Women's health research at Historically Black Colleges and Universities.

Abstract: The health status of African American women presents a composite picture of health disparities. Biomedical and behavioral research programs solely focused on women are recent. Research programs that address the health disparities of African American women are difficult to identify. The intent of this study was to establish a baseline of women's health research occurring at Historically Black Colleges and Universities (HBCUs). We explored the existence of such research programs by sending a questionnaire to 117 HBCUs. Information from the respondents (n =64, 42 institutions) highlight the minimal existence of these programs and the limited scope of their research activities.

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Persistent health disparities are well documented among minorities and women of color. At each age of the life span until age 44, African Americans, Latinos, and Native Americans have, on average, higher mortality rates than whites (Kaiser Foundation (a), 1999). In a survey conducted by the Kaiser Foundation in 1997, black infant mortality was 2.5 times higher than white (14.2 per 1,000 black infants born versus 6.0 per 1,000 white infants born), and blacks in 1996, on average, lived 6.6 years less than whites (Kaiser Foundation (b), 1999).

Leading causes of death are often used to measure the health status of groups, nationally and internationally. In the U.S., regardless of gender or ethnicity, the top three leading causes of death are heart disease, stroke, and cancer. However, the African American mortality rate far exceeds that of white Americans in heart disease, cancer, stroke, diabetes, and homicide. In fact, for every cause of death, female and male African Americans in the United States die at a higher proportion than whites except from chronic obstructive pulmonary disease and suicide. The chronic disease mortality rate among African Americans is higher than that experienced by whites and African Americans die earlier from these diseases than this comparison group (NCHS, 1998). Illness and disability also affect African Americans more often and is reflected in higher morbidity rates (CDC, 1994).

Health status disparities experienced by African Americans prompt several research questions including questions about: the role of Historically Black Colleges and Universities (HBCUs) in biomedical research, the level of involvement of HBCU researchers in exploring health issues that disproportionately affect African Americans, and identifying any specific focus on selected diseases that affect African American women more than other groups of women, e.g., lupus, breast cancer, HIV/AIDS, etc. The purpose of this study was: (1) to establish a baseline of HBCUs actively involved in biomedical research with a particular focus on women's health research and (2) describe a framework for the future development of women's health research programs at minority institutions.

HBCUS: WHAT, WHEN, WHY, WHERE, AND HOW ARE THEY?

The Higher Education Act of 1965 defined an HBCU as: "... (A)ny historically black college or university that was established prior to 1964, whose principal mission was, and is, the education of black Americans, and that is accredited by a nationally recognized accrediting agency or association...." (U.S. Department of Education, 1998). Most HBCUs are small undergraduate institutions founded and established to educate African Americans at a time when equal educational opportunities were not available to all Americans. Today these schools have trained thousands of African American educators, scientists, engineers, health professionals and others. As institutions open to all, the rich history, and learning environments of HBCUs have also prepared non-African Americans for a variety of academic and scientific fields. (U.S. Department of Education, 1998; Committee-AAUP, 1995)

Historically Black Colleges and Universities represent less than five percent of all institutions of higher education but enroll between 12 to 20 percent of African American undergraduate students. The White House Initiative on HBCUs lists 105 HBCUs composed of two-year and four-year public and private institutions as well as graduate and professional schools. Historically Black Colleges and Universities have been described as "a national resource to be treasured, nurtured and developed" (White House Initiatives on HBCUs, 1998-2000).

   HBCUs have performed a remarkable task, educating almost 40% of this
   country's Black college graduates, and at either the graduate or
   undergraduate level, some 75 percent of all Black Ph. Ds., 46 percent of
   all Black business executives, 50 percent of Black engineers, 80 percent of
   Black federal judges, and 85 percent of all Black doctors ... The
   historically Black health-professions schools have trained an estimated 40
   percent of the nation's Black dentists, 40 percent of Black physicians, 50
   percent of Black pharmacists, and 75 percent of the nation's Black
   veterinarians (HBCUs, 2000).

The strengths and accomplishments of HBCUs may be incalculable in many respects; there is little question that HBCUs have a remarkable record in awarding degrees. In spite of the significant contributions and major accomplishments produced by many HBCUs, most HBCUs have not excelled in the acquisition of extramural research funds, particularly in the biomedical field.

The Carnegie classification system, a taxonomy of colleges and universities, identifies fewer than five percent of HBCUs as "research institutions" (Carnegie, 2000). The category of "research" was defined by the number of doctorates (in a number of disciplines) awarded per year and the amount of federal support awarded to the institution. Consequently, very few HBCUs qualified for inclusion in the "research" category. The Carnegie Foundation classified Howard University as the only HBCU "research institution" in 1994 and in the revised 2000 classification system. However, five HBCUs have been added under a new doctoral research category in the 2000 classification.

