>> GOOD AFTERNOON. I'D LIKE TO WELCOME YOU TO TODAY'S OFFICE OF DISEASE PREVENTION, MIND THE GAP SEMINAR WITH DR. HENDRICKS BROWN. TODAY'S SEMINAR IS BROUGHT TO YOU CO-SPONSORED BY THE NATIONAL INTUITY ON ALCOHOL ABUSE AND ALCOHOLISM, THE NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES AND THE NATIONAL INSTITUTE OF MENTAL HEALTH OFFICE FOR RESEARCH ON DISPARITIES AND GLOBAL MENTAL HEALTH. THE OFFICE OF DISEASE PREVENTION HOPES TO BRIDGE THE GAP BETWEEN EVIDENCE AND PRACTICE WITH THE MEDICINE MIND THE GAP LECTURE SERIES. WE CHOOSE TOPICS THAT EXPLORE ISSUES AT THE INNER SECTION OF RESEARCH, EVIDENCE AND CLINICAL PRACTICE. AREAS IN WHICH CONVENTIONAL WISDOM MAY BE CONTRADICTED BY RECENT EVIDENCE. IT IS OUR HOPE THAT THE SEMINAR SERIES WILL ENGAGE THE NATIONAL INSTITUTES OF HEALTH COMMUNITY IN THOUGHT PROVOKING DISCUSSIONS TO CHALLENGE WHAT WE THINK WE KNOW AND TO THINK CRITICALLY ABOUT OUR ROLE IN TODAY'S RESEARCH ENVIRONMENT. SOME HOUSEKEEPING, FOR THOSE OF YOU IN THE AUDIENCE, IF YOU HAVE A QUESTION, PLEASE USE THE MICROPHONE BECAUSE WE HAVE A RATHER LARGE WEB PRESENCE AND FOR THOSE OF YOU WHO ARE WATCHING VIA WEBCAST, IF YOU'D LIKE TO PARTICIPATE IN TODAY'S DISCUSSION AND SUBMIT QUESTIONS, PLEASE DO SO IF YOU'RE USING TWITTER, USING THE # NIHMTG. YOU CAN ALSO SUBMIT QUESTIONS USING OUR E-MAIL PREVENTION AT: MAIL.NIH.GOV, AND WE WILL ASK THOSE QUESTIONS DURING THE QUESTION AND ANSWER SESSION. WITH THAT I WILL BRING UP THE ASSOCIATE DIRECTOR FOR DISEASE PREVENTION AND THE DIRECTOR OF THE OFFICE OF DISEASE PREVENTION, DR. DAVID MURRAY. >> THANK YOU. I'M VERY HAPPY TO INTRODUCE HENDRICKS BROWN TODAY. I HAVE FOLLOWED HIS WORK FOR SOMETIME. HE IS AN EPIDEMIOLOGIST AND BIOSTATISTICIAN, REALLY BIOSTATISTICIAN. I'M AN EPIDEMIOLOGIST AND A LOT OF PEOPLE THINK I'M A BIOSTATISTICIAN BUT HE HAS THE REAL CREDENTIAL WHERE I JUST SORT OF PLAY ONE. WE HAVE BEEN INTERESTED IN SIMILAR DESIGN, ANALYTIC ISSUES OVER THE YEARS SO I'M VERY HAPPY TO INTRODUCE HIM TODAY. HE'S PROFESSOR OF EPIDEMIOLOGY AND BUOY STATISTICS AT SCHOOL OF MEDICINE AT THE UNIVERSITY OF MIAMI. CAN YOU SEE HERE, HE IS DIRECTOR OF A COUPLE OF DIFFERENT CENTERS, ONE FUNDED BY MIMH, ONE FUNDED BY NADA, HE'S ALSO DIRECTOR OF THE SOCIAL SYSTEMS INFORMATICS PROGRAM IN THE CENTER FOR COMPUTATIONAL SCIENCE, HE HAS ADJUNCT APPOINTMENTS, TWOF THEM AT HOPKINS IN MENTAL HEALTH AND BIOSTATISTICS. HE HAS--I KNOW HIS WORK PRIMARILY IN THE AREA OF INNOVATIVE DESIGN FOR RANDOMIZED TRIALS, WE WERE CHATTING A LITTLE BIT BEFORE HAND, IT WAS HIS WORK THAT INTRODUCED ME TO STEP WEDGE DESIGNS SOME YEARS AGO AND GOT ME INTERESTED IN THOSE. HE HAS WORKED ON TRIALS RELATED TO THE PREVENTION OF DRUG ABUSE, DEPRESSION AND SUICIDE. I THINK WE'RE GOING TO HEAR SOME ABOUT THAT TODAY. HE'S DEVELOPED NEW METHODS FOR SYNTHESIZING DATA ACROSS RANDOMIZED TRIALS. HE ALSO APPLIES SYSTEM SCIENCE AND COMPUTATIONAL METHODS FOR IMPLEMENTATION AND RESEARCH. SO LET ME PLEASE INTRODUCE DR. HENDRICKS BROWN. [ APPLAUSE ] >> THANK YOU, DAVID. I APPRECIATE THOSE KIND WORKS OF INTRODUCTION, IT'S GREAT TO BE HERE AND BE PART OF THIS SERIES WITH THE OFFICE OF DISEASE PREVENTION WHICH IS INCREDIBLY IMPORTANT FOR US IN TERMS OF MOVING AN AGENDA FORWARD. TODAY I'M GOING TO BE TALKING ABOUT HEALTH DISPARITIES, IF I CAN--IF I CAN GET THIS RIGHT. PARTICULARLY AROUND WHAT WE'RE GOING TO BE CALLING SCIENTIFIC EQUITY AND IT'S A NEW TERM WE'VE BEEN USING IN HERE AS CERTAINLY INFLUENCED HEAVILY BY A LOT OF MY COLLEAGUES AT THE UNIVERSITY OF MIAMI WHO HAVE BEEN WORKING ON HISPANIC HEALTH ISSUES FOR GENERATION, BUT THIS ALSO GOES BACK TO MY EARLY DAYS AT THE UNIVERSITY OF CHICAGO WHERE I WAS WORKING ON THE WOOD LINE PROJECT WITH SHEPHERD AND A NUMBER OF OTHER PEOPLE HERE WITH AFRICAN AMERICANS, POPULATIONS IN HERE AND THE IDEA OF THIS IS THAT, WE REALLY NEED TO TAKE A VERY CAREFUL LOOK AT WHAT KINDS OF INFORMATION WE'RE COLLECTING. WHAT IS THE BROAD PICTURE OF THE SCIENTIFIC AGENDA AROUND ADDRESSING DISPARITIES AND MINORITIES AND OTHER POPULATIONS. I WANT TO START WITH ACKNOWLEDGING THE TWO GRANTS THAT I HAVE THAT NIMH THAT FUNDED IN THIS COLLABORATIVE SYNTHESIS. TRIALS ON ADOLESCENT DEPRESSION, I'LL TALK ABOUT MOSTLY TODAY AND SPEND A TURNOVER AMOUNT OF TIME TALKING ABOUT THE ISSUES WE LEARNED IN HERE. ALSO NIDA FOR THE CENTER FOR PREVENTION IMPLEMENTATION, METHODOLOGY, DRUG ABUSE AND SEX RISK BEHAVIOR. AND ALSO FOR 25 YEARS OF SUPPORT FROM NIDA AND NIMH, THE GROUND, THE PREVENTION SCIENCE AND METHODOLOGY GROUP, WHICH IS A NETWORK OF PEOPLE WHO WE HAD IN COLLABORATION ACROSS THE COUNTRY AND SOME OUTSIDE THE UNITED STATES HAVE BEEN WORKING TOGETHER, AROUND NOT ONLY DEVELOPING NEW METHODS BUT ALSO APPLYING THEM IN SETTINGS SO THAT WE CAN USE THE MAXIMUM KNOWLEDGE WE CAN POSSIBLY GAIN FROM THOSE KINDS OF STUDIES. ALSO WANTED TO POINT OUT THE CO-AUTHORS THAT ARE ON THIS PROJECT IN HERE, TATIANA, PERRINO, MENTIONED A LOT OF PLACES IN HERE WHERE SHE'S LEADING THE WORK ON DATA SYNTHESIS AND OTHERS IN HERE THAT ARE MOSTLY AT THE UNIVERSITY OF MIAMI BUT ALSO GUILLERMO BERNAL, GEORGE HOWE, AND OTHERS, BUT THIS IS A SMALL SET OF COLLABORATIONS THAT WE DO. SO I WILL GIVE YOU MORE PEOPLE AT THE END OF THIS ONE. I APPRECIATE ALL THE WORK THAT EVERYBODY'S DONE BECAUSE THIS REALLY IS TRULY COLLABORATIVE. SO HERE'S THE KIND OF OUTLINE I WANT TO DO. I THINK IT'S IMPORTANT THAT WE TAKE A LITTLE BIT OF TIME TALKING ABOUT HEALTH DISPARITIES, ITSELF. WHAT DOES THAT MEAN? WHAT ARE THE LEVELS OF HEALTH DISPARITIES THAT WE SEE IN THE U.S. I'M GOING TO FOCUS ON THIS APPLICATION AND ALL ABOUT YOUTH AND YOUNG ADULTS, EITHER WE COULD GO IN AND TALK ABOUT THE EFFECTS OF ADULTS AS WELL AND THE AREAS OF OUTCOMES THAT WE'RE GOING TO BE INTERESTED IN HERE IS WHAT WE'RE GOING TO BE CALLING, BORROWING FROM THE RECENT IOM REPORT IN HERE ABOUT MENTAL, EMOTIONAL AND BEHAVIORIAL PROBLEMS IN HERE. SO WE'LL TALK ABOUT PREVALENCES AND DIFFERENCES IN HEALTHCARE AS WELL. WE'LL ALSO TALK ABOUT, THIS WORD SCIENTIFIC EQUITY AND WHAT IT ACTUALLY MEANS IN HERE AND HOW DO WE USE THAT TO HELP AND SUPPORT ACHIEVING HEALTH EQUITY IN HERE. THIRD POINT IN HERE IS WE'RE GOING TO TALK ABOUT SPECIFICS, ABOUT THE DIFFERENT WAYS OF USING SCIENTIFIC EQUITY AND DIFFERENT PROBLEMS IN HERE. ONE OF THE AREAS, IS LOOKING AT WAYS TO SYNTHESIZE FINDINGS FOR MULTIPLE TRIALS IN HERE AND A SECOND POINT WHICH MAY COME UP MORE IN THE DISCUSSION, I WILL ALLUDE TO IT MOSTLY IN HERE IS ABOUT IMPLEMENTATION RESEARCH AS WELL. BECAUSE THOSE ARE THE KEY PROBLEMS THAT ARE CHALLENGES FOR THE NEXT PHASE OF WORK IN HERE. AND THEN FINALLY WE'LL DO A BIT OF SUMMARIZATION IN HERE AND LOOK AT WHAT NIH POLICIES LOOK LIKE RIGHT NOW AND HOW THEY MIGHT BE RELEVANT TO THIS ISSUE. SO, STARTING OFF WITH DEFINING SOME OF THE TERMS AROUND DISPARITIES AND EQUITIES AND INEQUALITIES. THE FIRST THING IS IF YOU START TO LOOK AT WHAT THE LITERATURE IS, THE FIRST THING YOU SEE IS A LOT OF AMBIGUITY. THERE ARE A LEAST 11 DIFFERENT DEFINITIONS OF HEALTH DISPARITIES IN HERE. MY FAVORITE ONE, I THINK, RIGHT NOW IS PROBABLY THE CDC ONE WHICH, YOU'RE WELCOME TO READ IN HERE BUT IT HAS TO DO WITH DIFFERENCES AND HEALTH OUTCOMES AND THE DETERMINANTS BETWEEN SEGMENTS OF THE POPULATION IS DEFINED BY SOCIAL DEMOGRAPHIC, ENVIRONMENTAL AND GEOGRAPHIC ATTRIBUTES. IN OTHER COUNTRIES, THE EXISTENCE OF DISPARITY SYSTEM INDICATED AS A HEALTH AND INEQUALITY. AND