures to 

help eliminate the racial/ethnic disparities in the causes 

of postneonatal mortality/morbidity rates, and 

conditions of infancy and early childhood associated 

with less than optimal birth outcomes. 

• Create a research infrastructure, linked to communitybased institutions, addressing the unique health needs 

of minority communities, that will 1) conduct basic 

research and design multidisciplinary interventions 

addressing poor outcomes from late pregnancy 

through early childhood, 2) provide opportunities for 

community-based research training, and 3) provide 

research-based information to the community. 

The research would simultaneously emphasize how 

9 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

community, family, and socioeconomic status shape 

the biological processes that govern health 

and development. 

• Collaborate with the National Institute on Alcohol 

Abuse and Alcoholism to examine factors leading to 

the pathogenesis of poor fetal and infant outcomes 

among American Indians and Alaskan Natives. 

Assess high prevalence of drinking during pregnancy, 

fetal alcohol syndrome, related pathologies, and 

possible association with SIDS. 

Goal 5: Target research efforts to reduce the 

significant disparity in adverse maternal events, 

including maternal mortality between racial and 

ethnic groups. 

• Target research to better understand the basic 

physiologic mechanisms leading to ectopic pregnancy 

and preeclampsia. Use this knowledge, combined 

with social/cultural data, to design targeted 

interventions to improve pregnancy outcomes for 

minority women. 

• Support collaborative research to create a national 

database of maternal deaths that would capture 

information from medical histories, autopsies, and 

forensic investigations of deaths among women of 

childbearing age. Based on analyses, develop 

appropriate medical care protocols and plans for 

prevention strategies. 

Goal 6: Collaborate with other agencies in their 

efforts to identify critical differences in quality of 

perinatal, maternal, and infant care that may lead to 

disparities in maternal and infant health outcomes. 

Identify factors and design immediate actions. 

• Support collaborative research symposia, program 

assessments/reviews, and other efforts to identify 

quality-of-care factors and develop interventions or 

remedial actions. Work with the Agency for 

Healthcare Research and Quality, other DHHS 

agencies, and community and professional groups. 

10 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

B REPRODUCTIVE HEALTH
 

The
 Facts 


• The permanent consequences of reproductive 

choices and disease burden fall disproportionately 

on women, particularly in the African American 

community, where many households formed 

by these choices are headed by women and live 

in poverty. 

• Women who are poor (under 100% of the Federal 

poverty level) have an unintended pregnancy rate 

that is twice the national average. 

• Puberty occurs approximately one year earlier in 

African American females compared with White 

females. Therefore, the reproductive health needs 

and associated emotional, social, and cultural 

effects of puberty may require earlier 

monitoring, treatment, and/or intervention than 

previously thought. 

• Although unintended pregnancy rates have 

declined overall, the unintended pregnancy rates 

remain high for some minorities: Nearly 1 in 10 

African American women and 1 in 14 Hispanic 

women of reproductive age experience an 

unintended pregnancy each year. 

• 12 to 18 million or 20 to 30% of all women of 

reproductive age have leiomyomata uteri, or 

uterine fibroids. African American women are 

diagnosed with fibroids up to two to three times 

more frequently than White women. Uterine 

fibroids, which can severely limit a woman’s 

reproductive options, remain the number one 

reason for hysterectomy. 

• The overall disparity in sexually transmitted 

disease (STD) rates is enormous. For example: 

◆ In 1998, the rate of gonorrhea remained 30 

times greater for African Americans than for 

Whites, and 3 times greater for Hispanics. 

While part of this disparity is due to the fact 

that African Americans are more likely to seek 

care in public clinics, which generally report 

STDs better than private providers, other 

important factors contribute to this disparity, 

including poverty, social networks, and healthseeking behaviors. 

◆ The adolescent gonorrhea rate is 4.6 times 

that of the total population, and the 

adolescent chlamydia rate is 6 times that of the 

total population. 

◆ The 1998 gonorrhea rate among African 

American adolescents ages 15 to 19 was 23 

times higher than it was for White adolescents 

in the same age range. Among 20- to 24­

year-olds, the gonorrhea rate among African 

Americans was almost 27 times greater than 

among Whites. 

◆ In 1998, the rate of congenital syphilis was 30 

times higher among African American infants 

and nine times higher among Hispanic infants 

than among White infants. Although 

completely preventable, congenital syphilis 

can cause serious physical deformities and 

mental retardation. 

11 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

Current Research 

• The NICHD supports basic, clinical, behavioral, and 

demographic studies concerning the mechanisms, 

treatments, outcomes, and behaviors that allow 

individuals to safely and effectively regulate their 

fertility, alleviate infertility, prevent STDs, and 

overcome a range of diseases/disorders of the 

reproductive system. 

• Many ongoing studies emphasize health disparity 

issues. For example, researchers are studying: 

◆ Comparative risk of hormone replacement therapy 

for uterine fibroids in both African American and 

White women. 

◆ Risk factors to help predict ectopic pregnancy more 

definitively and quickly. This is key to eliminating 

this leading cause of maternal death among African 

American women. 

◆ Cultural, psychological, and other predictors of 

unintended pregnancy in racially and ethnically 

diverse, and low-income groups. 

◆ The social context of teen’s health-promoting and 

risk behaviors, and interventions to help prevent 

unwanted pregnancies—especially among 

minority teens. 

Future Goals/Objectives 

Goal 1: Reduce disparities in unwanted pregnancy 

by understanding and better addressing the barriers to 

appropriate contraceptive services. 

• Support a special program effort, "Improving 

Contraceptive Services to Minority Women," to better 

understand the barriers that exist in minority 

populations, to encourage effective use of 

contraception and to design culturally, socially, and 

age-appropriate interventions. Efforts will include 

12 

basic studies to identify specific sources of risk and 

tailor strategies to meet these needs. 

• Support a new phase of the D.C. Initiative, specifically 

the protocol to develop an intervention program to 

delay sexual activity, and extend the program to 

children in the preadolescent years, their parents, and 

young males. 

• Support research on the factors leading to infertility 

among minority men and women and the reasons for 

lower use of infertility services in minority populations, 

leading to improved strategies for infertility prevention 

and treatment. 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

Goal 2: Support major research efforts to address 

the causes of excess reproductive morbidity among 

African American women. 