   "Historically, most funding for sponsored projects has been awarded to
   large research institutions -- one can frequently see printed lists of the
   `top 100 research institutions' in the country," (Davis, 1988, p. 41).

None of these "top 100 research institutions" are HBCUs. In fact, the subset of health professional HBCUs receive much less extramural research funding than other similar institutions. The top ten NIH-funded institutions of higher education and HBCUs received a significant amount of support from the National Institutes of Health during fiscal year 1999 as reflected in Table 1 (NIH, a 2000). The total received by all top ten ranked HBCUs equals only 20 percent of the amount received by Johns Hopkins University alone. In fact, the number of awards received by HBCUs, is a small percentage of the awards received by the top ten institutions, however, the amount per award is much greater.

Table 2 reflects NIH support awarded to the leading four U.S. Medical Schools as compared to the four HBCU medical schools (NIH, b, 2000). The HBCU medical school, with the largest amount of research funding (Morehouse School of Medicine), received only seven percent of the NIH funds awarded to the lead medical school, Johns Hopkins University.

Part of the issue is that HBCUs submit fewer applications for federal funding opportunities and consequently receive fewer awards. These well documented funding disparities provide important insight into the limited biomedical research enterprise existent among HBCUs and imply a diminished infrastructure or capacity necessary to acquire extramural biomedical research funding.

METHODS

The questionnaire used in the current study was previously developed for use in a pilot study conducted in 1997 at Morehouse School of Medicine (MSM) by one of the current investigators. For the purpose of this study, the same eight-item questionnaire was modified to include questions about the institution, the respondent's knowledge and experience in women's health research as well as the institutional activity in women's health research.

The investigators developed a list of target institutions using several source documents including: "The White House Initiative on Historically Black Colleges and Universities," and websites for the National Association for Equal Opportunity for Higher Education (NAFEO), and Minority On-Line Information Services (MOLIS). Once the list was completed, 117 schools were identified as Historically Black Colleges and Universities.

The study was conducted between June and August 2000. Nearly all questionnaires were sent by mail to the attention of the Director(s) of Grant and Contract offices from the identified HBCU list. Most institutions have an office or person with this function. If the institution did not have a person or office in this capacity, then the questionnaire was sent to the President's office of the university. Nine of the schools identified as Historically Black Colleges and Universities belong to the Association of Minority Health Professional Schools (AMHPS) and the Minority Health Professions Foundation (MHPF). Dr. Louis Sullivan (President of Morehouse School of Medicine and former Secretary of the Department of Health and Human Services) founded the association in 1976 as a way to "provide a means by which the need for a national minority health agenda could be addressed" (AMHPS, 1999). The nine AMHPS institutions were grouped into a health professions' subset of HBCUs. Morehouse School of Medicine was also a subset as the study site. The third subset was all other responding HBCUs.

The questionnaires were sent electronically for a second distribution and mailed again to those schools that did not have an electronic mail system in place. Follow up calls were made to all schools that did not return the initial questionnaire by the first due date. At the end of ten weeks, 64 questionnaires had been returned to the office of the Women's Health Initiative at the Morehouse School of Medicine. Twenty-two questionnaires were internal to MSM, thirty-six were received from "other" Historically Black Colleges and Universities and six were from the AMHPS institutions. In all, forty-two institutions (35.9%) participated and sixty-four respondents completed the questionnaire.

DATA ANALYSIS

All returned questionnaires were entered into a database created in SPSS for Windows. The analysis was primarily descriptive and determined by the general nature of the questionnaire and by the brief information it elicited. Frequencies were calculated for descriptive variables (i.e. type of institution, location of institution, etc.). Once returned, the questionnaires were divided into three clusters. These clusters represent 64 individual respondents and 42 institutions: (a) Minority Institutions (N=36), institutions/respondents that are not a part of AMHPS or Morehouse School of Medicine; (b) Morehouse School of Medicine (N=22) all MSM respondents; and (c) Minority Health Professions Schools (N=6) AMHPS institutions include: Morehouse School of Medicine, Howard University, Meharry Medical College, Xavier University of Louisiana, Florida A&M University, Hampton University, Texas Southern University, Charles R. Drew University and Tuskegee University.