THE EXISTENCE OF IT. SO IT'S A MUCH MORE PROACTIVE KIND OF ROLE IN HERE. IN THE UNITED STATES THERE IS A LEGAL DEFINITION, BY PUBLIC LAW. THE DEFINITION OF A HEALTH DISPARITY POPULATION THAT'S GIVEN BY SIGNIFICANT DISPARITY, IN THE OVERALL RATE OF DISEASE, INCIDENCE, PREVALENCE, MORBIDITY AND SURVIVAL RATE IN THE POPULATION COMPARED TO THE HEALTH OF THE GENERAL POPULATION. WE ARE GOING TO BE LOOKING AT ISSUES WITH DIFFERENT RACE AND ETHNIC MINORITIES IN HERE, PARTICULARLY AFRICAN AMERICANS, I'LL TALK A BIT BRIEFLY AROUND AMERICAN INDIANS AND ALASKA NATIVE BUT ALSO HISPANICS AS OTHER POPULATIONS IN HERE. I WON'T SAY TOO MUCH ABOUT LOW SOCIOECONOMIC STATUS, OR RURAL FACTORS IN HERE, BUT THOSE ARE IMPORTANT AS WELL. I'LL GIVE YOU A LITTLE BIT OF INDICATION FROM SOME OF THE DATA ABOUT THOSE AS WELL. SO QUESTION, ABOUT HOW DO WE MOVE TOWARDS HEALTH EQUITY. SO THE WORD SAYS HEALTH EQUITY, I THINK ARE REALLY VERY POSITIVE, IT DOESN'T FOCUS ON NECESSARILY THE DIFFERENCES IN HERE, BUT IT FOCUSES ON THE SOLUTION. THAT'S THE POINT THAT WE WANT TO MAKE IN HERE. SO MOVING TOWARDS HEALTH EQUITY AND ALSO HEALTHCARE EQUITY. THE ACTUAL SERVICES THAT ARE PROVIDED IN HERE. SO HEALTH EQUITY IS DEFINED AS HEALTH AND HUMAN SERVICES IS THE ACTINEMENT OF THE HIGHEST LEVEL OF HEALTH FOR ALL PEOPLE AND I'M NOT GOING TO READ THROUGH THE DEFINITIONS IN HERE, I'LL LET YOU READ THEM AT YOUR OWN. BUT YOU CAN SEE THAT THERE IS A REAL SENSE OF SOCIAL JUSTICE BEHIND THE IDEAS OF HEALTH EQUITY THAT HUMAN--YOU KNOW AMERICAN CITIZEN AND PEOPLE LIVING IN THIS COUNTRY SHOULD DESERVE THE BEST QUALITY OF HEALTH THAT WE CAN PROVIDE IN HERE. THE TALK ABOUT ACTUAL INIQUITIES ARE AROUND HERE, MENTAL EEMOTIONAL AND BEHAVIORIAL HEALTH. THE TERM MENTAL EEMOTIONAL AND BEHAVIORIAL HEALTH HAS BEEN USED BY THE INSTITUTE OF MEDICINE IN 2009. IT DOES LEAVE OUT AN IMPORTANT DIMENSION IN HERE WHICH HAS TO DO WITH COGNITIVE FUNCTIONING WHICH I THINK IS AN IMPORTANT ONE TO INCLUDE AS L. BUT WHAT WE'RE TALKING ABOUT IS DIAGNOSEABLE DISORDERS INCLUDES DEPRESSION, ANXIOUS, SCHIZOPHRENIA AND OTHER AREAS LIKE THAT. AS WELL AS PROBLEM BEHAVIORS, DRUG USE AND ABUSE, ANTISOCIAL AND AGGRESSIVE BEHAVIOR AND VIOLENCE FOR EXAMPLE. LOTS OF DESCRIPTION IS AVAILABLE ON THE WEB, CDC HAS A WHOLE WEB SITE FOR LOOKING AND IDENTIFYING HEALTH DISPARITIES IN THE 2011 REPORT WITH THE REFERENCE DOWN AT THE BOTTOM OF THIS ONE. NOTING THAT IT'S BEEN A PRIORITY FOR CDC AS WELL AS FOR SAMSA, AS WELL AS NIH FOR ADDRESSING ISSUES AROUND HEALTH DISPARITIES, YES. SO I'LL GIVE YOU A COUPLE OF IMPORTANT EXAMPLES IN HERE. I THINK YOU HAVE TO START OFF WITH THIS ONE. HIV INFECTION BY RACE AND ETHNICITY IS TOTALLY INTOLERABLE. FOR AFRICAN AMERICAN FEMALES WHO ARE EITHER YOUTH OR YOUNG ADULTS, THEIR RATES OF INFECTION IS 11 TIMES THAT OF OF WHITE NONHISPANIC FEMALES AND FOUR TIMES THAT OF HISPANIC FEMALES. FOR AFRICAN AMERICAN MALES IT'S SEVEN TIMES AS HIGH AS IT IS FOR WHITE NONHISPANIC MALES AND THREE TIMES AS HIGH FOR HISPANIC MALES. AND THAT'S A--THAT'S A NATIONAL PRIORITY THAT WE ADDRESS IT. I DO THINK AS WE THINK ABOUT WHAT THOSE STRATEGIES ARE, WHICH I HOPE WILL COME UP IN SOME OF THE CONVERSATIONS TODAY, THAT SOME OF OF THOSE SOLUTIONS, IN HERE ARE GOING TO BE INNOVATIVE AND THEY'RE DOING SOMETHING DIFFERENT THAN WHAT WE'RE ADDRESSING RIGHT NOW. BUT A LOT OF THE OTHER RATES IN HERE THAT IF YOU REPORT THEM, SIMPLY THE NATIONAL LEVEL WITH BROAD CATEGORIES, REALLY DON'T PICK UP THE REAL DIFFERENCES. AND YOU DO HAVE TO TAKE A LOOK MORE DEEPLY AT THOSE RATES AND UNDERSTAND THE SPECIFIC COMBINATIONS OF AGE FOR EXAMPLE, SOCIOLOGI CAL ECONOMIC STATUS, IMMIGRANT STATUS, ET CETERA, IN ORDER TO LOOK AT IT. SO I'LL GIVE YOU A COUPLE EXAMPLES, HERE'S ONE FOR SUBSTANCE USE OR ABUSE. THIS ONE COMES FROM MONITORING THE FUTURE, STUDIES FOR 10th GRADERS AND YOU CAN SEE THAT THE LINE WITH ONE OVER HERE, CORRESPONDS TO A COMPARISON RATE WITH NONHISPANIC WHITES AND YOU CAN SEE THAT THE RATES FOR AFRICAN AMERICANS AND THE BLUE LINE IN HERE IS ALMOST ALWAYS BELOW THAT FOR THE REPORTED RATES FOR WHITE NONHISPANICS. FOR HISPANICS, IT'S ABOUT THE SAME FOR MANY OF THE OUTCOMES IN HERE, BUT ONLY A COUPLE OF THEM WILL BE HIGHER OVERALL FOR HISPANICS. AND AGAIN THESE ARE NATIONAL RATES IN HERE. WHEN YOU START TO LOOK AT THEM, BY OTHER SUBGROUPS IN HERE, REALLY IMPORTANT DIFFERENCES START TO APPEAR. SUICIDE RATES IN HERE ARE DRAMATICALLY DIFFERENT. BY DIFFERENT GROUPS IN THE POPULATION, WHITES, PARTICULARLY, MALES HAVE MUCH HIGHER RATES THAN OTHERS, EXCEPT FOR THE POPULATION OF NATIVE AMERICANS AND ALASKA NATIVES, THOSE RATES HAVE COMPLETED THE DID SHE LINE THAT IS ELEVATED VERY HIGH AMONG THE YOUNGER YOUTH AND ADULTS AND THEN IT GOES DOWN AND DECREASES DRAMATICALLY EVEN WAY DOWN BELOW THE CONTINUING UPWARD LEVEL OF THE RATE FOR THE--FOR WHITE AMERICANS. SO YOU DO NEED TO TAKE A LOOK AT THE DISTINCTIONS, WHEN THESE RATES ARE IN FACT CHANGING. HERE'S AN EXAMPLE FOR SUICIDE AS WELL. NOT ONLY IS THERE A LARGE DIFFERENCE BY REGION OF THE COUNTRY, WHERE IN THE WEST, THE RATES OF SUICIDE ARE MUCH HIGHER THAN THEY ARE OVERALL, BUT THIS DISPLAYS A PICTURE OF THE LEVEL OF RURALITY, SO THESE ARE NINE CATEGORIES, OVERALL IN TERMS OF THE--THE LEVEL OF URBANISSITY TO RURAL COMMUNITIES AND WHAT YOU CAN SEE IS THAT VERY CONSISTENT PATTERNS FOR EVERYBODY EXCEPT IN THE SOUTH WHERE THE--AS GUTMACHER TO HIGHER LEVELS OF RURALITY, THAT THE RATES HAVE INCREASED. AND THIS OCCURS EVEN WITHIN STATES, SO THERE'S SOMETHING VERY SYSTEMATIC ABOUT THIS IN TERMS OF RURAL RATES OF SUICIDE OR HIGHER THAN THEY ARE WITH URBAN SETTINGS. THIS IS AN EXAMPLE OF A WIDE DIFFERENCE IN THE RATES FOR HISPANIC POPULATIONS. HISPANIC--THE TIME AT WHICH INDIVIDUALS COME OVER INTO THE UNITED STATES, CHOSE A LARGE VARIATION IN THE EFFECTS OF PREVENTIVE LANCES OF SUBSTANCE ABUSE FOR EXAMPLE, ANOTHER PSYCHIATRIC DISORDERS. IF YOU THINK ABOUT FIRST GENERATIONS IN HERE, FOREIGN BORN IS THE COMPARISON GROUP IN HERE AND THEN COMPARE IT THE SECOND GENERATION WHICH IS INDIVIDUALS WHERE THE KIDS ARE BORN IN THE UNITED STATES AND THE THIRD IS WHEN THE PARENTS ARE COMING OVER AND HERE THOSE. THE RATES, OUTCOMES ARE VERY OFTEN IN THE SENSE OF BOTH ILLICKITY DRUGS BENGING AND SUICIDE ATTEMPT, IT'S CLEAR THAT THE RATES ARE HIGHER, THE LONGER THAT PEOPLE ARE IN THIS COUNTRY. UNLIKE WHAT YOU MIGHT EXPECT, THIS IS--THIS IS HISPANIC PARADOX, IT ALSO SHOWS UP FOR ADULTS AS WELL. IT DOESN'T SHOW UP NATIONALLY ON DEPRESSIVE SYMPTOMS, THOUGH. THERE'S A LOT OF OTHER ISSUES BESIDES JUST THE RATES. OTHER IMPORTANT DIFFERENCES IN HERE, HEALTHCARE ACCESS AND QUALITY ARE INCREDIBLY VARYING AS A FUNCTION OF MINORITY STATUS FOR EXAMPLE. THE IOM BOOK IN 2003, DOCUMENT A LOT OF DIFFERENCES IN HERE, THAT IS STILL PREDICTIVE POORER OUTCOMES, POORER ACCESS TO CARE EVEN IF THE CONTROLS WERE SES AND AGE AND SEVERITY OF CONDITIONS AS WELL, THAT'S A MAJOR FACTOR IN HERE IN TERMS OF POOR OUTCOMES, AMONG A LARGE GROUP OF INDIVIDUALS, HAD WHO ARE MINORITIES IN OUR COUNTRY, MAGGIE AND HER COLLEAGUES HAVE TALKED ABOUT THE EFFECTS ON SUBSTANCE ABUSE DISORDER FOR AFRICAN AMERICANS IN HERE, WHO SEE LESS INFORMAL CARE AS WELL AS SPECIALTY CARE FOR DRUG USE. IT IS ALSO AFFECTING THE HAS PANICS AND HAITIAN YOUTH AS WELL. SO I WANT TO TURN NOW, JUST AFTERRA AN INTRODUCTION OF THOSE TOPICS IN HERE, TO SCIENTIFIC EQUITY. SCIENTIFIC EQUITY, WE THINK THIS IS