• Expand basic science and translational research 

studies of uterine fibroids to understand the biological 

reasons for increased incidence in African American 

women, and to determine whether there is a familial 

predisposition to this condition. 

• Develop a cooperative clinical treatment network to 

improve the diagnosis and management of uterine 

fibroids, including ways to reduce surgical 

interventions. Encourage involvement of communitybased practitioners to aid in recruitment and to ensure 

diversity in the teams conducting such research. 

• Expand current Women’s Contraceptive and 

Reproductive Experiences (CARE) Study to allow 

researchers to analyze racial/genetic differences in 

breast cancer risk and oral contraceptive use. 

Goal 3: Improve prevention, screening, and 

treatment of STDs, addressing the needs of different 

racial and ethnic populations, and to reduce disparities 

in reproductive health and in pregnancy outcomes. 

• Expand investigator-initiated research on behaviors 

related to the prevention and treatment of STDs, 

emphasizing sociocultural perspectives and beliefs 

concerning STDs and related barriers to prevention as 

a critical step in designing interventions. 

• Support multidisciplinary collaborative research on 

barriers that prevent minority women from being 

appropriately diagnosed and treated for STDs such as 

syphilis, and then passing the disease on to infants. 

Design effective interventions to help reduce 

preventable cases of congenital syphilis. 

Goal 4: Strengthen reproductive research 

infrastructure at minority institutions. 

• Develop an enhanced research infrastructure in the 

reproductive sciences that will address the needs of 

minority researchers through the Specialized 

Reproductive Science Research Centers at Minority 

Institutions Program. This will encourage 

collaborations between scientists at minority 

institutions and other NICHD-funded programs. 

13 
FROM CELLS TO SELVES 

15 

Health Disparities: Bridging the Gap 

C HIV/AIDS—TARGETING WOMEN AND TEENS 


The Facts 

• Despite stabilization of overall incidence rates in 

the United States, HIV transmission and the 

incidence of new AIDS cases have increased for 

such subpopulations as women and youth, 

particularly those of color. 

◆ Worldwide, 90% of new infections are through 

heterosexual transmission, placing women at 

increased risk of infection; most of these new 

infections occur in minority women. 

◆ In the United States, by the end of 1998, 57% 

of women with AIDS were African American 

and 20% were Hispanic. Of women newly 

diagnosed with HIV, 81% were African 

American or Hispanic. Emerging data suggest 

that some aspects of HIV disease in women 

differ markedly from those in men. 

◆ HIV infection rates continue to rise for American 

youth. In addition, in 1998, the majority of 

reported AIDS cases for youth between ages 13 

and 19 are among youth of color—57% 

African American and 23% Hispanic. 

◆ A similar percentage distribution characterizes 

young adults ages 20 to 24, many of whom 

likely acquired their infections as teens. In 

addition, the expanding HIV/AIDS epidemic 

among teens is increasingly female and 

sexually transmitted. 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

Current Research 

• Over the decade, the NICHD has fostered a range of 

clinical, applied, translational, and behavioral 

research to: 

◆ Define the epidemiology and natural history of HIV 

infection in women, infants, children, and 

adolescents (e.g., support of the Women and Infants 

Transmission Study). 

◆ Provide national clinical networks to rapidly 

advance prevention and treatment in trials primarily 

serving minority patients, including the 

1) Pediatric and Maternal HIV Clinical Trials 

Network and 2) Adolescent Medicine HIV/AIDS 

Research Network (AMHARN). 

◆ Develop microbicides/spermicides to allow women, 

particularly in vulnerable or high-risk relationships, 

to protect themselves from unwanted pregnancy and 

HIV infection. 

◆ Design and evaluate effective behavioral 

interventions, particularly targeting minority 

populations, many in inner-city areas. 

• Examples of some targeted studies include: 

◆ Studies assessing the transferability of successful 

interventions targeting minority youth in one 

location (e.g., African American youth on the 

Eastern Seaboard) to those in another (e.g., 

Hispanic youth in Texas). 

◆ The design and evaluation of interventions to 

improve minority women’s and couples’ skills at 

negotiating behaviors that can prevent both 

unwanted pregnancy and HIV infection, and to 

increase their consistent and correct use of 

protective behaviors. 

Future Goals/Objectives 

Goal 1: Expand and intensify HIV prevention efforts, 

targeting sexual transmission and related high-risk 

behaviors, in racial/ethnic minority populations. 

• Design, implement, and evaluate interventions based 

on the science of social/sexual networks to help 

prevent the sexual transmission of HIV, especially in 

high-risk communities, including minorities and teens. 

• Support research to link social and cultural 

understandings of gender, gender-related beliefs and 

expectations, and gender dynamics, to account for 

how these factors may influence HIV risk among 

different racial, ethnic, and socioeconomic groups. 

• Support research to better understand the impact of 

demographic and social trends (i.e., changes in family 

structure, marriage, and labor rates) on sexual 

behaviors related to HIV risk in different racial and 

ethnic populations. 

• Support research to better understand the influence of 

interpersonal and peer-related factors on HIV risk in 

different racial and ethnic populations. 

• Strengthen partnerships with institutions based in 

racial and ethnic communities, to develop more 

effective, research-based, HIV intervention programs 

(particularly targeting high-risk sexual behavior) that 

are closely linked to community needs, while 

generating new scientific data. 

• Support research to understand how the media 

differentially targets, represents, and exposes 

minority populations to messages involving high-risk 

behaviors that can place these populations at risk for 

HIV infection. 

16 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

Goal 2: Lead scientific efforts to better understand 

the pathogenesis of HIV infection among minority 

women, and tailor protocols, treatments, and regimens 

to their needs. 

• Develop and support the Women’s HIV Pathogenesis 

Program to better understand the causal relationships 

between HIV pathogenesis and factors unique to 

women (such as their reproductive physiology), 

directing studies to answer questions in minority 

populations. Investigate ways to improve the 

recruitment and retention of minority women in these 

studies and assess how their participation may 

influence behavior change. 

Goal 3: Lead research to develop more effective 

means of preventing and treating HIV in minority youth, 

using multidisciplinary and developmentally appropriate 

methodologies and resources. 