RESULTS

The institutions (N=42) responding to the questionnaire represent a range of academic settings and long, rich academic histories. They range in establishment age from 25 years to 148 years with a median of 112 years and a mean age of 99 years. Ninety-eight percent of the responding institutions reported that they are classified as a Historically Black College or University. The majority of the schools indicated they are located in urban centers as opposed to a rural setting. Only ten schools in the cluster for minority institutions identified themselves as rural. There was only one rural institution among the Minority Health Professions Schools. The majority of HBCUs are located in the Southern region of the United States and along the southeastern seaboard. Many of the schools indicated they have a student population of African Americans that exceeds 85%. Other minority populations included Asian Americans, Native Americans, Hispanics, Native Hawaiians, and Pacific Islanders.

Though all the institutions have varied research capacity, it appears that there is a limited amount of ongoing biomedical research. The majority of the institutions, 78.6% (N=33), indicated they had not been previously involved in women's health research. The majority of the subset of minority institutions that are involved in women's health research offers graduate degrees. There are only two participating undergraduate institutions that reported ongoing research activities related to women's health, Spelman College and Knoxville College. Sixty-six percent of the Minority Health Professions Schools respondents reported that they previously or currently have been involved in women's health research.

A majority of the respondents (N=36) were female (57%). All of the principal investigators listed for the minority institution cluster are women. Four of the six principal investigators listed for MSM are women and all of the principal investigators listed for the Minority Health Professions Schools are women. The respondents are a diverse cross section of faculty and staff. The bulk of the respondents in the minority institutions group represented staff in Offices of Sponsored Programs and/or Institutional Development. This group is the only cluster that also included a questionnaire returned from a women's center.

Within the Morehouse School of Medicine (MSM) cluster, the individuals that responded represent a variety of academic and support departments within the school. Yet, the respondents from the Minority Health Professions Schools represent a narrow range of faculty members and administrators. Two-thirds of these respondents are senior faculty or management staff and report more research activity related to women's health issues. Seventy-three percent of all respondents indicated that they (personally) are not currently involved in women's health research.

The questionnaire sought to identify specific research projects related to women's health. All of the respondents were asked to list projects at their institutions related to women's health. They reported research in cancer, HIV/ AIDS, and obesity/eating disorders among African American women. Although we wished to describe institutional expertise, many respondents focused on their individual research expertise. This expertise was in infectious disease (23.8%), HIV/AIDS (23.8%), nutrition/malnutrition (21.4%), reproductive issues (19.0%), violence (19.0%), cancer (16.7%), sexually transmitted diseases (16.7%) and physical activity (16.7%).

Finally, we assessed the level of service provided to women on HBCU campuses. Generally, HBCUs offer basic health services Such as first aid, some immunizations, some pregnancy counseling and testing. However, health care for women on college campuses is the responsibility of the individual and provided largely through a referral process.

DISCUSSION

There are fifteen National Centers of Excellence in Women's Health supported by the U.S. Department of Health and Human Services (DHHS) through the Office on Women's Health. None of these centers are located at HBCUs. One of the Centers of Excellence is in Puerto Rico and another is a collaborative between two Louisiana universities, one of these partners is an HBCU (Centers of Excellence, 2000).

Minority health professional schools and other HBCUs have more than a vested interest in expanding research activities into the field of women's health research, considering their missions and historical role in training minority health care professionals. However, the preponderance of HBCUs are focused on undergraduate education with limited research capacity, resources or infrastructure to support an expanded research role. The record of research funding received by HBCUs attests to the interest, skills and accomplishments of minority investigators, despite the limited research infrastructure and resources at many HBCUs. It was not surprising to find that the responding institutions, actively involved in women's health research, also offer graduate degrees. Those institutions have an adequate research infrastructure, graduate students, and faculty members engaged in research in a variety of areas, including women's health. A number of HBCUs have research centers and training programs in areas related to the environment, technology, education, science and biomedical research. In some respects, federal funding for training centers and institutes best describes the largest percentage of biomedical research support awarded to minority institutions.

In spite of limited resources and capacity, biomedical and behavioral research does occur at HBCUs, however, the promise of what more could be done remains unfulfilled. In order to excel in furthering the HBCU research enterprise and in closing the health disparity gaps, an adequate research infrastructure and resources must become available to these academic institutions. Forging successful research partnerships and other collaborative arrangements is one alternative to closing the gap between HBCUs and the research community. This approach or model is one recently adopted by the DHHS Centers of Excellence in Women's Health. Research-intensive universities (Carnegie, 2000) are paired with those institutions with less capacity and in many cases, with limited research faculty already overburdened by teaching loads without adequate release time.

The findings from this study found that respondents from HBCUs with active research portfolios have an acute interest and motivation for increasing biomedical and behavioral research. If HBCUs are going to effectively develop research programs focused on women's health issues, partnerships and collaborations seems to offer a viable opportunity to leverage limited resources with other institutions that have extensive research infrastructures. Partnerships between and among undergraduate and graduate institutions, with regional affinity, may offer one strategy to maximize existing resources in the pursuit of expanded research opportunities.