A STRATEGIC APPROACH TO TRY AND ADDRESS THESE ISSUES OF HEALTH EQUITY. WHAT DO WE MEAN BY SCIENTIFIC EQUITY. IT'S THE EQUITY, THE AMOUNT OF SCIENTIFIC KNOWLEDGE THAT IS PRODUCED TO UNDERSTAND BOTH THE CAUSES AND SOLUTIONS OF HEALTH AND EQUALITY. WHAT WE'RE TALKING ABOUT IS DO WE HAVE ENOUGH SCIENTIFIC KNOWLEDGE THAT WE'RE PUTTING TOGETHER TO BE ABLE TO ADDRESS THESE. AND ALSO IN PARENTHESES, IT'S NOT JUST THE PRODUCTION OF THAT INFORMATION, BUT IT'S ALSO THE ACTUAL USE OF THAT INFORMATION. THERE'S A LOT OF DATA MINING THAT NEEDS TO CONSIDER IN HERE, MAYBE A BETTER TERM IS WHAT NILA DWAN CALLS DATA FARMING, THAT IS MUCH MORE STRATEGIC USE OF THE DATA OUT THERE, TO JUST AS MUCH AS YOU CAN OUT OF IT. SO IT'S REALLY THE APPLICATION OF THAT KNOWLEDGE AS WELL, THAT'S IMPORTANT IN HERE. SO WHILE THERE'S A SUBSTANTIAL AMOUNT OF DATA TO INDICATE EQUITIES EXIST AND THEY EXIST IN HERE, WE NEED ADDITION ALGORITHMS RESEARCH TO TELL US WHAT EFFECTIVE STAT EDGYS SHOULD BE USED TO GUIDE OUR WORK ON THIS. HERE'S A COUPLE THINGS OF SCIENTIFIC EQUITY CAN BE HELPING US TO ANSWER AND HOW DOES THE CONDITION DEVELOP UPON IN THE FIRST PLACE AND WHAT ACTIONS CAN BE USED TO PREVENT THE CONDITION FROM DEVELOPING OR HELPING RESOLVE OR AMELIORATE IT ONCE IT DOES DEVELOP AND WHAT SERVICE SYSTEMS ARE NEEDED TO PREVENT OR TREAT THE CONDITION. THEY OCCUR IN CLASSES AND MINORITIES AND OTHER GROUPS. SO WE THINK IT'S IMPORTANT THAT WE HAVE TO ACHIEVE TO ADVANCE HEALTH INIQUITIES. IF WE DON'T HAVE THE SCIENTIFIC ADKNOWLEDGE IN HERE, WE CAN'T GO FORWARD. SO THAT MEANS TRYING UNDERSTAND WHAT ARE EFFECTIVE AND THAT'S A BROAD CATEGORY IN HERE WE NEED TO KNOW BEYOND THAT. DO EFFICACIOUS INTERVENTIONS OR EFFECTIVE INTERVENTIONS WORK WELL FOR OUR GROUPS, WE CAN'T GET THAT BE THE ANSWER OR BE ABLE TO ADDRESS INIQUITIES IN HERE. SO THE LINGO PEOPLE USE IN HERE HAS TO DO WITH MODERATORS AND MEDIATORS. MODERATORS HAVE TO DO WITH WHAT INTERVENTIONS ARE EFFECTIVE TAR SUBGROUPS. MEDIATORS HAVE TO DO WITH THE MECHANISMS, WHY DOES AN INTERVENTION WORK AND THERE'S BEGINNING INFORMATION THAT PEOPLE HAVE ABOUT THESE KINDS OF TOPICS IN HERE. I'LL GIVE A COUPLE OF EXAMPLES. IF YOU THINK ABOUT WHAT THE STRATEGIES ARE TRYING TO REMOVE THESE DISPARITIES THERE'S A LOT OF DIFFERENT APPROACHES THAT PEOPLE HAVE MADE, GEORGE ALBY ONE OF THE FATHERS OF PREVENTION REALLY FOCUSED IN A LATER PART OF HIS LIFE AROUND RACISM, SEXISM, POVERTY, STIGMA, ET CETERA AND THOUGHT THOSE WERE THE PRIMARY DRIVING FORCES. THEY CERTAINLY ARE IMPORTANT IN HERE, THEY CLEARLY ARE ONE OF THE QUESTIONS IS HOW MUCH OPPORTUNITY DO WE HAVE OF MAKING DIRECT IMPACT ON THOSE PARTICULAR BROAD CHARACTERISTICS IN HERE. SO IN THE MEAN TIME WE'VE LEARNED AN AWFUL LOT ABOUT WHAT PREVENTION PROGRAMS WERE. THE IOM REPORT IN 2009 AS WELL AS MANY OTHER PLACES HERE HAVE DEMONSTRATED THERE'S LOTS OF PREVENTION PROGRAMS, WORK ACROSS THE LIFE SPAN, ACROSS SPECIFIC POPULATIONS, THAT WE'RE NOW IN A PATCH WORK AREA, TO INTEGRATE ALL THAT MATERIAL TOGETHER, TO SEE, WONDER WHAT CONDITIONS DO THINGS WORK AND WHICH CONDITIONS CAN THINGS BE USED. STRATEGIES FOR DELIVERING PREVENTION PROGRAMS OR INTERVENTION PROGRAMS, RANGE ALL THE WAY FROM GENETICS AND BIOLOGY TO KIND OF WORK THAT GENE BRODY IS LOOKING AT AND LOOKING AT VARIATION AND GENETIC FACTORS WITH PREVENTION PROGRAMS IN HERE AND TARGET SPECIFIC BEHAVIOR AND SOCIAL ENVIRONMENT AND PHYSICAL ENVIRONMENTS OR EVEN THE VIRTUAL ENVIRONMENT IT'S VERY USEFUL AND IT IS IMPORTANT TO NOTE THAT THESE ARE MULTIFACETED KINDS OF STRATEGIES THAT ARE PROBABLY GOING TO NEED HERE BECAUSE IF YOU LOOK AT WHAT HAPPENS TO MINORITIES, THEY HAVE OFTEN A COMBINATION OF ARRANGE OF RISK FACTORS THAT ARE GOING TOGETHER FOR EXAMPLE, TOGETHER WITH HIV, THE SUSCEPTIBILITY FOR HIV, THE PREVALENCE OF THE HIV VIRUS IN AFRICAN AMERICAN COMMUNITIES IS HIGHER THAN OTHER ONES, FOR EXAMPLE. THERE'S LOW ACCESS TO HEALTHCARE, MORE DISCRIMINATION, INSTITUTIONAL RACISM, ET CETERA. SO WHEN HEALTH INTERVENTION CANS IMPROVE OVERALL POPULATION HELP, THEY ALSO HAVE THE PROBABILITY OF INCREASING HEALTH INEQUITY. THIS IS A RESULT THAT WAS POINTED OUT IN 2012, THAT SOMETIMES WE NEED INTERVENTION AND THE INTERVENTION IS NOT TAKEN UP EQUALLY BY GOOD POPULATIONS HERE. SO A GOOD EXAMPLE OF THAT IS ISHT VENTION GENERATED INIQUITIES IS WHAT THEY CALL THAT. A SMOKING BAN, THINGS LIKE IN THE WORKPLACE OFTEN HAVE HIGHER IMPACT AROUND THOSE WITH HIGHER SOCIOECONOMIC STATUS AND NOT AS MUCH ON LOWER SOCIOLOGICAL SOCIOECONOMIC STATUS. SO THERE ARE PLENTY OF EXAMPLES WHERE THERE ARE DIFFERENTIAL SUBGROUP DIFFERENCES IN RESPONSE TO INTERVENTIONS, PREVENTIVE INTERVENTIONS, PARTICULARLY, CARDEMIL AND OTHERS LOOKAD THE PENN RESILIENCE PROGRAM, AND FOUND THIS FOCUSING ON DEPRESSION, HAD IMPACT BENEFICIAL IMPACT ON LATINO CHILDREN BUT IT DID NOT HAVE IMPACT ON AFRICAN AMERICAN CHILDREN. SO IT RAISES SOME OF THE QUESTIONS ABOUT WHAT'S THE MECHANISM OF THAT. ANOTHER EXAMPLE THAT MIGHT BE USEFUL IN HERE, TO TAKE A LACK AT,--LOOK AT IS NANCY GONZALEZS STUDY IT'S OF OF PREVENTIVE AND HIGH SCHOOL FOR LATINOS, AND THEIR FAMILIES, THEY FOUND THERE WAS DIFFERENCES IN HERE, IN TERMS OF THE MECHANISM OF INTERVENTION. SO WHAT IT FOUND IS THAT FOR THOSE FAMILIES, WERE PREFERRED TO GET THE INTERVENTION IN ENGLISH, THEY SHOWED HIGHER INCREASES IN MATERNAL MONITORING AS THE MEDIATING FACTOR TOWARDS LATER OUTCOME. BUT THEY ALSO FOUND IN SPANISH PREFERRED SPEAKING FAMILIES, THEY FOUND REDUCTION IN ETERNAL PARENT ASKING THAT WAS THE ONE THAT MEDIATED. SO WHAT WE'RE LOOKING AT IS A POTENTIAL VARIATION IN THESE MEDIATIONAL PATHWAYS THAT WE NEED TO BE ABLE TO IDENTIFY AND DISCERN. SO THESE ARE THIS JUST ONE EXAMPLE AND WE HAVEN'T LOOKED FOR MUCH OF THIS. SO THE QUESTION IS HOW DO YOU LOOK? WHAT KINDS OF AREAS DO YOU TAKE A LOOK AT IN HERE? SO I'M GOING TO BRIEFLY TALK ABOUT TWO WAYS OF LOOKING AT THIS ONE. ONE IS THIS COLLABORATIVE SYNTHESIS IDEA AROUND RANDOMIZE TRIALS AND THE SECOND HAS TO DO WITH IMPLEMENTATION SCIENCE, BECAUSE I THINK THOSE ARE THE KEY FACTORS THAT I THINK WILL BE USEFUL. IF YOU REALLY START TO THINK, ONE OF THE REASONS WHY WE ARE NOT BEING ABLE TO REMOVE THE HEALTH DISPARITIES IN OUR COUNTRY, THE WAY WE WERE BEFORE, I THINK THERE ARE THREE POSSIBILITIES HERE. IF YOU JUST START OFF AND SAY, WELL, MAYBE WE JUST DON'T KNOW THAT THESE DISPARITIES EXIST. SECOND IS THAT MAYBE WE KNOW THEY EXIST, BUT WE DON'T KNOW OF ANY SUCCESSFUL INTERVENTIONS THAT WE COULD USE. AND THE THIRD QUESTION, IS MAYBE WE DON'T KNOW HOW TO IMPLEMENT THOSE EVIDENCE BASED INTERVENTIONS? SO I WILL TAKE US THROUGH THE LOGIC ASSOCIATED WITH EACH OF THOSE THREE KINDS ASSOCIATED HERE. THE FIRST ONE IS PRETTY EASY TO SEE. DO WE KNOW ABOUT DISPARITIES AND DO THEY EXIST? WE GAVE EXAMPLES IN HERE AND WE COULD DO HOURS AND HOURS OF PEOPLE AND DISPARITIES SO THAT REALLY IS--THAT'S NOT THE REASON WHY WE'RE NOT SUCCESSFUL SUCCESSFUL INTERVENTIONS. SO HERE'S THREE POSSIBLES AND WE WILL LOOK AT WHAT PREVENTION PROGRAMS OF STRATEGIES MIGHT WORK FOR HISPANICS, THE EXAMPLE HAS TO DO WITH THE NIMH PROJECT OF LOOKING AT DEPRESSION PREVENTING DEPRESSION IN HERE AND WE'RE GOING TO TAKE THREE POSSIBLE WAYS OF LOOKING AND ONLY SPECIFIC TO HISPANICS AND TAKE A LOOK AT, THE SECOND ONE IS TO TAKE A GENERIC PREVENTION PROGRAM THAT IS NOT SPECIFIC TO HISPANICS BUT LOOK AT WHAT HAPPENS TO THE HISPANIC SUBGROUP IN THAT TRIAL. THE THIRD