A Conversation on the Future of Health Equity Research

Jan 12, 2017, 4:43 PM, Posted by

In the past decade, the healthy equity research landscape has shifted from building the evidence to identifying solutions. David Williams and Paula Braveman share thoughts on the evolution of research with a look to the future.

Everyone deserves to live the healthiest life possible.

The latest National Academies of Science Engineering and Medicine report notes that compared to other fields of health research, health inequities is still a relatively new field that faces significant research and practical application challenges. The consensus report provides specific recommendations including: expanded health disparity indicators, longer-term studies, an examination of structural factors, and new research funding opportunities. RWJF’s Tracy Orleans talks with two of the nation’s leading experts on health equity and health disparities, Dr. David R. Williams and Dr. Paula Braveman, who share their thoughts on some of these issues and the evolution of research with a look to the future. 

Tracy Orleans: Nearly ten years ago you started work together on the RWJF Commission to Build a Healthier America. At the time, gaps in health between groups of people or communities were not news to health experts, but they were surprising to a lot of others. We’ve come a long way since then with a more explicit focus on health equity research. How do you view this shift?

David Williams: For a long time, researchers focused on documenting the health differences between populations. Those differences are now well-established and we’re able to point to more scientific evidence about why the gaps exist. For example, there’s a growing body of research around the effects of epigenetic aging, which shows that people who experience discrimination or other trauma are biologically older than people of the same chronological age. Science shows that their telomeres, which protect chromosomes from fraying, are shorter among both children and adults who are black, poor, or from unstable homes. This type of more explicit health equity research is a rapidly growing field.

Paula Braveman: Until recently, talking about “equity” in research was radical. We had to be subtle and use other words when seeking funding. Today, we can ask different questions, talk about social justice, and examine the health effects of bias and racism. It’s thrilling to see an entirely new research agenda around health equity that confronts previous bias in science. I’m not saying that we need to stop documenting health disparities—but we do need more support for research that addresses equity interventions. It’s a big shift for funders in particular.

Williams: It’s true. This health disparities evidence base is important for understanding how we arrived at where we are today. But there’s an opportunity for the next generation of research to focus on what’s working and why to improve health equity.

A research definition shapes what we measure, capture and focus on. And importantly, it allows us to assess whether we are reducing inequitable gaps rather than the overall gaps in health.

Orleans: Health equity means different things to different people. Paula’s Center on Social Disparities in Health at UCSF has been developing a new definition of health equity. Why is this important to have?  

Braveman: We’ve found at least 40 different definitions of health equity and there are strengths and weaknesses of each. We developed our new definition through a systematic process, looking for language that’s simple and concrete that can guide action. Being able to measure progress is crucial because otherwise there’s no accountability.

Williams: Health equity is a term that is used more traditionally outside of the U.S. Here, we’ve been focused on health disparities. I’ve seen a variation in comfort level with the term “health equity” and have also seen people use “health disparities” and “health equity” interchangeably. There’s enormous value in clarifying terms. A research definition shapes what we measure, capture and focus on. And importantly, it allows us to assess whether we are reducing inequitable gaps rather than the overall gaps in health. Not everyone understands this distinction.

Braveman: Yes, a definition must make that distinction. But I don’t think everyone needs to use exactly the same definition. Sometimes we get hung up on the eloquence of words. But we do need a common understanding of the concepts at the core of health equity. That’s what RWJF has been after, in the work we’ve done with them to develop a definition.

Orleans: Explain “inequitable gaps” in a research context.

Williams: Here’s one: public health interventions have reduced smoking rates since the 1960s—but when you apply an equity lens, you see that the life expectancy gap between smokers with higher levels of education and lower levels of education have actually increased. That’s because the declines in smoking have been much larger among adults with high levels of education than among those with low levels of education. Anti-smoking public health interventions are critically important and have made great strides in improving overall health—but they haven’t increased health equity.

Another example: overall childhood obesity rates have plateaued—but research shows that rates for children of parents with lower levels of education are still rising while rates are declining for children whose parents have a college education. A health equity definition allows us to assess what intervention works best for those who are most disadvantaged or face the highest barriers to health.   

Braveman: Similarly, research shows that infant safe sleep public education campaigns helped decrease the incidence of Sudden Infant Death Syndrome (SIDS) among parents and caregivers with higher incomes and more education but widened the gap between them and parents and caregivers with lower incomes and less education.

Orleans: Conversely, what’s an example of a health intervention that effectively reduced health inequities?

Williams: I can name a few: The Truth campaign aimed to reduce youth smoking by raising awareness of how tobacco companies focus manipulative marketing efforts on young people. This message resonated with youth of color and subsequently smoking rates went down at a faster rate among that group. Separately, tobacco taxes also helped smoking rates decrease at a faster rate among low-income populations.

And the State of Delaware provided colorectal cancer screenings and treatment for all residents but created targeted interventions and marketing campaigns for the black community, which experienced lower screening rates and higher colon cancer incidence rates than whites. As a result, screening rates among blacks rose from 48% in 2002 to 74% in 2009, which was equal to the improved screening rate for whites. Additionally, colon cancer incidence rates declined from 67 and 58 per 100,000 residents for blacks and whites respectively in 2002 to 45 per 100,000 residents among both populations in 2009.

Braveman: Another example is the reduction in black infant mortality rates after the passage of the 1964 Civil Rights Act, which withheld funding to hospitals that practiced racial discrimination. The enforcement of this provision led to the integration of hospitals and improved birth outcomes for blacks.

We need to develop new research methods and invest resources in higher standards for evaluation. This will require a significant culture shift.

Orleans: What are some of the challenges in health equity research? How can we shift the frame from focusing on problems to focusing on solutions?  

Braveman: It’s hard to evaluate health equity given its complexity and sometimes the research takes a long time to play out because you need to follow people for five or six decades and measure the effects of factors like poverty and discrimination. It’s difficult and expensive to conduct randomized trials—and unacceptable or outright unethical not to provide an intervention that’s promising to a comparison group. Well-done randomized studies like the Perry Preschool Study and Abecedarian Project, following participants for decades are rare. We need to develop new research methods and invest resources in higher standards for evaluation. This will require a significant culture shift.

Williams: I believe the single biggest thing we can do to advance health equity is to promote solutions, because while most people agree equity is important, they don’t know where to start. I would love to see a resource or portal that specifically showcases a broad range of health equity interventions so others can learn from them.

David R. Williams is the Florence and Laura Norman Professor of Public Health at the Harvard T. H. Chan School of Public Health and professor of African and African-American Studies at Harvard University.

Paula Braveman is the Director, Center on Social Disparities in Health and Professor, Family and Community Medicine at University of California, San Francisco.

Tracy Orleans

As Robert Wood Johnson Foundation’s senior program officer/senior scientist, Tracy Orleans, PhD, leads the Foundation's efforts to develop and disseminate science-based strategies for addressing the major behavioral causes of preventable death and chronic disease.