Council Concept Clearance - Chronic Pain Management in Rural Populations

Sponsoring ICs: NINR, NCCIH
Council Date: May 25, 2022

Description of Concept

The goal of this concept is to accelerate implementation of evidence-based non-opioid interventions for chronic pain management in rural and remote communities that experience health disparities. While effective, non-opioid pain management therapies are available, they are not being used in rural communities. Discovering and addressing the barriers to implementation of evidence-based pain management interventions is critical to alleviating the disparities between rural and non-rural populations. This is particularly important with the increase in drug overdose deaths during the pandemic. Rural communities have been particularly hard hit by the opioid epidemic and are disproportionately impacted by prescription opioid-related overdose. In 2017, of the 15 counties in the US with the highest opioid prescribing rates, 14 of them were in rural areas. However, patients with chronic pain are present across all geographic areas, and recent evidence indicates that percentage of adults with chronic pain increases as the place of residence became more rural. Furthermore, many patients with chronic pain have comorbidities, including mental health, and opioid and/or alcohol abuse disorders that complicate appropriate pain management. There are known disparities in management of chronic pain in rural areas, with rural residents having a greater likelihood of being prescribed an opioid analgesic than those in non-rural areas. Rural residents are also less likely to use self-management interventions for pain than those in non-rural areas.

Pain, like other health conditions, is shaped by both biological and social determinants of health. To fully address the factors affecting quality chronic pain management, the interrelationships between health policy, healthcare services, biology and genetics, individual behavior and social factors must be examined. Development and implementation of sustainable, effective non-opioid chronic pain management in rural and remote areas requires attention to the social determinants of health that affect overall health.

In rural settings, primary care practitioners, including physicians, nurse practitioners and physician assistants are responsible for addressing patients’ needs for chronic pain management while reducing opioid use. Limited community resources and/or long distances to reach specialists such as behavioral health, pain specialists, and physical therapists, increase the challenges of chronic pain management in rural communities. While there have been some promising studies integrating evidence-based chronic pain management in rural settings, there is still a need for a coordinated approach to identify and reduce barriers and accelerate the implementation of high-quality chronic pain care to optimize health and advance health equity.

Projects addressing multiple levels of NIMHD’s research framework would be encouraged. Stakeholder engagement including community groups, primary care practitioners, patients, caregivers, clinicians, community health workers, emergency medical service providers, and researchers is needed to support implementation of evidence based interventions that will be feasible, acceptable, and sustainable.

Examples of possible projects include:

• Assessing the impact of establishing mobile vans traveling across multiple communities to provide physical therapy for individuals with chronic pain related to orthopedic issues to address the limited number of specialty care providers available in these communities. The intervention could include both pre- and post-surgical therapies to address both chronic and acute pain.
• Multi-level education of primary care providers, pharmacists, patients, families, and the community in appropriate use of evidence based non-opioid medications (including anti-inflammatories, muscle relaxants, topicals, neuropathic pain agents, SSRIs, SNRIs, gabapentinoids, etc.) and implementation of use of these medications, with appropriate self-management and monitoring.
• Utilizing a hub and spoke strategy for providing training to partnering community centers in rural regions to provide training of local providers or when possible, community members for evidence- based interventions including movement, self-management therapies, and/or mindfulness.

This concept aligns with the HEAL goals of improving chronic pain management, and appropriate prescribing of analgesics including opioids across populations. Additionally, the NIH HEAL portfolio has limited projects focusing on implementation of evidence-based interventions, especially in populations with known disparities, such as those in rural and remote areas. This initiative will enable integration of pain, rural health, social determinants of health, and clinical implementation expertise to promote use of evidence-based solutions to chronic pain management where such solutions are most needed.

Council Concept Clearance - Research in NINR Areas of Emphasis

Program Lead/Presenter: David Tilley
Council Date: January 25, 2022

Purpose of the Concept

To stimulate research in NINR’s areas of research interests. This initiative will encourage research specifically relevant to NINR’s broad research interests as detailed in the forthcoming new NINR Strategic Plan (2022-2026). The goal of this initiative is to simplify the application process for investigators seeking NINR funding for applications of high relevance to NINR and to broadcast the Institute’s research priorities to the research community.