ONE IS TO SAY WE'RE GOING TO LOOK AT THE FOUR HISPANICS BY TAKING COMBINING TRIALS THAT HAVE HISPANICS IN THEM THEY'RE ONLY INDIVIDUALS IN THOSE STUDIES SO THOSE ARE THE THREE THINGS WE'RE GOING TO TAKE A LOOK AT ON SOME LEVEL OF DETAIL HERE. SO THE FIRST ONE IS MAYBE WE JUST DON'T KNOW THERE'S SUCCESSFUL INTERVENTIONS AT ALL. SO NUMBER ONE IN HERE, LET'S LOOK AT WHAT PREVENTION PROGRAMS ARE DONE ONLY SPECIFIC FOR HISPANICS. IF YOU LOOK AT THE AND AND NIH, NIDA, AND NIARKS AAA, AND WHAT YOU FIBBED IS THAT ALL OF ALL THE TRIALS THAT ARE OUT THERE, FIVE% OF THOSE ARE SPECIFICALLY FOCUSED ON AFRICAN AMERICANS AND 10% FOR HISPANIC. THAT'S CERTAINLY LESS THAN THE GENERAL POPULATION OF THOSE. AND SO WE THINK OF THE KNOWLEDGE WE ARE GAINING ABOUT SPECIFIC INTERVENTIONS. SPECIFIC TO THOSE POPULATIONS IS UNDERREPRESENTED HERE, BUT IT'S ALSO THAT WE HAVE TOO FEW THAT ARE EVIDENCE BASED THAT ARE REALLY WORK IN HERE. THE RATE OF NEW PREVENTION TRIALS FOR MINORITIES CERTAINLY NOT KEEPING UP WITH THE POPULATION BUT IF THAT WAS THE PERCENT AS A GENERAL POPULATION, IT WOULDN'T BE SUFFICIENT BECAUSE WE HAVE A SMALLER NUMBER OF TRIALS IN HERE, WHO STILL NEED TO HAVE SUFFICIENT NUMBERS THAT GIVE US A LARGE FRACTION THAT ARE GOING TO BE SUCCESSFUL. AND WE WOULDN'T EXPECT THAT THAT DIFFERS, ACROSS INTERVENTION BY ETHNICITY IN HERE. SO WE'RE NOT GAINING AS MUCH KNOWLEDGE AS WE NEED TO ADDRESS THESE ISSUES. OKAY, SO WE'RE NOW GOING TO GO TO THESE OTHER SECOND ISSUES IN HERE. TESTING AND GENERIC PREVENTION PROGRAM IN A TRIAL RESTRICTED TO HISPANIC SUBGROUP. OKAY? SO HERE'S THE NEXT STEP IN HERE. IN 19, NIH IDENTIFIED INCLUSION FOR WOMEN, MINORITIES AND CHILDREN ESPECIALLY IN PHASE THREE CLINICAL TRIALS. VERY LOGICAL REASONS IN HERE, HEART DISEASE WAS ONLY AROUND MEN AND WOMEN WERE DYING AT THAT TIME BECAUSE THE PREDICTIONS OF WHO WAS AT RISK FOR HEART ATTACK WAS NOT IDENTIFIED FOR WOMEN THE WAY IT IS FOR MEN. THIS IS THE DATA THAT CAME FROM A 1996, LET'S SAY, I GUESS THE FINAL REPORT IN HERE IS 2010 FOR PHASE THREE CLINICAL TRIALS. 600,000 TO 700,000 AFRICAN AMERICANS MADE UP EVEN MORE OF THE POPULATION IN THIS 1 PERCENTAGE WISE BUT HISPANIC AND LATINOS WERE LESS. SUBSTANTIALLY LESS THAN THIS. I SUSPECT THE MAJOR REASON OF THIS WAS BECAUSE OF LANGUAGE DIFFERENCES AND WERE AN IMPORTANT PART OF THIS ONE. SO WE'RE GOING TO TAKE A LOOK AT THIS ONE AND SAY, WHAT WOULD YOU GET IF YOU TOOK THESE GENERIC PREVENTION PROGRAMS AND THEN FOCUSED ONLY ON THE HISPANIC SUBGROUP TO SEE WHETHER THERE'S ENOUGH INFORMATION IN THERE TO GIVE YOU AN IDEA. IF YOU TAKE A GENERIC PREVENTION PROGRAM, AND YOU DO IT WITH A RANDOMIZED--SINGLE RANDOMIZED TRIAL, THE TYPICAL TRIAL IS STILL ABOUT $500,000 A YEAR. IT'S GETTING MORE COSTLY TO DO, AND THE NUMBER OF PEOPLE THAT WE'RE GETTING INTO THOSE TRIALS EACH WE'RE AND LESS BECAUSE OF THE COST. SO THAT THE PORTION UNLESS WE'RE GETTING HIGHER AND HIGHER PROPORTIONS OF MINORITIES. WERE PROBABLY GOING TO HAVE VERY FEW OF THOSE INDIVIDUALS, INDIVIDUAL TRIALS, WHO ARE GOING TO GIVE US SUFFICIENT INFORMATION FOR MINORITIES. STATISTICAL POWER IN HERE FOR THE IMPACT ON MINORITIES AND MODERATION, IS PROBABLY NOT GOING TO BE IMPROVING OVER TIME IF ANYTHING, IT'S PROBABLY GOING TO DECREASING. SO WHAT WE'VE GOT IS, A SINGLE TRIAL IS PROBABLY NOT GOING TO HELP US, PARTICULARLY IF A LOT OF THEM ARE $500,000 A YEAR AND THAT'S THE MAXIMUM. SO WE'RE REALLY GOING TO THIS LAST PART OF IT HERE OF EXAMINING HOW CAN WE SYNTHESIZE FINDINGS ACROSS MULTIPLE TRIALS AND THAT'S THE PLACE THAT WE THINK WE CAN REALLY MAKE A HUGE AMOUNT OF GAIN. IN FACT, WE PROBABLY HAVE SUFFICIENT DATA ALREADY TO BE ABLE TO MAKE SOME OF THESE GAMES. SO THE COLLABORATIVE DATA SYNTHESIS PROJECT FOR ADOLESCENT DEPRESSION TRIALS, THE SYNTHESIS TRIAL IN HERE, IS FUNDED BY NIMH, AND MY COLLEAGUES GEORGE HOWE, AND HILDA AND TATIANA, ARE THE KEY LEADERS ON THIS ONE. IT HAS THREE AIMS, ONE OF THEM IS TO DEVELOP TECHNIQUES FOR SYNTHESIZING FINDINGS PARTICULARLY AROUND MEDIATION AND MODERATION, AS YOU INDGREAT CROSS PULLET PEL TRIALS, TALKING ABOUT INDIVIDUAL LEVEL DATA, TALKING ABOUT HOW DO WE DEAL WITH DIFFERENCES IN POPULATIONS SUPPRESSED TRIALS, ACROSS INTERVENTION, ACROSS THE DESIGN OF THE STUDY, DIFFERENT TIME POINTS FOR EXAMPLE IN OUTCOMES. AND THOSE ALL ARE TECHNICAL PROBLEMS THAT ARE MORE COMPLICATED THAN THE TRADITIONAL META-ANALYSIS PROBLEMS IN HERE. OUR FOCUS IS THE ON THE APPLICATION OF METHODS FOR PREVENTION OF DEPRESSION IN ADOLESCENTS. AND WE DECIDED WE WOULD INCLUDE TREATMENT IN THOSE. WE HAVE 40 INDIVIDUAL DATA SETS, WE ARE IN THE PROCESS OF COLLECTING A DEBT, WE HAVE MOST OF THOSE SO FAR AND WIRE LOOKING PARTICULARLY AROUND MODERATION AND MEDIATION. THE THIRD AIM IN THIS ONE HAS TO DO WITH SCIENTIFIC GUIDELINES FOR CONDUCTING THE NEXT GENERATION OF INTERVENTION TRIALS. SURE, GO AHEAD, DAVID. >> [INDISCERNIBLE]. >> DO YOU KNOW IF THERE ARE DIFFERENCES IN POPULATIONS AND INTERVENTIONS OF POPULATIONS THAT YOU'RE TRYING TO POOL AND ONE OF THE TRIAL DESIGNS, THAT I THINK IS A REAL CHALLENGE IS SOME STUDIES ARE RANDOMIZED AT THE INDIVIDUAL LEVELS, SOME STUDIES RANDOMIZED TRIAL--AT THE GROUP LEVEL, WILL WE HEAR ABOUT THAT AS WE GO ALONG? >> SO THE QUESTION HAD HAD DO WITH RANDOMIZING THESE IN A GROUP LEVEL, IT TURNED OUT IN THIS STUDY WITH NIMH, WE ARE ONLY LOOKING AT TRIALS AT THE INDIVIDUAL LEVEL, OR VERY, VERY, SMALL GROUPS. SO THAT'S NOT A SPECIFIC AREA THAT WE'VE BEEN LOOKING AT YET, BUT ALONG WITH A LOT OF OTHER PROJECTS, THIS IS A CRITICAL PIECE OF HOW DO YOU SYNTHESIZE WHEN THE DESIGNS ARE QUITE DIFFERENT, PARTICULARLY WHEN YOU LOOK AT LONGITUDINAL DESIGN, SOME OF THEM WITH THE RANDOMIZED TRIAL DESIGN, SOME OF THEM WITH AN ACTIVE ISHT VENTION, WITH AN IMPLEMENTATION TRIAL DESIGN OR THAT THEY HAVE A CONTROL, A CONTROL GROUP AS WELL AND LIZ STEWART HAS DONE SOME WORK RELATED TO THOSE. THOSE ARE OPEN QUESTIONS, COMPLETELY OPEN QUESTIONS. HERE'S, THE TOP ONE BECAUSE OF THE EMPHASIS ON DATA LABRATIVE SHARING, WHAT WE DECIDED IN TRYING TO WORK TOGETHER IN GETTING THESE DATA WHICH ARE FROM RANDOMIZED TRIALS IS A BIT DIFFERENT FROM GETTING THOSE LONGITUDINAL STUDIES. WHO OWNS THE DATA, WHO IS RESPONSIBLE FOR THE INTEGRITY OF THE FINDINGS OF THOSE DATA, WHAT PEOPLE HAVE ALREADY PUBLISHED ON THOSE DATA AND NEED TO CONTINUE TO PUBLISH, ARE ALL BIG ISSUES OF WORKING TOGETHER WITH THIS AND SO, INSTEAD OF AUTOMATICALLY HANDING OVER THESE RANDOMIZED TRIALS INTO A REGISTRY OR INTO A REPOSITORY, MANY OF THE INTERVENTIONS THAT WE'RE LOOKING AT WITH BEHAVIORIAL INTERVENTIONS, PEOPLE ARE NOT READY TO DO THAT. AND SO IT BECOMES QUITE DIFFICULT TO WORK OUT THOSE DETAILS. WE DECIDED, IS WE WANTED TO DO IT COLLABORATIVELY, SO A PARTNER, USING CBPR KIND OF APPROACH, WE SAID LET'S GO TO THE PEOPLE WORKING WITH THOSE DATA SETS, THEY HAVE THEM, APPROVED AT THEIR ON OWN IRBs. WE WANT TO GET THE DATA IN THE DE-IDENTIFIED FORM FOR US TO COMBINE TOGETHER AND INTEGRATE TOGETHER AND A LOT OF THOSE DETAILS ARE WORKED OUT IN THIS FIRST PAPER WITH ALL THIS COMES ON PERSPECTIVES AND PSYCHOLOGICAL SCIENCE AND MAYBE WE COULD TALK ABOUT THE MECHANISMS ON DOING THAT LATER ON. BUT IF WE THINK, IN THIS TIME AND AGE, BEFORE WE GET TO THE ACTUAL DATA SHARING, THAT THE NIH POLICY SAYS THAT THEY'RE GOING TO DO. AND HAVE THEM SHARE THEIR DATA AT A MUCH RICHER WAY IN HERE, LOTS OF PEOPLE HAD DATA SETS THAT ARE PRECLUDING AND USING