• Initiate an Adolescent Trials Network (ATN) to develop 

collaborative, primary prevention studies, as well as 

studies of effective and appropriate antiretroviral 

therapy in adolescent, high-risk, primarily minority 

populations. This would include support of Project 

ACCESS (Adolescents Connected to Care, Evaluation, 

and Special Services), a social marketing program to 

encourage teens to access health care and, if 

appropriate, enrollment in clinical studies. 

17 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

D EARLY ANTECEDENTS OF DISPARITIES IN DISEASE AND GROWTH 

Part 1: Understanding the Fetal Mechanisms Leading to Health Disparities 

The Facts 

• Scientists believe that inequalities in health start 

with the earliest prenatal and gestational 

mechanisms. Not all of these events are under 

genetic control. 

◆ The early interactions between fetal, maternal, 

and external factors may explain much of the 

health disparities seen in adult rates of 

hypertension, obesity, diabetes mellitus, and 

coronary artery disease. 

◆ These interactions may lead to fetal 

"programming" contributing to changes that 

may be transmitted across generations, and 

perpetuating disparities. 

• Fetal conditions such as small-for-gestational-age 

and intrauterine growth retardation are important 

biomarkers since these conditions are associated 

with increased risk of diabetes, obesity, coronary 

artery disease, and hypertension, which occur 

disproportionately in African American 

populations. 

◆ Birth weight is the most reliable index of fetal 

growth. Depending on their age, African 

American mothers are up to two-thirds more 

likely to have a previous preterm or small-forgestational-age infant. 

19
 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

Current Research 

• The NICHD supports basic and clinical research to 

understand "fetal programming" and many factors 

that perturb fetal development in utero through 

research on pregnancy and perinatology, 

developmental biology, and related studies. 

◆ Many studies in this area target low-income or 

minority women, and include research on maternal 

behaviors (smoking/drug use) that influence the 

intrauterine environment; the impact of diabetes and 

hypertension on pregnancy, birth, and later health 

outcomes; and the impact of prenatal nutrition, 

maternal stress, and other external factors on 

pregnancy outcome. 

Future Goals/Objectives 

Goal 1: Support research to understand the fetal 

antecedents of and biomarkers for disparities in 

hypertension, stroke, diabetes, and coronary artery 

disease. Use findings as a basis for prenatal and early 

intervention programs targeting special populations. 

• Support studies to identify how intrauterine growth 

retardation and deficient intrauterine environments 

influence the developing fetus, providing the basis for 

future chronic disease. Define "normal" fetal growth, 

and identify other biomarkers as they apply to 

minority and nonminority groups. 

• Determine whether maternal/fetal responses to 

external stimuli vary between racial/ethnic groups. 

Examine physiological response to stress, identify 

biological and genetic factors that account for 

differences, and identify other factors (e.g., history of 

small babies) to serve as markers or potential points 

for intervention. 

• Support a prospective, multiagency, longitudinal, 

cohort study to understand the many factors 

(biological, psychosocial, physical/environmental, 

behavioral) contributing to differential health outcomes 

over the lifespan. This will include up to 400,000 

participants and capture events that predate 

conception. It will also examine critical chronic and 

episodic events, including environmental exposures, as 

well as survey and biologic data to relate external 

events to physiological changes. Comparisons will be 

made across racial and ethnic groups. 

Part 2: Understanding Disparities 

in Growth and Development— 

Obesity and Nutrition 

TheFacts 

• Good nutrition must start early and is essential for 

optimal growth and development, and for preventing 

conditions (such as obesity or heart disease) that can 

start early in life. 

• Achieving good nutrition is complicated, given 

biological mechanisms/genetic predisposition, 

and social, cultural, emotional, economic, and 

geographic factors. 

◆ Risk factors for diet-related diseases vary based on 

gender, age, race, ethnicity, and income; obese 

children may be at even greater risk for developing 

obesity-related conditions (e.g., hypertension, Type 

2 diabetes, heart disease, gall-bladder disease). 

◆ The disparity in obesity is greatest among lowincome teens, where the percentage of obese teens 

is twice that for middle/upper-income teens. Young 

African American females (6 to 17 years old) are 

50% to 60% more likely to be overweight than 

young White females. 

20 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

◆ The increase in obesity rates is fueling an epidemic 

of Type 2 diabetes appearing in Hispanic and 

Native American teens. 

◆ Despite strong recommendations on the importance 

of breastfeeding, only 43% of African American 

women choose to breastfeed their newborns, 

compared with 66% of Hispanic and 68% of White 

women. This may place African American infants 

at a disadvantage for a healthy start. 

Current Research 

• The NICHD supports research concerning the early 

biological, developmental, nutritional, and behavioral 

mechanisms underpinning growth, nutrition-related 

diseases and conditions, complemented by social, 

cultural, and behavioral studies. Some targeted 

studies include: 

◆ Identifying risk factors for obesity-related 

complications in African American women— 

researchers have already identified differences in 

fat distribution and metabolism. 

◆ Developing innovative means to prevent obesity 

among African American adolescent females living 

in rural areas. 

◆ Developing childhood metabolic markers of adult 

morbidity in African Americans. 

Future Goals/Objectives 

Goal 1: Better understand the interaction between 

the biology of nutrition and growth with social and 

cultural forces to help prevent the early onset of 

health disparities. 

• Expand NICHD research addressing African American 

teenage women, to understand the genetic, 

physiologic, metabolic, and behavioral characteristics 

leading to their increased risk of obesity; provide 

training opportunities for minority researchers in these 

clinical studies. 

• Support research to assess factors that influence the 

calcium intake of different ethnic/racial groups, 

targeting children and teens, with particular 

reference to social, cultural, and ethnic influences on 

food preference. 

• Identify how social and cultural factors interact with 

food availability to influence the development of 

dietary habits in infancy through adolescence. Assess 

the impact of these habits on disparities in obesity and 

other chronic conditions, particularly in Hispanic and 

Native American teens; include research on 

biomarkers, dietary supplements, and complementary 

feeding practices. 

Goal 2: Eliminate the disparity in the percentage of 

African American women who choose to breastfeed 

their infants. 