Research Objectives

The initiative specifically aims to encourage research on:

• Health Equity: Studies aimed at producing evidence needed to reduce and ultimately eliminate the systemic and structural inequities that place some population groups at a disadvantage in attaining their full health potential.
• Social Determinants of Health: Research examining the conditions in which people are born, live, learn, work, play, and age-identifying effective approaches to address social risk factors, social needs, and/or to capitalize on positive social factors (e.g., strengths, assets) in order to improve health outcomes.
• Population and Community Health: Studies that address critical health challenges at a macro level by focusing on interventions that affect groups of people with shared characteristics or who live within a shared area.
• Prevention and Health Promotion: Projects studying how to prevent disease and promote health through the continuum of prevention-from primordial prevention that targets the underlying factors that increase risk of illness, to tertiary prevention that aims to reduce disease severity, symptoms, and progression - with a particular emphasis on eliminating health disparities.
• Systems and Models of Care: Research that addresses clinical, organizational, and policy challenges through the development, dissemination, and implementation of new systems and models of care, including those that bridge clinical and community care with social factors and needs.

Council Concept Clearance - Addressing Nurse Burnout Amidst the COVID-19 Pandemic

Program Lead/Presenter: Shweta Singh, Kris Bough, Rebekah Rasooly
Council Date: January 25, 2022

Purpose of the Concept

The purpose of this concept is to provide opportunities for researchers to develop, implement, and/or evaluate effective system-level interventions to prevent and reduce nurse burnout, which has been greatly exacerbated by the COVID-19 pandemic.

Research Need/Challenge to be Addressed

Burnout is an occupational phenomenon fundamentally characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment. The COVID pandemic has shined a spotlight on another epidemic impacting the nation’s largest health care workforce: nurse burnout. Nurse burnout is a healthcare crisis now affecting over half of U.S. nurses and has wide-ranging consequences.

At the nurse level, burned out individuals have been found to exhibit many health problems including sleep disturbances, fatigue, exhaustion, substance abuse, cardiovascular disease, as well as delayed recall and impaired general cognitive processing.

As a consequence, at the patient level, research has linked nurse burnout to higher odds of patient mortality, failure to rescue, longer length of stay, poor quality of care, preventable adverse events, increased hospital-acquired infections, and decreased patient satisfaction. Research has shown RNs with burnout were five times more likely to leave necessary patient care undone.

In addition, at the system-level, nurse burnout negatively impacts other providers, healthcare organizations, healthcare costs, and most alarmingly, the quality and safety of care. Furthermore, nurse burnout increases absenteeism and turnover. In turn, this reduces access to care and increases the nursing workforce shortage, adding even more stress on an already overburdened system. Marginalized populations have reduced access to safe, high-quality care, and nurse burnout exacerbates these inequities. Furthermore, a 2020 survey by the American Nurses Foundation found that Black and Hispanic/Latinx nurses were more likely to be in roles providing direct care to COVID-19 patients than White nurses, and twice as likely to have been diagnosed with COVID-19. These findings highlight existing disparities and inequities in healthcare systems that are further exacerbated by the pandemic.

Research Objectives

• Expand research on the development, implementation, and evaluation of system-level interventions that can prevent and reduce nurse-, individual-, and/or system-level impacts of burnout. Examples of system-level interventions include improvements to modifiable components of the work environment such the management and support of nurses, nurse participation, team collaboration, staffing adequacy, and resources. Applications should not include individual-level nurse burnout interventions (e.g., mindfulness, yoga, etc.)
• Understand the mechanisms and conditions under which these system-level interventions succeed or fail to improve outcomes.
• Encourage research in healthcare systems where care or services are provided to underserved populations. This might include safety net providers - such as Federally Qualified Health Centers (FQHCs), Rural Health Centers, Disproportionate Share Hospitals (DSH), and Community Health Centers - that are disproportionately impacted by COVID-19. This also includes other community-based settings such as long-term care facilities, homes, nursing homes, justice settings, workplaces, and schools.

Council Concept Clearance - Algorithmic Bias Workshop

Program Lead/Presenter: Rebekah Rasooly
Council Date: September 14, 2021

Goal

Develop a workshop to bring together panelists to discuss ways nursing science can help to detect and prevent unintended or undetected bias that result from machine learning (ML) algorithms (a subset of artificial intelligence or AI) used in biomedical research. 

Rationale

In healthcare settings, ML-based algorithms are frequently used in medical devices, diagnostic platforms, and clinical risk assessment applications. As the use of ML continues to gain popularity in healthcare systems, there is growing concern about algorithmic bias that leads to or exacerbates health disparities. Algorithmic bias may arise from issues within the data used to train and evaluate the algorithms or reflect and perpetuate structural inequalities in the form of measurement/label choice bias. 