OUR DATA FOR ANY OTHER PURPOSE THAN MEN AND WHAT WE'VE SAID SO IT'S BEEN DIFFICULT TO WORK OUT A LOT OF THOSE DETAILS AND EXISTING DATA SETS. BUT AS TIME GOES ON, I THINK WE'LL GET A NEW BETTER POLICY, AND PEOPLE ARE GOING TO BE SHARING THEIR DATA MUCH MORE THAN WE HAVE, RIGHT NOW. ONE OTHER COMMENT ABOUT THIS ONE IS ABOUT THE COLLABORATIVE NATURE. WE THINK THAT OUR THIRD AIM IN HERE IS WHAT IS THE FUTURE LOOK LIKE FOR IMPLEMENTATION FOR RANDOMIZED TRIALS. AND THEN PEOPLE WHO ARE COLLABORATING ON THIS WOULD BE PARTNERS IN DEVELOPING. HOW DO YOU MAKE SURE THAT THE DATA IS BEING COLLECTED HAS MAXIMUM USE AS YOU INTEGRATE ACROSS ALL OF THESE DIFFERENT TRIALS TOGETHER. SO IT'S NOT JUST SINGLE TRIALS, ONE AT A TIME THAT WE CAN'T QUITE FIGURE OUT WHAT TO DO WITH BUT WE CAN TRY TO FIND WAYS TO COLLABORATE THIS. OKAY, SO WE'RE TALKING ABOUT COLLABORATING INDIVIDUAL LEVEL DATA, ACROSS THESE, TO LOOK AT DIFFERENT IMPACT ON SUBGROUPS IN HERE. ONE OF OUR TRIALS FOR HERE IN PREVENTION HAS TO DO WITH THE FOCUS INTERVENTIONS THAT ARE NOT SPECIFIC TO RACE ASK ETHNIC MINORITY GROUPS AND WE HAVE SEVEN OF THOSE RIGHT NOW, THAT WE HAVE DATA AT HAND AND WE LOOK AT THAT TO SEE WHETHER OR NOT THE INTERVENTION LOOKS SUCCESSFUL FOR HISPANICS VERSES NOT SUCCESSFUL. SO IN THIS DATA SET FOR SEVEN PREVENTION TRIALS, THE OUTCOMES ACTUALLY ARE BETWEEN 14 MONTH LONG TO TWO YEARS WE'VE BEEN LOOKING AT IN HERE. OVER ALL OF THESE TRIALS, EACH INDIVIDUAL TRIAL HAS SOMETIMES, AS LITTLE AS EIGHT HISPANIC IN THAT AND TO THE MAXIMUM OF 42, BUT WHEN YOU COMBINE THEM TOGETHER, YOU GET 159 INDIVIDUALS WHO ARE HISPANIC AND SIMILAR WITH AFRICAN AMERICANS AND WHITE NONHISPANICS ACTUALLY HAS SUBSTANTIALLY MORE IN HERE. SO THIS IS THE RESULT OF A MULTILEVEL GROWTH MODEL THAT WE'VE BEEN DOING IN HERE. WE'VE LOOKED SPECIFICALLY AT THE IMPACT OF THESE PREVENTIONS, THESIS PREVENTION TRIALS ON DEPRESSION. TURNS OUT THAT ALMOST ALL OF THESE OUTCOMES, ALL THESE TRIALS WERE DESIGNED INITIALLY FOR DRUG ABUSE OR HIV SEX RISK BEHAVIOR, VERY FEW OF THEM WERE SPECIFICALLY FOCUSED AROUND DEPRESSION, BUT THEY DID COLLECT DEPRESSION DATA, MANY OF THESE HAVE NEVER BEEN PUBLISHED AND IF YOU ONLY HAD A HANDFUL OF CASES IN HERE, WITH HISPANICS, YOU WOULD NEVER HAVE ANY CHANCE OF WRITING ANYTHING ELSE THAT WOULD BE MEANINGFUL TO BE ABLE TO COLLECT INFORMATION ABOUT THE EFFECTS OF THIS. SO THIS IS NEW TYPES OF RESULTS IN HERE, THAT WE THINK ARE AT LEAST A FIRST PASS AT WHAT KINDS OF IMPACT THESE INTERVENTIONS MIGHT HAVE. SO AMONG HISPANICS, THE EFFECT OF THIS INTERVENTION ON 159 PEOPLE IS A NEGATIVE EFFECT OF THIS SLOPE OF THAT REGRESSION CO EFFICIENT OVERTIME. NEEDING THE BENEFICIAL REDUCTION IN DEPRESSIVE SYMPTOMS OVERTIME, SIGNIFICANT AT A .01 LEVEL FOR THAT ANALYSIS. FOR AFRICAN AMERICANS, THE DATA IN THE 125 DOESN'T SUGTHEY ARE SIGNIFICANT IN HERE, GOES IN THE SAME DIRECTION AND IN FACT, IF YOU LOOK AT THE MAGNITUDE OF THESE EFFECTS, THESE ARE ON ESSENTIALLY THE SAME SCALE IN HERE, AND THEY'RE STRONGER FOR HISPANICS AND THAN IT DOES FOR WHITES. THAT WAS BASED ON THE INITIAL STUDY THAT WE DID WHERE WE WENT TO ALL OF OUR FRIENDS AND RELATIVES THAT HAD HAD DATA THAT WE KNEW ABOUT BUT THEN WE DID A FARTHER SEARCH THROUGH THE PREVENTION TRIAL LITERATURE. AND BROADEN THE SCOPE OF THE KIND OF INTERVENTIONS TO LOOK AT THAT. WE FOUND ANOTHER 66 ADDITIONAL TRIALS AROUND THE ADOLESCENT DEPRESSION, WE THOUGHT THEY MATCHED THEIR CRITERIA AT MINIMAL LEVELS OF INTERVENTION, TRIAL DESIGN THAT WAS RIGOROUS IN HERE AND COULD BE USED TO EVALUATE THE EFFECTS OF THIS ONE. IF YOU LOOK AT THESE, THE TRIALS, SOME OF THESE TRIALS WERE OUTSIDE THE UNITED STATES, THE TRIALS IN THE UNITED STATES HAD 620 AFRICAN AMERICANS OR BLACKS AND HISPANIC POPULATION IN HERE, OVER A THOUSAND. SO THAT'S SUFFICIENT FOR US TO BE ABLE TO TAKE A LOOK AT MUCH BROADER KINDS OF QUESTIONS INCLUDING MEDIATION AND MODERATION WE HAVE HERE. SO WE THINK THAT THE DATA EXISTS OUT HERE, MANY ANSWERING SOME OF THE MANY QUESTIONS WE HAVE, WE JUST HAVE NOT ASSEMBLED THAT. AND IT TAKES A WHILE TO DO THAT BUT IT'S IMPORTANT TO DO IT. I DO HAVE AN EXAMPLE FOR MEDIATION AND MODERATION TO TAKE A ELECTRIC AT IN HERE, WHEN YOU CAN COMBINE TRIALS TOGETHER, SO HERE'S AN EXAMPLE. SO WE TOOK THREE RANDOMIZED TRIALS, ALL FROM THE SAME GROUP, IT HAD THE SAME INTERVENTION BUT DONE ON THREE DIFFERENT KINDS OF POPULATIONS IN TERMS OF LEVEL OF RISK TO BEGIN WITH, SO THESE ARE--THREE ARE THREE RANDOMIZED TRIALS, WHEN YOU COME BINE THEM TOGETHER, WHAT WE FOUND IS THAT--THERE'S AN EFFECT OF BOTH MODERATION AND MEEDSIATION IN THIS ONE. BUT YOU DIDN'T SEE THAT UNTIL YOU COMBINE THE DATA TOGETHER, AND JUST REMEMBER THIS IS DESIGNED INITIALLY FOR LOOKING AT DRUG USE AND SEX-RISKED BEHAVIOR, IT WASN'T DESIGNED FROM DEPRESSION AND WE CAN LEARN FROM THESE THINGS, AND WHAT IT SAYS IS WHEN THERE'S LOW BASELINE, THERE'S INTERVENTION BENEFIT AND THAT WHAT HAPPENS TO EXPLAIN THAT BENEFIT IS THAT WE--THE INTERVENTION ACTUALLY IMPROVES A PARENT'S COMMUNICATION AND ONCE IT IS IMPROVED, IT BENEFITS THE RESULTS HERE ON DEPRESSION. SO THAT'S WHAT THIS LAST SUMMARY IS. THEY HAD BEEN 721 ADOLESCENTS THAT WERE COMBINED TOGETHER AND WE FOUND DEFINITIVE KIND OF WORK ON HERE AND DEPRESSION AND IT TURNS OUT TO BE THE SAME MECHANISM WE SAW WITH DRUG ABUSE. I DID WANT TO GIVE YOU THIS POINT ABOUT, THERE ARE IN FACT SUCCESSFUL PREVENTION PROGRAMS IN MINORITY POPULATIONS THAT ARE SPECIFIC TO THOSE POPULATIONS. SO, EVEN THOUGH THERE AREN'T MANY OF THESE, THERE ARE A COUPLE OF THEM, FAMILIES THEY MENTIONED IN HERE, STARTED OFF WITH A HUNDRED PERCENT HISPANIC, DRUG ABUSE AND SEX REASK REPEATEDLY BUT IT ALSO SHOWED UNDEPRESSIVE SYMPTOMS IN MEDIATION AND MODERATION EFFECTS WHEN WE COMBINE THE DATA ACROSS STUDIES. WE NEVER WOULD HAVE FOUND HAD WE NOT COMBINED THE DATA. SO IT'S A FIRST GRADE INTERVENTION THAT WAS FOCUSED ON MOSTLY INNER CITY URBAN POPULATIONS, MOSTLY AFRICAN AMERICANS NOW, IT'S BEING TESTED IN SOME LATINO POPULATIONS AS WELL. AND IT'S ALSO BEING PART OF SAMSA'S ROLL OUT OF INTERVENTION AND 21 SCHOOL DISTRICTS. HERE'S A SET OF OUTCOMES THAT BOTH OF THESE HAVE. IF YOU LOOK AT WHAT THE OUTCOMES IN HERE, THIS HAS IMPACT BOTH ON DRUG USE AND ABUSE, ON RISK BEHAVIORS IN TERMS OF CONDOM USE THE LAST TIME AND UN PROTECTED SEX, COMBINE DRUGS AND UNPROTECTED SEX TOGETHER AS WELL AS DEPRESSIVE SYMPTOMS FOR THE FAMILIES THAT NEED THIS. AND ALSO FOR SUICIDE ATTEMPTS WITH THE GOOD BEHAVIOR GAIN, SO THESE ARE MAJOR EFFECTS THAT ARE POSSIBLY DUE. WE THINK THAT THERE ARE USEFUL INTERVENTIONS IN HERE. SO WE GO BACK TO LOOK AT THIS ONE. LET'S MOVE TO THE LAST PART OF THIS ONE. MAYBE THE REAL REASON THIS IS--WELL, THERE ARE INTERVENTIONS OUT THERE THAT DO WORK. BUT WE JUST DON'T KNOW HOW TO IMPLEMENT THOSE. I THINK THAT'S THE NEXT STAGE, AND THAT'S THE BIG UNKNOWN IN THIS NEXT FIELD OF TRYING TO DO THIS ONE BECAUSE IF YOU KNOW HOW TO--THE INTERVENTIONS MIGHT WORK IN HERE, YOU STILL NEED TO DELIVER THEM EFFECTIVELY IN POPULATIONS. SO THIS IS A PICTURE FROM THE INSTITUTE OF MEDICINE REPORT STAGES OF IMPLEMENTATION RESEARCH ON LOOKING AT WHAT ARE THE STAGES OF RESEARCH QUESTIONS AROUND DISSEMINATION AND IMPLEMENTATION RESEARCH. THREE OR FOUR, THE ADOPTION PHASE AND THE THIRD, HOW DO YOU SUSTAIN THAT INCREASE IN SCALE AND UP OVER TIME. SO THOSE ARE THE NEXT SETS OF RESEARCH QUESTIONS: I DO THINK THAT IT'S IMPORTANT TO REALLY