• Support research to understand the social, cultural, 

and behavioral factors that influence the decisions of 

women of various racial/ethnic subpopulations to 

breastfeed their infants and to continue breastfeeding 

throughout the first year of life. Target barriers 

that may exist in different racial and ethnic 

communities; share data to design interventions/ 

education programs. 

21 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

E EARLY ANTECEDENTS OF CHILD WELL-BEING 


AND ADVERSE BEHAVIORS 


The Facts 

• Racial and ethnic disparities in the development 

and well-being of children are striking 

when examined in relation to poverty and 

family structure: 

◆ In 1996, African American and Hispanic 

children were four times more likely to live in 

poverty than White children. 

◆ In 1996, children living in female-headed 

households were five times more likely than 

those in intact families to live in poverty; most 

African American and Hispanic children live in 

female-headed households. 

◆ Low-income minority children face a 

disproportionate array of problems, including 

low birth weight, contagious diseases, and 

childhood injury and death. Thus, these children 

are at greater risk for developmental delays and 

social/emotional and behavioral problems. 

• The well-being of our youth, especially in minority 

communities, is also being threatened by 

increasing rates of unintentional and intentional 

injuries or violence. 

◆ Unintentional injuries account for over 40% of 

deaths in children ages 1 to 4, and 80% of 

deaths in young adults 15 to 24 years of age. 

◆ Death rates are high among minority children 

and adolescents for certain causes, e.g., Native 

American teens have disproportionately higher 

death rates from motor vehicle crashes than 

other racial/ethnic groups. Many of these 

deaths are preventable. 

• Violence in the United States is pervasive. 

◆ On average, nearly 3 million children are 

reported as suspected victims of child abuse or 

neglect, and nearly 1,000 die from such 

maltreatment. A disproportionate number are 

minority youth. 

◆ Up to 20% of women report violence during 

pregnancy; at least 3 million children witness 

domestic violence each year, while millions 

more witness violence in their communities. 

Minority and low-income women and children 

are at increased risk. 

◆ Homicide has reached epidemic proportions 

for African American youth. Homicide rates 

for teens (ages 10 to 14) are three to four 

times greater than for Whites; they are eight 

times greater for older African American 

adolescent males. 

• Unstable family structure may have additional 

adverse consequences. Infant deaths due to 

abuse are 3.4 times greater in the African 

American and 3.5 times greater in the Native 

American population than among Whites. 

These rates are also higher for infants born to 

African American teenage mothers who are 

living in unstable family situations. 

23 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

24 

F

Current Research 

• The NICHD supports collaborative multidisciplinary 

research to clarify how biological, social, and 

behavioral processes interact with socioeconomic 

status (SES) to produce these health disparities. 

• Many data collection and longitudinal studies examine 

national child health trends to inform policymakers, 

develop research agendas, and develop interventions. 

Many oversample minority populations to make 

comparative analyses and study disparities. 

◆ Notable efforts include the National Longitudinal 

Study of Adolescent Health and the annual 

production of America's Children: Key National 

Indicators of Well-Being. 

• Other targeted efforts include studies concerning: 

◆ Changes in child care, child support policies, 

welfare reform policies, and medical care 

availability as they affect differences in family and 

child health outcomes. 

◆ How family and individual acculturation affects 

health care outcomes in various immigrant 

populations, particularly those of Hispanic origin. 

◆ New methods and models to help predict 

differences in such outcomes as birth rates, birth 

weights, infant mortality, adult mortality, STDs, and 

even gunshot wounds. 

◆ The family and developmental origins of behaviors 

that place youth at risk for unintentional injury 

and violence. 

• Next, researchers must further clarify and 

better understand: 

◆ How SES, family structure, and parenting combine 

with other factors to produce disparities in 

developmental outcomes, child neglect and abuse, 

and unintentional injuries. 

◆ The antecedents of and impact of violence on 

development, starting in infancy through 

early adulthood. 

◆ How these patterns change over time and vary 

across racial/ethnic groups. 

uture Goals/Objectives 

Goal 1: Understand how the relationships between 

poverty, single-parent families, and related factors affect 

childhood well-being for minority children. Encourage 

targeted interventions to strengthen family support 

systems and sense of connectedness. 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

• Extend the "Science and Ecology of Early 

Development" (SEED) program, which is examining 

the complex interactions of poverty with other factors 

that influence developmental outcomes and resilience 

in children and families. Link studies to the evaluation 

of government intervention programs. Use the 

initiative to create an ongoing dialogue between 

researchers, policymakers, and program officials. 

• As a followup to the NICHD conference on Parenting 

and the Child’s World, encourage researchers to focus 

on the roles of parents in promoting healthy 

development, particularly among children of different 

racial/ethnic backgrounds and sociocultural settings. 

Examine how parenting interacts with a variety of 

other factors to influence children’s social, moral, 

emotional, and cognitive development in these 

different settings. 

• Expand support of the Early Head Start Fathers studies 

and the Early Childhood Longitudinal Study—Birth 

Cohort, to determine the antecedents, consequences, 

and meaning of parental involvement, program 

intervention, and other social/community factors, for 

child outcomes including health, social, and cognitive. 

• Collaborate with the CDC’s Healthy Futures Program, 

targeting White, African American, and Hispanic 

youth to determine the developmental path of health 

risk behaviors and adverse health outcomes. 

Goal 2: Identify antecedent and etiologic factors, 

and understand complex interactions between social, 

cultural, biological, and developmental processes, which 

contribute to intentional and unintentional injury, 

violence, and other adverse health outcomes for 

minority youth. Use data to design, implement, 

and evaluate programs that promote healthful and 

preventive behaviors. 

• Support interagency efforts to encourage research on 

injury prevention and emergency services for children 

affected by injuries, disabilities, illness, or violence. 

Clarify factors that place minority youth at greater 

risk, and develop effective preventive interventions. 

• Lead trans-NIH efforts to develop a research definition 

and taxonomy concerning child neglect, ensuring that 

the definition considers the impact of social and 

cultural norms. 

• Support research to examine the social, parental, and 

other antecedents of child neglect and abuse, while 

also determining the consequences of this behavior. 