Several new NIH-wide activities are seeking to strengthen and diversify the AI workforce, including the NINR 2020 and 2021 Methodologies Boot Camp focused on Artificial Intelligence, the ODSS-led "Developing Experts for Better Biomedical and Behavioral Research Data: FAIR and AI/ML-Ready Data" initiative, and”¯the NIH AIM-AHEAD Initiative, which is working to increase the participation and representation of researchers and communities currently underrepresented in the development of AI/ML models. Other NIH efforts are focused on specific aspects of ML/AI, such as the "NLM Research Grants in Biomedical Informatics and Data Science" initiative, which is focused on research to reduce or mitigate gaps and errors in health data sets.  

However, as ML algorithms continue to be integrated into nursing practice and research, it is critical to address algorithmic bias that exacerbates health disparities.  There are no existing NIH-wide activities focused in this area. 

Nursing scientists need to understand ML thoroughly enough to consider and mitigate risks of developing and using ML.  

Objectives and Scope

1. Create an advisory group with co-chairs with related expertise to plan the workshop 
2. Gather and synthesize information about research gaps and training needs via a workshop and other activities

Council Concept Clearance - Addressing Long-Term Social Impacts of the COVID-19 Pandemic on Health and Health Disparities

Program Lead/Presenter: Amanda Price, Karen Huss, Lois Tully
Council Date: September 14, 2021

Purpose of the Concept

To identify and address the ongoing and long-term impacts of the COVID-19 pandemic, focusing specifically on policies and policy changes that addressed two specific social determinants of health: nutrition/food security and housing security and the resulting effects on health. The initiative will examine the impact of these pandemic mitigation efforts on health disparities and health in populations who experience health disparities, especially racial/ethnic minority and socioeconomically disadvantaged individuals, families, and communities. 

Rationale 

The COVID-19 Pandemic and Health - Although the US is traversing the worst pandemic in 100 years, the long-term effects on the health and well-being of the nation, beyond the enormous morbidity and mortality due to viral infection itself, are just beginning to be realized. Both pandemic prevention efforts such as social distancing and isolation policies and the related social and economic consequences of the pandemic such as increased food insecurity and widespread unemployment have had adverse effects on public health which will persist for years. Of particular concern is the impact of the pandemic and prevention efforts on health disparity populations, including racial and ethnic minority groups and those of lower socioeconomic status/position. The pandemic vividly highlighted ongoing social problems that influenced health and health equity before the onset of the pandemic, and then exacerbated many of these problems.  

Food Insecurity - Food insecurity is a well-known health risk factor for both children and adults. Children who are food insecure, for example, are twice as likely to report fair or poor health and adults with lower food security have a higher likelihood of chronic disease in general. The impact of the pandemic on nutrition was striking. It is estimated that the prevalence of food insecurity has risen sharply from an estimated 11% of US households to an estimated 18-35% of US households. Correspondingly, use of food banks has risen dramatically during the pandemic.  
 
Housing - Housing is also an important social determinant of health, a central component of the relationship between poverty and health. Substandard housing increases the risk of chronic diseases such as asthma and lead poisoning, reduces the availability of recreation and groceries, and is often associated with reduced employment opportunities. The pandemic caused significant financial hardship, with Census Bureau data showing 42% of working-aged adults experiencing household financial hardship by December 2020, leading to 51.7% of renters reporting a high likelihood of being evicted. In addition to being impacted by the pandemic, housing has also played a key role in the spread of COVID in two ways. First, COVID transmission has been associated with crowded households, and researchers have found a strong association between poor housing and a high incidence of and mortality from COVID. Second, public health officials have recognized that stable housing is also a critical part of the response to the pandemic, as it allows individuals who become ill or who are at risk of transmitting COVID to self-isolate, a major rationale for the national eviction moratorium. 
 
Policies Aimed at Mitigating the Pandemic’s Effects - Major policy and programmatic initiatives attempted to blunt the pandemic’s effects by addressing key social determinants of health, such as nutrition security and housing security. The effects of these initiatives are poorly understood and their long-term consequences remain to be studied. Deeper understanding of the effects of pandemic mitigation policies that were aimed at reducing social risk factors will contribute both to lessons for dealing with future pandemics as well as for addressing persistent structural factors influencing health equity. This is directly related to the research interests of NINR, which include supporting studies that address the realities of people’s daily lives and living conditions and that aim to identify solutions that improve health in the many clinical and community settings where nurses practice including people’s homes, schools, and communities. 