REFRAME AND FOCUS OUR ATTENTION IN THESE AREAS. HAIR OLD WHO IS HERE, I WOULD LIKE TO QUOTE IN HIS 2011 PAPER IN HERE, WHICH I THINK HAS A GREAT TITLE, THAT WE MAY BE ADDICTED TO DISCOVERY, BUT DOES THAT QUEST FOR NEW KNOWLEDGE PRACTICE IMPROVEMENT AND I THINK THOSE ARE THE NEXT STAGES MUCH RESEARCH SCIENTISTS IN HERE. WE NEED BETTER TOOLS, WE NEED TO HAVE A PARTNERSHIP IN HERE, WE NEED TO MAKE IT RELEVANT, THE SCIENCE RELEVANT TO PRACTICE F. WE'RE EVER GOING TO BE ABLE TO REDUCE THESE DISPARITIES IN HERE. THE SCIENCE HAS ANYTHING TO SAY ABOUT THE ACTUAL REDUCTION OF PROBLEMS, MME PROBLEMS IN OUR SOCIETY IN HERE. THAT'S THE FOCUS OF OUR NIDA FUNDED CENTER FOR PREVENTION IMPLEMENTATION, NOW AND I WILL JUST MENTION AND CLOSE WITH ONE TOOL THAT WE'VE THOUGHT HAS BEEN USEFUL IN HERE AT THIS EARLY STAGE. HAS TO DO WITH RANDOMIZED TRIAL AUTOMATICKIZE TED IMPLEMENTATION TRIALS. THIS IS USED SPECIFICALLY TO TEST TO SEE WHETHER ONE STRATEGY OR ANOTHER CAN CHANGE THE SPEED, QUALITY AND QUANTITY OF IMPLEMENTATION OF AN EVIDENCE BASED PROGRAM. I'LL GIVE YOU AN EXAMPLE OF THAT ONE. THIS IS RANDOMIZED TRIAL WHERE YOU WERE TESTING HEAD-TO-HEAD, TWO IMPLEMENTATION STRATEGIES BUT THE INTERVENTION ITSELF IS THE EXACT SAME INTERVENTION. SO, WE'LL TAKE A LOOK AT THIS ONE AND IT TURNS OUT THAT THIS WAS DONE IN 51 COUNTIES ACROSS TWO STATES, LOOKING AT HOW FAST, HOW WELL CHILDREN WERE SERVE INDEED A CHILD WELFARE DIMENSION CALLED MULTIDIMENSIONAL FOSTER TREATMENT CARE. THIS IS A PICTURE. IF WE WERE DOING THE TRIAL OF MULTIDIMENSIONAL FOSTER CARE, MTFC, WE WOULD LOOK AT THE LEFT SIDE. WHAT WE WOULD LOOK AT IS THE COMPARING IMPACT ON YOUTH, BY LOOKING AT THOSE THAT GET RANDOMIZED TO MTFC VERSES THE CONTROL CONDITION. AND EVERYTHING ABOUT THE IMPLEMENTATION OF THAT MTFC IS ALL IN THE BACKGROUND. THAT'S ALL THE STUFF IN RED, WE USUALLY DON'T EVEN TALK ABOUT. WE MAY NOT EVEN WRITE ABOUT IT VERY MUCH, BUT IT'S ALL OF THE STUFF THAT REALLY DEPENDS ABOUT WHAT WE GET THE IMPACT IN HERE AND WE CAN DO THIS IN EFFECTIVENESS OR EFFICACY TRIALS ON THE LEFT-HAND SIDE, EFFECTIVE IS STILL WE TYPICALLY DON'T PUT ALL OF THE KNOWLEDGE ABOUT WHAT WE'RE ACTUALLY IMPLEMENTING IN HERE. WHAT WE'RE DOING IN HERE, ON THE LOOKING AT WHETHER OR NOT TWO DIFFERENT IMPLEMENTATION STRATEGIES CHANGE THE OUTCOMES OF THE MTFC INTERVENTION, IS WE'RE DOING RANDOMLY ASSIGNING COUNTIES FOR EITHER THE STANDARD VERSION OF IMPLEMENTING A COUNTY VERSES ONE OF THIS COMMUNITY DEVELOPMENT TEAM APPROACH. WHICH IMP LEMENTS AT A COUNTY LEVEL. COMMUNITY DEVELOPMENT TEAM APPROACH USES PEER TO PEER NETWORK, WHERE THE COUNTIES GET TOGETHER AND WORK CLOSELY TOGETHER SO WE HAVE TO TAKE INTO ACCOUNT THE CLUSTERING OF COUNTIES IN THIS ANALYSIS AS L. SO LET ME SUMMARIZE THIS ONE BY LOOKING AT QUESTIONS ABOUT HOW DO THE CURRENT NIH STRATEGIES SUPPORT SCIENTIFIC EQUITY. IF YOU LOOK ON THE NIH WEB SITE, THE 2008 REPORT ON THE SCIENCE OF OF ELIMINATING HEALTH DISPARITY SYSTEM ONE OF THE LATEST VERSIONS THAT I THINK IS A USEFUL DOCUMENT TO TELL US WHAT THAT IS. AND ONE OF THE STEPS IN HERE IS TO "INCREASE THE NUMBER OF PARTICIPANTS IN CLINICAL TRIALS FROM RACIAL ETHNIC MINORITY POPULATIONS AND OTHER HEALTH DISPARITY GROUPS." THAT'S TRUE BUT THERE'S A BUT TO THAT ONE. I THINK FOR SPECIFIC EQUITY, WE NEED TO MAKE SURE THAT WE DO MORE THAN JUST INCREASE NUMBERS BECAUSE WE'VE BEEN DOING THAT FOR A LONG TIME SINCE 1993, WE STILL HAVEN'T GOTTEN ENOUGH INFORMATION TOGETHER TO BE ABLE TO COMBINE OR UNDERSTAND WHAT THOSE ARE. SO SWREE TO HAVE SUFFICIENT NUMBER OF TRIALS THAT ARE RESTRICTED AND LIMITED TO SPECIFIC MINORITIES AND SUFFICIENT NUMBERS OF MINORITIES AND TRIALS AND THAT I THINK WITH THE MAIN PART, I THINK WE'RE GOING TO BE ABLE TO BENEFIT IN HARD TIMES, SUCH AS OURS IN TERMS OF THE BUDGET IS TO BE ABLE TO SYNTHESIZE FINDINGS THAT COMBINE MINORITIES OF ACROSS TRIAL. SECONDLY, THE RYE WAY RELATED TO THIS ONE IS THE NEED THAT NIH IDENTIFIED TO IMPROVE THE RESEARCH DATA COLLECTION SYSTEMS, ENHANCE DATA QUALITY, REGARDING HEALTH DISPARITIES AND BEAUTIFUL AND DATA SYSTEMS TO FACILITATE STRATEGIES FOR THE ELIMINATION OF HEALTH DISPARITIES. THE SYNTHESIS METHODS WE'RE DEVELOPING HERE ARE--I HOPE WOULD BE A FIRST GENERATION. I THINK WE'RE TACKLING REALLY COMP LITICATED PROBLEMS ABOUT WHAT HAPPENS TO THE MEASURES AND NOT IDENTICAL TO ONE ANOTHER, YOU DO WHAT WE CALL HARMONIZATION IN HERE, BUT IF WE HAD MEASURES THAT WERE SIMILAR OR IDENTICAL, WE WOULD BE A MUCH, MUCH, BETTER SHAPE HERE UNTIL WE NEED TO HAVE SOME ABILITIES TO TRY TO BRING TOGETHER THE FIELD WHICH IS MOVING IN WAYS AND DIFFERENT TIMES IN HERE SO FINALLY IN HERE, THE ONLY WAY WE CAN ADDRESS THESE PROBLEM SYSTEM A COMBINATION OF THINGS WITH RESEARCH QUALITY, PRACTICES AND METHODOLOGY, THIS IS THE GROUP OF PEOPLE WHO WE HAVE IN OUR NIMH SYNTHESIS ECTOMYOSIN. THIS IS A GROUP OF PEOPLE IN OUR CENTER HERE INCLUDING THOSE THAT WE'RE PARTNERING WITH SA MHSA. SO THANK YOU VERY MUCH. [ APPLAUSE ] >> BE HAPPY TO TAKE COMMENTS OR QUESTIONS. >> HIGH, THANK YOU SO MUCH FOR YOUR ENGAGING TALK, I'MOT OFFICE OF RESEARCH AND DISPARITIES AND GLOBAL MENTAL HEALTH. I WAS REALLY EXCITED TO HEAR ABOUT THE DATA SYNTHESIS, THE COLLABORATIVE WORK THAT YOU'RE DOING, IN COMBINING DATA AND YOU TALKED ABOUT THE HARMONIZATION OF THE MEASUREMENTS AND ONE THING THAT I WAS REALLY CURIOUS TO KNOW MORE ABOUT IS EACH STUDY HAS--A PARTICULAR INTERNAL AND EXTERNAL BIASES ISSUES AND SO WHEN WE'RE ANALYZING DATA, HOW DO YOU TAKE THAT INTO CONSIDERATION, SO THAT WAS MY FIRST QUESTION. >> GREAT QUESTION, SO, I DON'T KNOW IF EVERYBODY CAN HEAR THAT, SO THE QUESTION IS, HOW DO YOU TAKE INTO ACCOUNT SOME OF THE INTERNAL AND EXTERNAL BIASES OF EACH OF THE STUDIES IF YOU TRY TO INDGREAT THOSE TOGETHER. WE HAVE A--WE HAVE A--I THINK WE HAVE--ONE THING WE'VE BEEN TRYING TO DO IS TRYING TO GET COLLABORATIONS WITH THE PEOPLE WHO HAVE COLLECTED THE DATA WHO RUN THE TRIALS, BUT WE'VE CALLED TACIT KNOWLEDGE IS A CRITICAL PART OF THIS STUDY, AND IT GOES BEYOND JUST WHAT DOES THE MEASURE SAY, HOW IS IT COLLECTED BUT IT ADDRESSES THOSE SAME KINDS OF QUESTIONS THAT YOU HAVE. SO FOR EXAMPLE, ONE INTERVENTION TRIAL THAT I KNOW, USES A VERY WELL KNOWN PROFESSOR AS THE CONTROL GROUP, INTERVENTIONS AND HE DELIVERS LECTURES ON THAT. AND SO IF WE DON'T TAKE INTO ACCOUNT THE KIND OF EFFECT THAT THAT PERSON MIGHT HAVE IN TERMS OF MAKING CHANGES IN THE DEVELOPMENTAL COURSE OF THOSE INDIVIDUALS AND COMPARE IT WITH SOMEBODY IS NOT--TO A LESS ACTIVE CONTROL GROUP, WE CAN HAVE SOME PROBLEMS IN HERE. I PART I THINK WE NEED TO DO IS MAKE SURE ESPECIALLY WITH RANDOMIZED TRIAL SYSTEM WE DO THIS IN PARTNERSHIP WITH THE PEOPLE WHO RUN THE TRIALS. I WOULD HATE TO RUN, REALLY WORK WITHOUT THAT KIND OF COLLABORATION, SO THAT'S KIND OF A FIRST LEVEL. THAT MAYBE YOU HAVE OTHER SUGGESTIONS. >> WELL I KNOW MEAN IT WILL BE GREAT TO HAVE SYSTEMATIC WAYS TO ACCOUNT FOR THOSE THINGS. SO, I MEAN, I LOOK FORWARD TO HEARING MORE ABOUT THE GUIDELINES THAT YOU PUBLISH. AND THE SECOND QUESTION WAS, ONE OF THE ADVANTAGES OF THESE DATA COMBINING DATA BETTER IS THAT YOU'RE ABLE TO BETTER CAPTURE THE MEDIATING AND MODERATING VARIABLES AND SO, I WAS WONDERING, SO WE HAD THESE CLINICAL TRIALS, AND LOOKING INTO THESE IMPLEMENTATION PATHWAYS, WHETHER--THESE MEDIATING MODERATING VARIABLES HAVE THE POTENTIAL TO INFORM WHAT KIND OF EVIDENCE BASED PRACTICES CAN BE IMPLEMENTED