Also identify the factors protecting infants and young 

children from neglect and abuse, with a focus on 

racial and ethnic differences. Include basic research 

in these efforts and the design and evaluation of 

parenting interventions to reduce rates of infant deaths 

due to such abuse. 

• Examine, through multidisciplinary studies, the 

developmental antecedents, causes, and health 

consequences of unintentional injuries in childhood 

and adolescence, addressing environmental, social, 

and cultural factors that lead to racial/ethnic 

disparities, especially among Native American and 

Hispanic populations. 

• Collaborate with the NIH Child Abuse and Neglect 

Working Group in developing a formal program to 

supplement ongoing projects that address child 

developmental processes in high-risk settings and 

violent/abusive environments. 

• As part of the NIH Youth Violence Consortium, 

develop a comprehensive, collaborative effort to 

understand the antecedents, etiology (e.g., social, 

neurobiologic, cognitive, and academic), and 

outcomes of violent behavior in youth, with the goal of 

identifying different pathways among various racial 

and ethnic groups. 

25 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

• Support a collaborative effort to understand the 

immediate and long-term impact of domestic violence 

during pregnancy, and children’s exposure to 

domestic and community violence. Address 

differential risk factors and impact across racial and 

ethnic groups. 

Goal 3: Train and encourage more minority 

researchers to address these health disparity issues that 

affect the long-term well-being of minority families. 

• Create research/training opportunities at Historically 

Black Colleges and Universities (HBCUs), and 

universities with a cadre of Hispanic and Native 

American Indian researchers for minority researchers 

to examine: 1) ways to strengthen parenting and a 

sense of connectedness between minority children, 

parents, families, schools, and communities; 

2) unintentional injury; and 3) violence prevention. 

Include special outreach workshops. 

26 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

F SCHOOL READINESS,
 

COGNITIVE AND BEHAVIORIAL DEVELOPMENT
 

The Facts 

• Children’s early cognitive/behavioral development 

is key to later success in life; however, 1998 data 

show that African American, Hispanic, and 

American Indian students in 4th, 8th, and 12th 

grades were nearly twice as likely to perform 

below basic levels in reading. Similar disparities 

exist in math and science. 

• By 2030, Hispanic children will comprise onefourth of the Nation’s total student population; yet, 

data show that: 

◆ Young Hispanic children lag behind White 

children in early school-related skills. 

◆ Many Hispanic American students are below 

grade level, which contributes to their higher 

dropout rates: e.g., 28% of Hispanic 16- to 

24-year-old students dropped out of school, 

more than double the rate for African 

Americans (14%) and three times that for nonHispanic Whites (8%). 

• Data show that children living in poverty (many of 

whom are minorities) have smaller vocabularies at 

early ages and their vocabulary growth rate is less 

than that for more advantaged children. These 

early differences translate into disparities in later 

vocabulary use and IQ test scores, measures often 

used to predict future success at school and work. 

• Low literacy also appears to play a role in the 

disparities affecting those children raised in 

poverty, many of whom are minority children. Of 

Hispanic and African American students, one-half 

or more of 4th and 8th graders, and one-third of 

12th graders, read at or below the basic level 

necessary to read to learn. A large percentage of 

these students’ parents are not high school 

graduates, indicating that adult/family literacy 

may be a factor. 

27 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

Current Research 

• The NICHD supports basic, applied, and translational 

research addressing all facets of children’s 

development from infancy into early adulthood. 

◆ This includes studies on the neurological/biological, 

cognitive, emotional, behavioral, social, cultural, 

and related factors contributing to language 

development and disorders, attention deficit 

disorders, mathematical cognition, problem-solving, 

reading disabilities, and other learning disabilities. 

• Many studies address lower socioeconomic and 

minority populations: 

◆ The NICHD pioneered studies to develop and 

evaluate programs like Head Start. Current 

studies are examining a father’s impact on 

development, and how program interventions can 

strengthen a father’s involvement, across racial/ 

ethnic communities. 

◆ The Institute supports a range of collaborative and 

data collection activities, such as the Early 

Childhood Longitudinal Study—Birth Cohort, which 

oversamples minority populations to help analyze 

health disparities in developmental outcomes 

associated with school readiness. 

◆ In other studies, researchers are trying to: 

1) understand how sociocultural factors influence 

English reading and writing abilities for Spanishspeaking children; 2) develop cross-cultural norms 

to aid early diagnosis of abnormal developmental 

patterns; 3) clarify family factors that influence early 

school performance among Latino children; 4) learn 

how racial/ethnic discrimination impacts academic 

motivation, school performance, and problem 

behaviors; and 5) learn how school-based 

interventions can promote achievement for at-risk 

youth in economically depressed and rural areas. 

◆ Early data from the NICHD/District of Columbia 

Public Schools Early Interventions Reading Project 

show that the program has significantly improved 

the reading levels of extremely high-risk, primarily 

minority, children. 

Future Goals/Objectives 

Goal 1: Identify barriers to school readiness and 

academic success for minority and low-income children; 

examine the effect of barriers in language, cognitive, 

and behavioral development and the subsequent and 

cumulative effect on school readiness. Design 

appropriate developmental interventions to ensure 

optimal development and optimal school readiness for 

these children. 

• Identify whether linguistic barriers exist for nonEnglish-speaking ("language minority") children. 

Address cognitive, developmental, and social/cultural 

factors to design appropriate interventions to ensure 

school readiness for these children. This includes 

studies addressing adult and family literacy. 

• Determine factors that contribute to disparities in 

mathematics acheivement and how best to address 

them. Address cognitive, developmental, and 

social/cultural factors on a child’s ability to learn 

mathematical concepts and information. 

28 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

• Identify the unique developmental and linguistic 

challenges facing children of migrant workers, an 

often overlooked subset of children living in poverty. 

Define which aspects of their unique living 

environment might be advantageous in educating 

them, and the specific aspects of their living 

environment and lifestyle that are most likely to lead to 

disparities in their physical, linguistic, cognitive, and 

social-emotional development. 

• Identify the interactions among biobehavioral, social, 

environmental, and community stressors leading to 

minority disparities in academic achievement and 

dropout rates among minority adolescents. Develop 

effective multidisciplinary interventions for reducing 

these disparities during the critical developmental 

period of adolescence. (See also Section E. 