Table 1. NIH Support to U.S. Institutions of Higher Education, Fiscal
Year 1999.

                                    Research      Grant
Rank            Institution          Awards       Amount
                                      (N)

 1     Johns Hopkins University       827      $307,750,244
 2     University of Pennsylvania     792      $268,288,070
 3     University of Washington       651      $239,251,955
 4     University of California,
         San Francisco                658      $235,413,011
 5     Washington University          596      $222,169,575
 6     University of Michigan         640      $208,985,741
 7     Yale University                621      $210,830,415
 8     Harvard University             447      $193,625,363
 9     University of Pittsburgh       558      $186,802,543
10     University of California,
         Los Angeles                  564      $182,704,829

                                               Research     Grant
Rank            Institution/HBCU                Awards      Amount
                                                 (N)

101    Howard University * ([dagger])            22       $13,740,290
105    Morehouse School of Medicine *
         ([dagger])                              23       $14,961,058
122    Meharry Medical College * ([dagger])      25        $8,644,219
136    Jackson State University                   9        $4,082,160
140    Charles R. Drew University ([dagger])     13        $6,114,937
156    Florida A&M University * ([dagger])        5        $4,412,914
163    Clark Atlanta University                   7        $3,661,265
183    Morgan State University                    3        $2,022,970
198    Tuskegee University * ([dagger])           3        $2,083,702
200    Tennessee State University                 3        $1,880,570

Source: NIH/IMPAC-IRS Program, 1999

* Respondent

([dagger]) Belongs to the Minority Health Professional Foundation
Table 2. NIH Support to U.S. Medical Schools, Fiscal Year 1999

                                    Research      Grant
Rank          Institution            Awards       Amount
                                      (N)

1      Johns Hopkins University       629      $227,125,299
2      University of Pennsylvania     616      $220,628,766
3      Washington University          553      $211,938,148
4      University of California,
         San Francisco                557      $201,174,472

                                    Research     Grant
Rank       Institution/HBCU          Awards      Amount
                                      (N)
 81    Morehouse College School
         of Medicine                  23       $14,961,058
 83    Howard University College
         of Medicine                  16       $11,998,550
 92    Meharry Medical College
          School of Medicine          25        $8,644,219
100    Charles R. Drew University
         of Medicine & Science        13        $6,114,937

Source: NIH/IMPAC-IRS Program, 1999
Table 3. Women's Health Research Activity.

                                           Respondents
                                            currently
                                           involved in
                                Total        women's
                             Respondents     health
         Cluster               (N=64)       research
                                  N          N    %

Minority Institutions (MI)       36          7   19.0
MSM                              22         12   54.0
Minority Health Profession
  Schools (MHPS/AMPHS)            6          4   67.0

                               Institutions
                                conducting
                                  women's
         Cluster              health research
                                  N    %

Minority Institutions (MI)        5   14.0
MSM                              --   --
Minority Health Profession
  Schools (MHPS/AMPHS)            4   67.0

         Cluster                Types of Institutions
                              Graduate   Undergraduate

Minority Institutions (MI)      42.0         58.0
MSM                            100.0        N/A
Minority Health Profession
  Schools (MHPS/AMPHS)         100.0        N/A

REFERENCES

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Centers for Disease Control and Prevention (1994) Chronic Disease in Minority Populations Atlanta, Georgia: Centers for Disease Control and Prevention.

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Davis, S.K. (1988). Research Administration at Predominately Undergraduate Institutions With a Small Volume of Sponsored Programs. Research Management Review, 2(2), 41-45.

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Anonymous. (1998-2000). White House Initiative on HBCUs. Presidential Proclamation National HBCU Week, 1998, 1999, 2000. (On-line). http://www.ed.gov/officies/OPE/hbcu/hbcuweek.html.

http://ed.gov/offices/OPE/hbcu/proclamation1999.html.

http://www.ed.gov.offices/OPE/hbcu/proclamation2000.html.

Brenda D. Hayes, D.S.W., M.P.H., M.S.W., is a Research Assistant Professor and Director of the Women's Health Initiative in Community Health and Preventive Medicine at Morehouse School of Medicine. Leslie R. Boone, M.P.H. is the Project Coordinator of the Women's Health Initiative in the Morehouse School of Medicine. Please address all correspondence to Dr. Hayes at the Women's Health Initiative; Morehouse School of Medicine; 720 Westview Dr., SW; Atlanta, GA 30310; Ph: 404.756.5794; Fax: [phone]; Email: [e-mail].