WELL OR NOT AND WHAT THE STEPS COULD BE AND I WAS WONDERING IF THESE TRADITIONAL CLINICAL TRIALS AND THE METHODS THAT THEY USE AND THE QUANTITATIVE CAPTURING OF THESE THINGS OR WORKING WELL, AND WHETHER, YOU KNOW, IN YOUR EXPERIENCES, WHAT ARE SOME OTHER THINGS, AREAS THAT ARE USUALLY NOT BEING CAPTURED THAT THAT SHOULD BE PART OF THE--STANDARD MEASUREMENT AS PART OF THE RANDOMIZED TRIAL RANDOMIZED CONTROL TRIAL. >> GOOD QUESTION. WHAT OTHER THINGS COULD YOU CAPTURE IN HERE? TWO THINGS COME TO MIND. ONE OF THEM HAS TO DO WITH DISCIPLINARY O DISTINCTIONS AND EFFICACY IN THESE TRIALS AND I DON'T THINK THOSE WORDS ARE USED EXACTLY THE SAME WAY ACROSS DIFFERENT INSTITUTES OR ESPECIALLY WITH THE TERMINOLOGY OF THIS ONE. IT'S NOT THE SAME WITH EDUCATION FOR EXAMPLE, I LIKE TO DISTINGUISH BETWEEN THE TWO IN TERPS OF--IF SOMEBODY'S NOT DELIVERING THE INTERVENTION AS EXPECTED, CAN YOU GET RID OF THEM OR RETRAIN THEM OR NOT. SO EFFICACY, STUDIES YOU CAN DO THAT. EFFECTIVENESS STUDIES, YOU MAY BE ONLY ABLE TO USE THE PEOPLE IN THE HOST OR ORGANIZATION THAT MIGHT BE A SCHOOL OR COMMUNITY SETTINGS, PREVENTION OR THERAPISTS, YOU CAN'T GET RID OF THEY'RE THE ONES THERE. AND I DON'T THINK WE DO A GOOD JOB OF DISTINGUISHING THOSE KINDS OF CHARACTERISTICS, EXACTLY WHO THOSE ARE, THE SECOND THING, I THINK IS RELY RELATIVELY WEAK IN HERE IS THE INFORMATION WE GET ABOUT FIDELITY. WHAT ARE THE FIDELITY AND MONITORING AND FEEDBACK SYSTEMS THAT PEOPLE NEED TO USE TO BE ABLE TO DELIVER AN INTERVENTION WITH THE LEVEL OF PRECISION THAT IS REQUIRED. AND I THINK WE'RE NOW IN THE PROCESS IS ONE OF THE BIG HUGE ISSUES IN IMPLEMENTATION TO GET A BETTER WAY OF DEFINING EXACTLY WHAT'S HAPPENING IN THERE. >> I ALSO HAVE SEVERAL QUESTIONS. I'LL ASK ONE AND THEN LETTH--LET OTHERS. >> THE RANDOMIZED IMPLEMENTATION TRIAL, THE DIAGRAM IT SHOWS, THE DESIGN YOU SHOWED, TWO ARMS IN THAT DIFFER BY VIRTUE OF [INDISCERNIBLE] IF YOU FIND NO DIFFERENCE BETWEEN A RANDOMIZED IMPLEMENTATION TRIAL, IF TURNS OUT THAT, THE PROCESS, WHAT WE'RE LOOKING AT IS OUTCOMES THAT ARE PROCESS OUTCOMES FIRST. AND MOSTLY WHAT CAN YOU DO IN THOSE RANDOMIZED RANDOMIZED IMPLEMENTATION TRIALS AND IN FACT, IT'S MORE DIFFICULT TO LOOK AT OUTCOMES THAT ARE ON THE TARGET POPULATION THAN THOSE RANDOMIZED TRIALS BECAUSE THE KIDS ULTIMATELY ARE NOT RANDOMIZED AT THAT LEVEL; OKAY, SO WHAT WE'RE LOOKING AT IS RANDOMIZING AT A COUNTY LEVEL TO SEE WHETHER THE PROCESS ITSELF CHANGES. THAT'S VERY MEASURABLE, AND THAT IS WORTH WHILE TO TRY AND TAKE A LOOK AT DIRECTLY, AS A MEDIATOR TO ULTIMATE OUTCOMES. WHAT--ONE OF THE THINGS, I THINK PEOPLE ARE LOOKING AT IS LOOK AT THE RELATIONSHIP BETWEEN, THE IMPLEMENTATION OF THAT INTERVENTION AND THE ULTIMATE OUTCOME, FROM PREVIOUS RESEARCH. AND SO PEOPLE ARE OFTEN PIGGYBACKING ON THE EXISTING RANDOMIZED EFFECTIVENESS TRIALS TO TRY TO SEE WHETHER THAT KIND OF IMPACT WOULD BE DEMONSTRATED BUT PREVIOUS BASED ON PREVIOUS WORK. >> HOW ARE YOU? >> GOOD HOW ARE YOU? >> I WAS INTRIGUED BY WHAT YOU WERE TALKING ABOUT IN GENERATION EQUALITIES AND WONDERING IF YOU HAVE THOUGHTWAYS THAT RESEARCHERS CAN DESIGN STUDIES THAT INSURE THAT THAT IS ADDRESSED IN THE FRONT END IF YOU WILL OF EFFICACY TESTING. >> WELL THAT SOUNDS LIKE A PERFECT PROGRAM ANNOUNCEMENT, DOESN'T IT? I DON'T--ACTUALLY I DON'T HAVE A--I THINK THIS IS ONE OF THOSE ISSUES THAT'S A LITTLE BIT DIFFERENT THAN SORT OF THE STANDARD APPROACH THAT WE'VE TYPICALLY TAKEN FOR LOOKING AT ATROUGH GENIC EFFECTS. IT'S SOMETHING WE HAVEN'T PUT OUR ATTENTION TO AND I THINK IT'S WORTH WHILE DOING THIS. I DO KNOW THAT WHEN I LOOK AT RANDOMIZED TRIALS, I ALWAYS LOOK FOR STROGENIC EFFECTS, BECAUSE I DON'T BELIEVE THAT ANY EFFECTS ARE GOING TO WORK FOR EVERYBODY AND SOMETIME CANS CAN BE HARMFUL. WE DON'T LOOK AT THAT. I DO THINK THAT ONE OF THE THINGS THAT IF YOU GO TO THE SOCIETY FOR PREVENTION RESEARCH MEETING COMING UP IN MAY, AMY GOLD STEIN WHO IS A PROJECT OFFICER WITH A SYNTHESIS PROJECT FOCUSED A NUMBER OF US ON THIS QUESTION OF WHO ARE NONPRESPONDY LIGHTISSERS--RESPONDERS TO FOCUSED AROUND DEPRESSION, SO THAT I'M HOPING WILL GIVE US SOME BETTER CLUE, BUT WE GENERALLY DON'T HAVE OUR EYE ON THAT AT ALL. >> HI, [INDISCERNIBLE]-- >> YEAH. >> [INDISCERNIBLE]. YEAH OULE--SO ALL I'M SAYING OF THIS INITIAL ANALYSIS IS IT'S VERY CRUDE. WHAT I WAS INTENDING TO DO IS SAY IS THERE ANY DATA OUT THERE THAT GIVES SMU SUGGIESTION. I DON'T THINK THIS IS BY ANY MEANS COMPLETE, CERTAINLY, LOOKING AT GENDER EFFECTS WHICH BY ONLY ADDING IN A MAIN EFFECT IN THIS ANALYSIS, I DID HERE, JUST STATUS, AND FOR THE POPULATIONS AND YOUKNOW THAT ARE JUST MIXED TOGETHER IN HERE. IT'S NOT THE SAME. SO I DO THINK WHAT WE HAVE PLANNED IN HERE IS A MUCH MORE STRATEGIC WAY OF THINKING AND DEALING WITH MULTIPLE LEVELS OF ADVERSITY, AND BRING THEM INTO FOCUS ONE AT A TIME AND THEN IN COMBINATION TO THE LEVEL OF EXTENSION WE CAN GET TO. AND I THINK WE'VE GOT A LONG WAYS TO GO YET. SO THAT'S MY SHORT ANSWER TO AN APOLOGYY TO WHAT WE WERE ABLE TO GET TO SO FAR. >> [INDISCERNIBLE]. >> YEAH. >> [INDISCERNIBLE]. --PICTURELY THE WAY YOU MIGHT PRESENT THAT. IT IS, YOU KNOW, GENDER--VARIOUS CIRCUMSTANCES. >> RIGHT, SO TAKEN. >> HI, HENDRICKS. >> HELLO. >> AS YOU KNOW, ADAPTATION OF PREVENTION INTERVENTIONS IS A G ISSUE, ESPECIALLY WITH SOME OF THE SERVICE DELIVERY AGENCIES WHO FEEL VERY STRONGLY THAT EVIDENCE BASED INTERVENTIONS THAT HAVE BEEN TESTED AT A GLOBAL LEVEL ARE REALLY NOT APPROPRIATE FOR SOME DIVERSE POPULATIONS, SPECIFICALLY AFRICAN, AMERICAN RURAL POPULATIONS, AMERICAN INDIAN POPULATIONS, ALASKA NATIVE POPULATIONS. THIS SEEMS LIKE IT WOULD BE AN APPROACH TH WOULD AT LEAST HARNESS DATA, TO GIVE SOME SORT OF AN ANSWER TO THOSE CONC HOW WOULD YOU RESPOND IF YOU WERE PUT ON THE SPOT BY ONE OF THOSE AGENCIES? >> WELL I THINK THE FIRST PART IS,--AND WE HAVEN'T DONE THIS YET, BUT THE FIRST PART IS TO IDENTIFY WHAT THE GAPS ARE AND I THINK WE'VE GOT PLENTY OF GAPS IN THIS WHOLE AREA THAT NEED TO BE IDENTIFIED FIRST AS A BROAD SCIENTIFIC STRATEGY OF WHERE WE WILL PUT OUR FOCUS. AND I THINK THAT THE COMBINATIONS THAT WE'RE LOOKING AT ARE CHALLENGING TO TRY TO IDENTIFY WHICH ONES ARE THE MOST PRIORITY ONES TO ADDRESS IN HERE, BUT I THINK WE--IF WE DON'T PUT THOSE ON A MAP, I DON'T THINK WE'LL BE ABLE TO GET VERY FAR AT ULTIMATELY. I DO THINK THAT THE ISSUES THAT YOU'RE RAISING ABOUT WHAT IS THE--NOT JUST THE LEVEL OF FIDELITY BUT WHAT IS THE LEVEL OF INTERVENTIONS THAT IS DELIVERED IN HERE AND AS IT GETS MODIFIEDED AND ADAPTED, IS THE NEXT GENERATION OF WORK THAT WE NEEDED AROUND IMPLEMENTATION. AND WE'RE LOOKING FORWARD AND PARTNERING WITH PEOPLE TO UNDERSTAND HOW THAT HAPPENS AND WHAT THE NEXT PROCESS IS. GENE PEDUSKA HAS BEEN FUNDED SPECIFICALLY TO LOOK AT ADAPTATION FOR THE GOOD BEHAVIOR GAIN. BUT THIS IS A BIG GENERIC ISSUE AND WE WILL NEED TO TAKE THE SPECIFIC KNOWLEDGE OF INDIVIDUAL INTERVENTIONS AND THEN LEARN FROM THOSE TO TRY TO GET GENERALIZABLE KNOWLEDGE ABOUT WHAT COULD WE MAKE AN INFERENCES IN A BROADER SETTING ACROSS DIFFERENT POPULATIONS IN THE CREST OF INTERVENTIONS. >> ONE OF THE CHALLENGES IN DOING RIGHT. CAN YOU TALK ABOUT HOW THAT DIFFERS FROM WHAT YOU'RE DOING, WHETHER IT'S SOMETHING THAT YOU ANTICIPATE DOING GOING FORWARD. I KNOW NHLBI IS PLANNING A WORKSHOP THIS FALL ON METAREGRESSION AND I'M SEEING IT USED YOU'RE ASKING, DAVID, ONE OF THEM IS IF YOU THINK