Early Antecedents of Child Well-Being and 

Adverse Behaviors.) 

29 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

G RESTORING FUNCTION AND PREVENTING DISABILITY 

Part 1: Physical Disabilities 

The Facts 

• Minorities suffer a disproportionate incidence of 

trauma and illnesses, such as stroke, that lead to 

permanent disabilities. These disabilities add a 

double social, economic, and health burden to 

many minority families already at a disadvantage 

(e.g., minority victims of spinal cord injury are 

2.8 times less likely to resume employment after 

injury than their White counterparts). 

• Patients from minority groups access and utilize 

outpatient rehabilitation services less frequently 

than White patients. 

• Preliminary data indicate that there may be no 

differential response of minority patients to acute 

rehabilitation interventions; however, these 

findings need further review. 

31 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

Current Research 

• The NICHD’s medical rehabilitation research program 

addresses many issues that could help reduce the 

excessive disability burden on minorities, such as 

research to: 1) improve functional mobility, 2) promote 

behavioral adaptation to functional losses, 3) develop 

improved assistive technologies, 4) develop more 

precise methods of measuring societal and functional 

limitations, and 5) train minority researchers. 

• The NICHD supports many stroke and spinal cord 

injury studies with large percentages or oversamples 

of minority participants; other studies lend themselves 

to such oversampling, especially those dealing with 

pediatric trauma. 

• More research is needed to examine the issue of 

differential response to rehabilitation strategies. 

Future Goals/Objectives 

Goal 1: Improve rehabilitation outcomes for racial 

and ethnic minorities, building on newly established 

research programs. Identify specific social, cultural, and 

community factors that may lead to differences in: 

1) responses to disabilities and to rehabilitation 

interventions, 2) access and use of outpatient 

rehabilitation services with varying impacts on health 

outcomes, and 3) risks in developing secondary 

conditions associated with disabilities. 

Goal 2: Acquire basic data and develop 

appropriate interventions to reduce the double burden of 

being a racial/ethnic minority individual or family with 

a permanent disability. Build on newly established 

programs to identify specific barriers that impede racial 

and ethnic minorities from returning to work, reintegrating 

themselves into the community, and returning to school 

and to other educational opportunities. 

• Supplement newly established sites in the Regional 

Rehabilitation Network (which integrate basic science 

with clinical rehabilitation studies) to link with minority 

institutions to address targeted questions concerning 

minority populations. 

• Supplement grants stemming from a new initiative to 

encourage researchers developing innovative 

rehabilitation interventions, with the goal of targeting 

the needs of racial/ethnic minority families. 

• Supplement new clinical rehabilitation networks 

targeting pediatric trauma and traumatic brain injury, 

to understand how socioeconomic, cultural, and other 

external factors influence short- and long-term 

rehabilitation outcomes. 

Part 2: Developmental Disabilities 

in Children 

TheFacts 

• Having children with developmental disabilities puts a 

disproportionate burden on minority families. Early 

data from an NICHD-supported study suggest that the 

divorce rate for families of young children with 

disabilities may be twice as high among African 

American families as it is for similar White families. 

• Data suggest that the stigma associated with having a 

child with a developmental disability varies across 

racial and ethnic groups. This ultimately influences 

access to health services and health outcomes. 

32 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

Current Research 

• The Institute leads research efforts serving the needs of 

children, adults, and families with developmental 

disabilities, defining the etiology, pathophysiology, 

and epidemiology of these conditions. The NICHD 

also funds significant intervention research to aid the 

early diagnosis and treatment of developmentally 

delayed children. 

• Some targeted research includes studies: 

◆ Addressing Hispanic families of children with 

mental retardation, to understand their unique 

psychosocial problems and how they are influenced 

by social/cultural experiences, beliefs, goals, needs, 

resources, and strengths. 

◆ Comparing culturally diverse, primarily low-income, 

ethnic families whose children may be at risk for 

developmental delay or related maladaptive 

behaviors. Researchers are examining how family 

adaptation varies among cultural groups and 

influences "resiliency." 

◆ Examining the early home and school events of 

Hispanic children at risk for educational and 

developmental disabilities; the effects of 

acculturation on the home environment of Asian 

American children with developmental delay; and 

the unique factors that may account for different 

outcomes among developmentally disabled adults 

from both African American and White families. 

Goal 1: Promote stability in racial/ethnic families 

with disabled children by designing and implementing 

research-based interventions based on the special needs 

of these families. Address the father’s role in influencing 

health outcomes of disabled children and understanding 

various social/cultural factors that may increase the risk 

for adverse family outcomes. 

• Develop a multisite collaborative program to design 

and evaluate interventions to promote stability within 

families of disabled children. Assess data from 

ongoing studies and acquire range of racial/ethnic 

data as needed; design interventions with community 

advice/input; focus on those minority families where 

children with disabilities do well, to determine what 

particular factors or interactions of factors contribute 

to such successes. 

33 
FROM CELLS TO SELVES 

H TRAINING AND CAREER DEVELOPMENT
 

35 

Health Disparities: Bridging the Gap 

The Facts 

• Eliminating health disparities demands the same 

type of talent pool that exists to address our other 

science and engineering research needs. In 

particular, researchers are required who 

understand the needs of the community that this 

science is meant to serve. 

• Providing the opportunity to network and meet 

with NIH and NICHD officials is also key to 

furthering the careers of minority researchers. 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

Current Training/ Career Development

Programs 

• The NICHD actively evaluates and makes 

recommendations on funding of Research Supplements 

for Underrepresented Minorities, and facilitates 

communication among minority investigators, at all 

levels, to help them advance their careers. The 

Institute also participates in the: 1) MARC Visiting 

Professors for Minority Institutions Program, 

2) Minority High School Student Research Apprentice 

Program, and 3) Minority Biomedical Research 

Support Program. 

• NICHD’s small grants (R03) program offers 

opportunities to new investigators or those from 

institutions without well-developed research traditions 

or resources, to begin independent research. One 

goal is to encourage researchers from 

underrepresented institutions and institutions that do 

not traditionally apply to the NICHD, to initiate 

research programs or expand their research interests. 

