Populations at risk: a critical need for research, funding, and action.

About 20 years ago I was a young college senior applying to medical school. I remember being interviewed by a stately, gray-haired, white-coated professor of pediatrics who was close to retirement. I told him that I was eager to address the problems of the medically underserved, but I wondered whether the major clinical, research, and policy challenges of populations at risk would be largely solved by the time I finished my training. The professor smiled at my naivety and told me that unfortunately these problems were unlikely to go away in the near future. He confidently reassured me that the next generation of physicians would step up to the plate when it was our turn. Fast forward to 2005 and we are now in the midst of a critical era for populations at risk. The latest U.S. Census Bureau report estimates that 45 million Americans have no health insurance,1 and overall the policy environment is concerning for the poor and vulnerable. Expansion of health services in some areas is likely. President George W. Bush's proposed 2005–2006 budget earmarks $304 million more for the community health center program, and the massive Medicare prescription drug benefit is scheduled to begin in 2006. However, tax cuts for the rich and the war in Iraq have led to relative reductions in most of the budget not related to either defense or homeland security, including Medicaid, food stamps, preventive health, chronic diseases, and obesity.2,3 Historically in difficult times, the parts of the budget that are deleted or reduced are the ones that provide for the politically weak, including many of the populations at risk for poor health outcomes. This issue of the Journal of General Internal Medicine contains six articles in the Populations at Risk section that show the breadth of issues relevant for these groups while simultaneously exemplifying the relative lack of research in other key areas. These gaps in knowledge highlight the types of papers that will be the highest priority for the Populations at Risk section over the next 5 years. Most studies about populations at risk can be categorized into three groups: 1) description of disparities in access to care, quality of care, and outcomes; 2) mechanisms of disparities; and 3) interventions to reduce disparities. Mohanty et al.'s analysis of Asian Indians with National Health Interview Survey (NHIS) data is an example of a purely descriptive study.4 Asian Indians had higher odds of diabetes and nonsignificantly lower odds for coronary heart disease compared with non-Hispanic whites. An extensive literature documents health disparities,5 and the Agency for Healthcare Research and Quality's (AHRQ) National Healthcare Disparities Report will regularly supply national data.6,7 However, some groups and clinical areas remain relatively understudied and thus opportunities for new descriptive studies remain. Rangel et al.'s paper documenting lower influenza vaccination rates in Hispanics and non-Hispanic blacks compared with non-Hispanic whites in the NHIS combines elements of description and mechanism.8 Disparities still remain after controlling for a variety of demographic and structural predisposing and enabling access to care indicators. Karliner et al.'s survey of women in San Francisco looks at mechanism of disparities in breast cancer in more detail than is possible in most large general national datasets such as the NHIS.9 The investigators found that 51% of the women with suspicious abnormalities on mammogram did not understand that their result was abnormal. Women who were notified of their result in person or by telephone were more likely to understand that the result was abnormal compared to women notified in writing. Barragan et al. 's paper spans the realms of description, mechanism, and intervention.10 They found that low-literacy patients were more likely to follow their provider's advice to undergo HIV testing. A low-literacy brochure used for pretest counseling may have contributed to this effect. On the whole, though, intervention studies attempting to improve the quality of care and outcomes of populations at risk are the rarest but potentially most important type of study. Interventions can be directed at any of a variety of levels in integrated models of health care disparities including the provider-patient interaction, family and social environment, system of care, and macro policy.5 Interventions can be efficacy studies that determine whether an idealized program can be successful or effectiveness studies testing whether the program will succeed in real-world settings including community-based locations. Interventions and their evaluation need to be culturally sensitive to the population at risk, and the papers by Sheppard et al. and Napoles-Springer et al. give useful advice for studies on specific Latino and African-American populations.11,12 Community-based participatory research (CBPR) techniques that include the community as true partners in the research process to accomplish these goals are promising and have attracted significant attention, exemplified by rising interest by journals in this work as well as recent program announcements and requests for application by the National Institutes of Health (NIH).13–15 In CBPR, the community is involved as an equal partner in all aspects of the research process including choosing the research question, designing and implementing the study, analyzing and interpreting results, and disseminating findings.16 CBPR has become an important method in translational research because community insights, strengths, and buy-in are crucial for sustainable change.17 Cost studies are also needed, both the traditional societal cost-effectiveness analysis as well as analyses that take the perspective of players such as the health care organization, because interventions must be financially viable if they are to be sustained in the long run. In addition, there is a relative lack of intervention studies in medical education that evaluate innovative training programs on such topics as cultural competence and socioeconomic aspects of medicine pertinent for populations at risk. For example, a complicated set of factors affects the behavior of populations at risk including health beliefs, social network, neighborhood context, health insurance coverage, and eligibility for social service programs. Educational programs that demonstrably provide insight into these complex areas are critical to ensure a steady pipeline of providers competent to care for and advocate for populations at risk. Part of the reason for the relative dearth of intervention studies is that they can be challenging to undertake scientifically, logistically, and financially. Over the past 4 years, I have been a member of one of AHRQ's study sections that reviews grant applications relevant for populations at risk. I have been impressed by the number of strong proposals, and frustrated that the vast majority are not funded because of the tight AHRQ budget. While most institutes within the NIH have more money, this source for new investigator-initiated grants is also drying up in President Bush's recently submitted 2005 budget. The NIH budget doubled between fiscal years 1999 and 2003, but the fiscal year 2006 program level is only 0.7% more than the fiscal year 2005 appropriation.18 Limited funding will be available for new investigator-initiated awards because existing obligations have priority, including current grants and the NIH Roadmap Initiative for Biomedical Research.19 Some innovative local single-institution studies can be performed with modest budgets, but studies that address organizational and system-level factors impacting care and outcomes frequently need to be multisite to be generalizable. These latter studies are expensive and have required significant funding from organizations such as the AHRQ and NIH. Without further funding, we may lose the opportunity to follow up on exciting advances in health disparities research over the past decade and also risk losing a generation of researchers in this important field. The Journal of General Internal Medicine strongly encourages you to submit manuscripts for the Populations at Risk section. We define Populations at Risk broadly, including but not limited to the poor, frail, disabled, economically disadvantaged, homeless, racial and ethnic minorities, persons with low literacy,20 victims of abuse or persecution, and persons with social risk factors such as isolation. Papers across the spectrum of description, mechanism, and intervention are encouraged. However, the Editors and Deputy Editors are particularly interested in innovative articles that advance the field, and the greatest need is at the intersection of mechanism and intervention. 2005 is a challenging time for populations at risk and those working to eliminate health disparities, but we share the confidence my medical school interviewer had in the current and future generations of physicians and invite you to step up to the plate with your scholarly work about populations at risk.