ABOUT THE VARIATIONS ACROSS TRIALS, PART OF THAT IS ACCUMULATED BY LOOKING AT RANDOM EFFECTS AT THE TRIAL LEVEL WHICH WOULD COMBINE AND CHARACTERISTICS OF VARIATIONS IN THOSE INTERVENTIONS, BUT WITHOUT SPECIFYING ANYTHING, PARTICULARLY ABOUT THOSE INTERVENTIONS. YOU CAN PUT IN DOSAGE FOR EXAMPLE, AS A CHARACTERISTIC. WE'RE NOT TOTALLY SURE OF IT. THAT WILL BE A REALLY GOOD ONE. AND I THINK WE'RE JUST IN THE PROCESS OF TRYING TO LEARN WHETHER OR NOT WE HAVE ANY KIND OF DIFFERENCES. EVEN IF YOU GO BACK TO THE HEART DISEASE PREVENTION TRIALS THOUGH OF LOOKING AT ASPIRIN AND YOU LOOK AT WHAT WE LEARN WHEN PEOPLE DID META-ANALYSIS ON THOSE, THE LEVEL OF DOSAGE OF ASPIRIN IN THOSE TRIALS WAS, I DON'T KNOW SOMETHING ON THE ORDER OF A VARIATION OF FIVE OR SO, FIVE FOLD AND NOBODY REALLY ANALYZED THAT DATA EITHER. SO I THINK IT'S--IT'S AS COMMON IN META-ANALYSIS AS IT IS SORT OF THIS ISSUE THAT WE'RE HAVING IN HERE. BUT WHEN YOU CAN GET A MET'S REGRESSION VARIABLE IN HERE AND IT DOES WORK WELL, YOU GET A MUCH BETTER EFFICIENT RESULT THAN THAT. IT WOULD ALSO LET YOU INCLUDE MORE STUDIES IN A GIVEN ANALYSIS FELT SO WHEN YOU TRY TO IDENTIFY THESE WITH THE INTERVENTION SIMILAR ENOUGH AND YOU INCLUDE IT, THEN IT LIMITS THE NUMBER OF STUDIES THAT YOU INCLUDE IN A GIVEN ANALYSIS. IF YOU'RE WILLING TO ALLOW GREATER VARIABILITY, BECAUSE OF THESE COMPONENTS AND LOOK AT THE EFFECTS OF THOSE KINDS OF THINGS, IT ALLOWS TO YOU INCREASE THE NUMBER OF STUDIES GIVEN THERE. >> THAT'S RIGHT. DEFINITELY THE WORK. OTHER QUESTIONS? QUESTIONS FROM FOLKS WATCHING ON THE WEB SO FAR? [INDISCERNIBLE]. THEN I'LL ASK ANOTHER. IN YOUR LABERATION,--COLLABORATION, YOU'RE REACHING OUT IN ORDER TO GET THE INDIVIDUAL LEVEL DATA, AND I CAN CERTAINLY UNDERSTAND THE NEED TO DO THAT AND YOU'RE NOT JUST NOT GOING TO [INDISCERNIBLE] AND DO WHATEVER YOU WANT, DID YOU RUN INTO ANY IRB OR ETHICS ISSUES BECAUSE JUST WITH THOSE STUDIES [INDISCERNIBLE]-- >> RIGHT. >> --FURTHER DOWN THE ROAD. >> RIGHT, WE WENT INTO LOTS AND LOTS OF IRB ISSUES. THAT PARTICULAR ONE WHICH WE THOUGHT WOULD BE AN IMPORTANT ONE IN HERE WAS REALLY NOT A BIG ISSUE FOR US. I DON'T THINK OF OF ALL OF THE 40 TRIALS WE'VE BEEN LOOKING AT IN THIS COLLABORATIVE, ANY ONE OF THOSE WAS REALLY A PROBLEM BECAUSE OF THAT. WE WERE UNSUCCESSFUL IN ONE SINGLE STUDY THAT WE'RE THOUGHT ABLE TO GET DAT DATA, BUT ALL THE REST OF THE DATA, WE SO FAR, WE'VE BEEN ABLE TO GET OR THAT PEOPLE ARE PROMISING, AS SOON AS THEY COMPLETE THEIR SPECIFIC SETS OF ANALYSIS THEY WOULD BE DOING THAT THEY WOULD BE WILLING TO SHARE THAT WITH US. THERE ARE SOME MOTH BALL DATA SETS THAT HAVE BEEN DIFFICULTIES TOO IN TRYING TO GET AN OLD DATA SET BACK UP ONLINE, AND GET THE KNOWLEDGE AVAILABLE FOR THAT, TOO. >> FOLLOW UP. DID YOU HAVE TO GET DE-IDENTIFIED DATA SETS OR DATA SETS THAT HAVE THE IDENTIFIERS. >> THE WE DID NOT GET ANY IDENTIFIERS IN THEM. BUT WE-- >> THAT WOULD BE THE WAY TO ADDRESS THE IRB? >> THE RECENT RULE CHANGES AROUND IRBs, USING DE-IDEBTIFIED DATA SETS AND NOT HAVING TO ACTUALLY TREAT THAT AS HUMAN SUBJECTS, IS I THINK, IS GOING TO BE BENEFICIAL TOWARD THE FUTURE. MANY OF THESE HAVE ALREADY BEEN ON IRBs THAT ARE NOTA THAT WAY THOUGH. THE OTHER PART OF IT IS TRYING TO GET DATA SETS THAT WE HAVE A LOT OF TREATMENT DATA SETS AS WELL SO MANY OF THOSE ARE FROM PHARMACEUTICAL COMPANIES. THOSE HAVE BEEN A BIT CHALLENGING TO GET AND THEY'RE NOT AVAILABLE FOR EVERY--EVERY ANTIDEPRESSANT FOR EXAMPLE. >> HELLO. HOW ARE YOU? >> GOOD. >> SO I KNOW YOU'RE ALL ABOUT THE DATA, BUT I WANT TO ASK YOU SOME--LET YOU HAVE YOUR SAY, I GUESS IN SOME KIND OF FAR REACHING QUESTIONS, SO THEY'RE NOT THAT TRICKY, BUT--IF YOU COULD--I GUESS, TWO AUDIENCES IF YOU COULD HAVE, YOU KNOW, I GUESS THE ELEVATOR PITCH SPEECH ABOUT WHAT THE DIRECTOR OF NIH, THE NEXT RFA NEEDED TO ADVANCE SCIENTIFIC EQUITY, WHAT WOULD YOU--WHAT WOULD YOU WANT IT TO BE CALLED AND WHAT--YOU KNOW WITH THE GAPS, AND THE GAPS IDENTIFY IN YOUR WORK, WHAT WOULD YOU WANT IT TO BE AND THEN THE SECOND PART OF THAT, IF YOU GO HIGHER, IF YOU WERE STUCK IN THE ELEVATOR AT THE WHITE HOUSE, THINKING OF AFFORDABLE CARE AND HOW THAT MIGHT PLAY INTO THE FUTURE INTERVENTIONS WHAT WOULD YOU TELL THE PRESIDENT. ELEVATE YOU TO NIH AND PRESIDENT, ON THOSE LEVEL WHAT IS WOULD YOU WANT TO SAY. >> LET ME SAY THE FIRST ONE FIRST. >> THERE'S A RULE ABOUT THAT, TOO. >> I HON EVAPORATELY THINK THAT--HONESTLY THINK THAT THE KNOWLEDGE BASE WE'RE GETTING IN DOING RESEARCH, RESEARCH STUDIES, WITH EFFICACY AND EFFECTIVENESS IS REALLY IMPORTANT FOR US TO LEARN. WE LEARN ABOUT MEDIATION MODERATION THERE. EVEN IF WE LEARNED THOSE, I STILL THINK THE MAJOR PROBLEMS WE HAVE OF DEALING WITH HEALTH EQUIT NEUROECTODERMAL OUR COUNTRY, HAVE ALL TO DO WITH IMPLEMENTATION. I WOULD SAY THAT'S WAY MORE THAN 50% OF WHAT WE REALLY NEED TO DO AND I THINK WE ARE NOT CONCENTRATING SERIOUSLY ENOUGH AROUND WHAT ARE THE FACTORS THAT ALLOW COMMUNITIES AND ORGANIZATIONS INCLUDING HEALTHCARE ORGANIZATIONS TO DECIDE TO IMPLEMENT. WHY WOULDN'T YOU WANT TO HAVE PARENTS PROGRAMS FOR EXAMPLE, IMP IMPLEMENTED AND PAID FOR BY INSURANCE COMPANIES. I THINK THAT WOULD BE A GREAT OPPORTUNITY FOR HELPING AND IMPROVING THE HEALTH OF THE UNITED STATES. AND THAT'S POLICY AS MUCH AS SCIENCE IN A COMBINATION OF THAT. I DO THINK THAT THE--I DO THINK THAT THERE NEEDS TO BE SOME CAREFUL LOOK AT THE WHAT ARE WE GETTING FROM THE SCIENTIFIC SIDE IN MAKING MAXIMAL USE OUT OF THE DATA THAT WE HAVE ALREADY. SO THAT'S THE FIRST PART YOU'RE LOOKING AT ABOUT THE NIH WORLD. I THINK WE'RE NOT DOING AS WELL AS WE CAN IN TAKING SO MUCH TROUBLE TO COLLECT. AND IT'S TIME TO DO THAT. THESE KIND OF EARLY STAGES IN THE FIRST STEPS IN THIS, WE WILL LEARN A LOT MORE AND WE WILL WILL LEARN ABOUT WHERE THE IMPORTANT PIECES ARE THAT WE'RE GOING TO BE ABLE TO GAIN MATERIAL INFORMATION FROM AND WHICH ONES WON'T BE AS USEFUL. >> OKAY SO FOLLOWING UP, WE HAVE A GREAT SECONDARY DATA ANALYSIS, PROGRAM ANNOUNCEMENT, OTHER INSTITUTES AS WELL, BUT ARE YOU SAYING, I MEAN DO YOU THINK WE HAVE WHAT IS NECESSARY, REALLY, THERE, OR ARE WE MISSING OUT BECAUSE USUALLY, THE KIND OF STAGES YOU'RE TALKING ABOUT NERMALS OF DISSEMINATION AND IMPLEMENTATION ARE SEPARATE--YOU KNOW IT'S A SEPARATE FIELD, IT'S A SEPARATE STUDY, SO ARE YOU SUGGESTING WE CAN BUILD THAT ON TOP OF WHAT WE HAVE, HOW DO WE PUT THAT ALTOGETHER. >> I DO THINK THERE'S A BROADER BASE OF WORK ON THAT IT'S KIND OF LIKE THE WORD, BIG DATA KIND OF IDENTIFIED NSF, OUT OF THE PRESIDENT'S OFFICE OF TRYING TO SAY WHAT CAN WE LEARN FROM KIND OF APPROACH THE WAY WE LEARNED FROM BIOINFORMATICS AND KNOWLEDGE INFORMATIONATTICS, HERE AND I DON'T THINK WE TACKLED IT SUFFICIENTLY WELL, OF TWO OR THREE DATA SETS THAT ARE SIMILAR, WE LEARN AN AWFUL LOT ABOUT THE METHODOLOGY AROUND THAT AND SOME RESULTS BUT I THINK IT'S TIME TO REALLILY LOOK AT THAT IN THE BIG PICTURE AND I DON'T THINK WE REALLY QUITE DONE THIS YET. >> SO PUTTING MORE OF A CEREAL SYSTEM INFORM ATTIC AND CONDITION TEXT IS PROBABLY WHERE I THINK WE CAN REALLY MAKE SOME BIG HEAD WAY IN HERE AND MUCH LIKE BIOINFORMATICS IS DONE WITH THE GENOME AND OTHER BIG PROJECTS LIKE THAT. I THINK THERE'S REAL POTENTIAL, HERE TO DO THAT. >> NOW WE HAVE TO GET YOU STUCK IN THE ELEVATOR WITH-- >> [LAUGHTER] >> I'D BE HAPPY TO. >> WELL, THANK YOU VERY MUCH, HENRY. >> [ APPLAUSE ] -- >> THANK YOU EVERYONE FOR COMING TODAY.