• The Institute works with minority institutions to increase 

applications from their students to the NICHD summer 

Intramural Research Training Award (IRTA) program 

and the Summer Internship program. 

• To encourage networking and enhance our 

commitment to the minority researchers that we 

support, the Institute sponsors biennial meetings for 

these investigators. The meetings highlight the 

significance of the Minority Supplement Program, by 

recognizing their achievements as promising 

researchers, and by allowing them to meet personally 

with program and executive staff. 

Future Goals/Objectives 

Part 1: Training and Career 

Development Programs 

Goal 1: Build on the strength of the NICHD’s existing 

Institutional Training Programs (T32s) in the 

demographic behavioral, reproductive, maternal/child 

health, and rehabilitation sciences, which already target 

health disparity research issues. Expand these programs 

to better link to the minority communities that we serve. 

• Target additional slots (in the short term) for existing 

T32s, institutional training programs, to pursue health 

disparities research, particularly targeting scientific 

areas outlined in this strategic plan, and encouraging 

the recruitment of minority researchers. 

• Add a third level of NICHD review to substantively 

evaluate minority recruitment plans prior to making 

funding decisions for new or recompeting T32 grant 

applications. Re-rank the applications based on an 

additional score reflecting the strength of the 

applicant’s minority recruitment plans. 

• Encourage existing T32 programs to form consortia 

with Historically Black Colleges and Universities 

(HBCUs), Hispanic Serving Institutions (HSIs), tribal 

colleges, and schools in underserved areas to provide 

opportunities for students to train at the parent site. 

Goal 2: Provide coordinated national clinical 

research opportunities for minority investigators and for 

persons seeking to conduct research on health disparity 

issues of importance to the NICHD. 

36 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

• Build upon the NICHD’s existing clinical research 

networks to create additional research training 

opportunities, in sites located throughout the country, 

for minorities and others wishing to pursue clinical 

health disparities research. 

• Create a program to assist minority investigators in 

developing competitive research proposals (R01s) 

targeted to minority communities through 

long-term, intensive training in research methodology 

and grantsmanship, and the establishment of 

formal mentoring relationships between senior and 

new faculty. 

Goal 3: Build on the strength of NICHD’s existing 

career development programs in reproductive 

maternal/child health and the rehabilitation sciences to 

provide additional opportunities for minorities who are 

interested in pursuing health disparity research. 

• Target new slots to existing K12, Mentored Research 

Scientist Development Program Awards, particularly 

encouraging minority researchers to pursue health 

disparities issues outlined in this strategic plan. 

• Support "Scholar" positions in the Building 

Interdisciplinary Research Careers in Women’s Health 

(BIRCWH) program, where investigators have been 

asked to address health disparity issues. 

Part 2: Other Activities to Enhance 

Professional Development 

Goal 1: Expand and strengthen incentives to aid 

and further encourage more racial and ethnic minority 

students to enter research careers. 

• Encourage professional societies to help with outreach 

to local minority students in cities where conferences 

are held by supplementing conference grants, 

providing direct support or, if necessary, starting a 

new grant program. 

37 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

I OUTREACH TO COMMUNITIES AND THEIR INSTITUTIONS 

Part 1: Enhancing Participation of 


Minority Communities in the Design of Clinical Trials
 

The Facts 

• The NIH Revitalization Act of 1993 mandated 

outreach to minority groups for recruitment into 

clinical trials. Much has been learned about 

enhancing minority recruitment, but more needs to 

be learned and applied. 

• Clinical researchers need adequate numbers of 

women and minorities in clinical studies to enable 

them to detect and account for the significant 

differences in health status between racial and 

ethnic groups where they exist. 

• Impediments to recruiting women and minorities 

into clinical trials include: 

◆ Reduced income, lower educational levels, 

reduced access to quality health care 

information and services, and impoverished 

living environments. 

◆ Lack of awareness of opportunities to 

participate in clinical trials, enrollment criteria, 

or enrollment mechanisms. 

◆ A shortage of minority biomedical scientists to 

recruit and effectively communicate with 

potential research participants. 

39 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

Current Outreach 

• NICHD clinical trial networks customize recruitment 

and retention strategies to the needs of individual 

studies: 

◆ Phase III trials related to perinatal transmission and 

to gynecologic manifestations of HIV infection are 

located in minority community facilities, such as 

Harlem Hospital in New York and Howard 

University Hospital in Washington, D.C. Day care 

and transportation expenses are paid; some sites 

provide meals for the women and children when 

clinic visits require a full day. 

◆ Researchers conducting intervention studies for 

high-risk pregnant women and their infants reduce 

the number of trips required by study subjects by 

scheduling clinical trial visits with other medical 

care appointments at the same treatment facility. 

Connections to social services provide "one-stop 

shopping" and incentives to keep appointments. 

◆ In rural areas, investigators travel to outlying clinics 

and community centers, some even make home 

visits to hard-to-reach populations. 

Future Goals/Objectives 

Goal 1: Ensure the enrollment of a greater number 

of individuals from various racial and ethnic minority 

communities in clinical trials. Ensure that the Institute’s 

intramural and extramural investigators understand 

community characteristics and needs, receive adequate 

training and guidance, and communicate information 

about the trials to appropriate health care providers and 

to the community. 

• Support research using focus groups and increased 

interactions with health care and patient 

representatives from the communities in which new 

clinical trials are planned to: 1) apprise the 

community of the nature and scope of the research, 

2) build the community’s trust in the research effort, 

and 3) ensure that the trial design adequately meets 

community needs and concerns. Apply appropriate 

social marketing and outreach techniques to enhance 

recruitment where necessary. 

• Enhance training opportunities for intramural and 

extramural investigators in designing and conducting 

trials, and in outreach techniques, to better meet the 

needs and concerns of racial and ethnic populations. 

• Establish a committee to develop guidance for NICHD 

intramural and extramural staff in the design, 

implementation, and evaluation of clinical trials that 

seek to recruit minority subjects. Use guidance to 

enhance extramural staff interaction with investigators 

initiating trials in these populations, working to 

supplement their current population base, or falling 

short of expected recruitment/retention levels. 

Intramural investigators will be given guidance and 

suggestions when conducting their clinical trials. 