Research Objectives

Analyze two areas where policy and programmatic interventions were aimed at reducing the pandemic’s effects on health, quantifying the costs and benefits of such interventions as potential approaches to addressing long established determinants of health inequity. 

• Food insecurity and nutrition security interventions such as changes in subsidized/free meal programs (e.g., in schools), food assistance programs (e.g., SNAP, WIC) 
• Risky housing and housing displacement interventions, such as the moratorium on evictions, emergency rental assistance, elimination of single family zoning

Council Concept Clearance - Advancing Integrated Models (AIM) of Care to Address Racial/Ethnic Disparities in Maternal Health Outcomes

Program Lead/Presenter: Shalanda Bynum
Council Date: September 14, 2021

Purpose of the Concept

To characterize and develop integrated models of maternal care delivery to improve maternal health outcomes among women of color and reduce racial/ethnic disparities in maternal mortality and morbidity. For this concept, integrated maternal care is defined as care that incorporates pregnancy support such as through the use of a doula and/or social service providers to address healthcare access, healthcare quality, and social factors impacting maternal health outcomes.  

Rationale

Maternal mortality, defined as "death of a woman while pregnant or within 1 year of the end of pregnancy regardless of the outcome, duration, or site of the pregnancy - from any cause related to or aggravated by the pregnancy or its management" has steadily increased over the years. The rate increased from 17.4/100,000 maternal deaths per live births in 2018 to 20.1/100,000 in 2019. Black women bear a disproportionate burden at 44.0/100,000 maternal deaths per live births versus 17.9 for non-Hispanic White women and 12.6 for Hispanic women. American Indian/Alaska Native and Pacific Islander women also have higher rates of maternal mortality compared to White and Hispanic women.  Severe maternal morbidity, defined as "unexpected outcomes of labor and delivery that results in significant short- or long-term consequences for a woman’s health", has increased over the years and also disproportionately impacts racial/ethnic minority women.  
 
To eliminate these racial/ethnic disparities in maternal morbidity and mortality, research is needed to identify new models of care that improve outcomes. In addition, research on the factors that contribute to maternal health disparities is especially needed for American Indian/Alaska Native and Native Hawaiian/Pacific Islander communities, where less is known about root causes. 
 
Factors Contributing to Adverse Maternal Health Outcomes - Data from 13 state maternal mortality review committees identified a conceptual framework outlining drivers of adverse maternal outcomes, with factors encompassing 1) unstable housing, availability of healthy foods, and clinical care and transportation access; 2) obstetrics emergency inexperience and lack of personnel or services to attend to such emergencies; 3) patient awareness and knowledge of warning signs, pre-existing chronic conditions, age, and medication adherence; 4) provider missed/delayed diagnosis, implicit bias, and lack of care continuity; and 5) inadequate access to care and poor case coordination. The National Academy of Sciences reports similar contributors to maternal morbidity and mortality. Despite the complexity of the problem, research suggests that approximately 60% of pregnancy-related deaths and a large proportion of maternal morbidity are preventable.  
 
Improving Maternal Health Outcomes - Many of the contributing factors point to the need for improved healthcare access and quality and the need to address women’s social risk factors and needs. Integrated models of care may be an effective approach to address those factors and improve maternal health outcomes among racial/ethnic minority women based on the limited existing research:  

• Healthcare Access - Health system access related to appointment scheduling, care coordination, and health insurance status are longstanding barriers to women’s health. Research suggests that patient navigators can improve access to services and continuity of care.  
• Health Care Quality - Implicit bias and healthcare discrimination contribute to patient-provider communication lapses and unequal provision of care. Continuous support especially from a doula or midwife, has been shown to improve pregnancy outcomes. Moreover, birthing centers and group-based prenatal care have also resulted in positive outcomes.  
• Social Care - Research documenting the influence of housing, healthy food availability, and transportation access on pregnancy outcomes highlights the importance of integrating approaches that address social risk factors and social needs into maternal care delivery models. 

This concept seeks to fill existing scientific knowledge gaps in understanding the impact of integrated supportive care on improving maternal health outcomes among racial/ethnic minority women by carrying out rigorous studies.