• Continue to expand the cadre of minority researchers 

in scientific areas addressing our mission to increase 

the availability of clinical researchers who are able to 

communicate with research subjects in a manner they 

can understand and trust. (See also, the training and 

career development objectives above.) 

40 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

Part 2: Outreach to Minority 

Communities, Youth, and 

Their Institutions 

TheFacts 

• Getting children engaged in the world around them 

and their own health is a first step in feeding the 

pipeline for biomedical research scientists of the 

future. It is also the first step in sparking the 

interest of children, their families, and their 

communities to take active steps to safeguard or 

improve their own health. 

• It is important to encourage scientists to periodically 

take stock of their research accomplishments, and to 

consciously translate their research findings not only 

to fuel the next scientific discovery, but to improve 

public health. 

• We need to listen to various communities and learn 

about their information needs and health concerns, 

and reflect these needs when we develop our 

research priorities. 

Current Outreach 

• In 1991, the NICHD "adopted" Highland Elementary 

School, where 89% of the students come from minority 

populations (primarily Hispanic, African American, 

and Asian American), and where 60% of the children 

qualify for free or reduced price lunches. The NICHD 

activities include: 

◆ The Scientist Volunteer Program, where individual 

scientists visit classrooms, help teachers to design 

projects, and work with children to promote their 

appreciation for health-related topics and the 

scientific method. 

◆ "Presentation Day," where intramural and 

extramural scientists and staff members visit and 

speak on health topics. 

◆ A pen pal program, providing support for many 

children throughout the school year. 

◆ Tutoring for individual children with special needs. 

◆ Participation in programs to help the school acquire 

needed computers and technologies. 

Future Goals/Objectives 

Goal 1: Work with children and the educational 

systems, particularly those serving racial/ethnic 

communities, to enhance their interest in and excitement 

about science and health. 

• Enhance NICHD’s pioneering efforts to partner with 

local schools and educators, and to work with children 

from disadvantaged and minority backgrounds. 

• Enhance the NICHD Web site by adding a "children’s 

corner" targeted to the interests of young children, 

their parents, and teachers. The site will be designed 

to be attractive for children, reflecting their interests 

and providing health information which is both 

culturally and age appropriate. 

Goal 2: Actively identify and translate NICHD 

research findings important to various minority 

communities to help them and their health care 

providers obtain and use research-based information. 

Actively seek the advice of communities in preparing 

these materials. 

• Support the analysis and synthesis of research findings 

most relevant to minority communities, developing 

materials useful to providers and members of 

racial/ethnic communities. Areas in which new 

41 
FROM CELLS TO SELVES 

Health Disparities: Bridging the Gap 

targeted materials will be developed in the short term 

include: 1) nutrition for pregnant mothers and for 

children and teens, 2) reading and related school 

readiness issues, and 3) parenting. Also, expand 

efforts to publicize the NICHD Clearinghouse in 

minority communities. 

• Through targeted research studies, focus groups, and 

working with community leaders and organizations, 

determine future information needs and gaps among 

various racial, ethnic, and disadvantaged 

communities, particularly in areas addressed in 

this plan. 

Goal 3: Increase awareness of the scientific 

community and policymakers to the issues outlined in 

this plan, and help translate interest into viable NICHD 

research efforts. 

• Support the development of targeted issue papers, 

articles, speaker series, and forums to translate the 

newest NICHD scientific findings and projects 

addressing health disparities into implications for 

health care researchers, health care providers, 

policymakers, and community/advocacy groups. For 

example, sponsor regular symposia and develop 

summer scientific/policy internships, linking whenever 

possible to HBCUs, HSIs, and similar institutions. 

• Identify a coalition of members of the minority 

community, as well as health care providers, 

foundations, and others that serve the minority 

community to: 1) advise and assist the NICHD in 

developing goals for health disparities research 

through a planning process, 2) assess the Institute’s 

success in meeting goals/objectives, and 3) generally 

provide a sounding board for minority community 

issues related to health needs, research, and outreach. 

Goal 4: Ensure that the NICHD, and the researchers 

we support, actively contribute to the communities 

standing to benefit from our research. 

• Determine the feasibility of developing and 

implementing a standard policy that requires both 

intramural and extramural recipients of NICHD 

research funds to assess and translate their research 

findings into media that will help educate the local 

communities in which they reside or serve. Materials 

should be proactively and regularly shared with 

local communities. 

• Lead and expand support for activities that allow the 

NICHD to participate in local community health 

activities and functions, particularly those serving 

minority and economically disadvantaged 

populations, around the country. 

42 
F R O M C E L L S T O S E L V E S 

Health Disparities: Bridging the Gap 

Appendix—Roster of Advisors
 

Although this planning document has benefited from the 

input of the public and of many scientists within and 

outside the NICHD, we wish to particularly note the 

advice of the following panel of advisors convened by 

the Institute Director. 

Robert H. Bradley, Ph.D. 

University of Arkansas 

PonJola Coney, M.D. 

Southern Illinois University 

Elena Fuentes-Afflick, M.D., M.P.H. 

San Francisco General Hospital 

University of California, San Francisco 

Robert Goldenberg, M.D. 

University of Alabama, Birmingham 

Ruby Hearn, Ph.D. 

The Robert Wood Johnson Foundation 

Karen Hendricks, J.D. 

American Academy of Pediatrics 

Bette R. Keltner, Ph.D., R.N., F.A.A.N 

Georgetown University 

Kristin Moore, Ph.D. 

Child Trends, Inc. 

Karen Rothenberg, J.D., M.P.A. 

University of Maryland School of Law 

Penelope Trickett, Ph.D. 

University of Southern California 

43 
For addtional copies of this publication...

Or, for a list of scientific contacts and resources, 

please contact us at:

NICHD Information Resource Center

1-800-370-2943

Fax: 301-984-1473

Mail: P.O. Box 3006, Rockville, MD 20847

E-mail: NICHDInformationResourceCenter@mail.nih.gov

Internet: http://www.nichd.nih.gov/publications/

For additional information about other NICHD strategic plans 

and research, visit the NICHD Web site at: http://www.nichd.nih.gov.
September 2000

Reprinted June 2003