Research Objectives

Formative
Among racial/ethnic minority populations about which little is known: 

1. Conduct qualitative, quantitative, or mixed-methods research to inform development of integrated models of maternal care delivery to improve maternal health outcomes.
2. Develop partnerships and conduct pilot studies of integrated models of maternal care that utilize supportive care to address healthcare access, healthcare quality, and social risks and needs. 

Intervention
Conduct studies among racial/ethnic minority women to evaluate the impact on maternal health outcomes of integrated models of maternal care that utilize supportive care to address healthcare access, healthcare quality, and social risks and needs. 

Council Concept Clearance - Strengthening the Impact of Community Health Workers on HIV Care Continuum in the US

Program Lead/Presenter: Rebecca Henry
Council Date: January 15, 2020

NINR and OAR Strategic Plan Relevance

This concept fits with NINR’s Self-management of HIV/AIDS and related co-morbidities priorities and with the following NIH OAR (Office of AIDS Research) and EHE (Ending the HIV Epidemic) research priorities: Decrease the incidence of HIV transmission and decrease and/or mange HIV-associated comorbidities, coinfections, and complications

Purpose

The purpose of this concept is to promote research on the use of community health workers (CHW) to improve care engagement leading to durable antiretroviral (ARV) medication adherence in U.S. populations with the poorest HIV treatment outcomes. The concept is intended to support research on the effectiveness and real-world translation of local and regional CHW strategies, as well as integration of mHealth and virtual reality tools to strengthen CHW’s ability to improve HIV care among people living with HIV (PLH). This program of research is geographically aimed at US counties, states and territories with the highest concentrations of HIV disease identified in the President’s plan to End the HIV Epidemic (EHE).

Rationale

Despite the availability of highly effective HIV-targeted medicines, many of the approximately 1.2 million PLH living in the United States are not benefitting from them. The causes for lack of engagement in HIV care that leads to durable viral suppression are complex, rooted in poverty and the social stigma attached to HIV illness itself, compounded by a person’s gender, race, class, and sexual identity. Acceptance and integration of the realities of a serious health condition and developing a realistic daily management strategy takes time and support and is always vulnerable to a person’s changing circumstances. Given the limited time of clinicians, the fragmented condition of the US health care and insurance system, and the challenges inherent in the lives of poor or stigmatized groups, the development of a robust, diverse, community-savvy cadre of health workers in the US holds promise for addressing some of these ongoing challenges. As part of a provider team in the US, CHW have been successfully deployed to support people living with a variety of chronic conditions, including hypertension, diabetes, cancer and infectious illness such as TB (CDC). In the context of the US HIV epidemic, "patient navigators" have had some success in improving HIV health outcomes in research settings

In recognition of the importance of this research question, the NIH Office of AIDS Research (OAR) is supporting an NINR-led initiative on CHWs and the HIV Care Continuum. As a first step, on September 16-17, 2019, NINR led an NIH conference, funded by the NIH Office of AIDS Research (OAR) on "Strengthening the Impact of Community Health Workers on HIV Care and Viral Suppression in the U.S." The issues and gaps identified by the attendees were used in the development of this concept.

Public Health Relevance/Impact

Research on how community health workers and programs impact HIV care engagement, ARV adherence and other HIV health-related outcomes, and their value to improving the quality of health care to under-resourced communities, will provide guidance for bringing CHW to scale as a significant force in solving the large gaps in care engagement and between ARV prescription and viral suppression in the US. In addition, impactful CHWs strategies and programs, backed by clinical-evidence and, over time, supported through training, supervision and pay, could be an effective resource to addressing HIV comorbidities and many other clinical and public health problems in areas targeted by EHE initiative.

Research Objectives

• Community-based participatory methods including thorough assessment of the policy and clinical practice context preliminary work to set the stage for scale up
• Pragmatic trials of active (or augmented) CHW programs in EHE locations that study the impact of CHWs on HIV care and adherence health outcomes
• Implementation research that translates CHW strategies with demonstrated efficacy in other locales and regions, to ETH locations
• Development and testing and/or expansion of existing mHealth and Virtual approaches that strengthen work of CHWs, CHW/CBO programs or extend the geographic reach of CHW activities to support care engagement and medication adherence to EHE locations
• Study of factors that influence how CHW draw from and impact social cohesion and program success;
• Characterization of how, why and which specific program elements or combination of elements provide the highest impact on targeted HIV-related medication adherence and other health outcomes;

Potential Collaborators: NIDA, NIMH, NIMHD, NIDCR, OBSSR