From Equality to Equity: Increasing Equity-based Approaches in Epidemiology

Dr. Carlos Rodriguez-Diaz joins EPITalk host and co-author, Dr. Patrick Sullivan, for an enlightening conversation about ways that epidemiologists can make important contributions in measuring and describing inequitable health outcomes. Their editorial, "From equality to equity: Increasing the use and reporting of equity-based approaches in epidemiology” can be found in Annals of Epidemiology’s Special Issue on Health Equity: Novel Equity-Based Approaches in Epidemiology.

Read the full article here:
https://www.sciencedirect.com/science/article/abs/pii/S1047279724001091

Call for papers on Novel Equity-Based Approaches in Epidemiology:
https://www.sciencedirect.com/special-issue/300230/health-equity-novel-equity-based-approaches-in-epidemiology

Episode Credits:

• Executive Producer: Sabrina Debas
• Technical Producer: Paula Burrows
• Annals of Epidemiology is published by Elsevier.
  
  
  

Chapters

• 20:23 Behind the Paper

Transcript

Patrick Sullivan: 0:12

Hello, you're listening to EpTalk Behind the Paper, a monthly podcast from the Annals of Epidemiology. I'm Patrick Sullivan, editor-in-chief of the Journal, and in this series we take you behind the scenes of some of the latest epidemiologic research featured in our journal. Today we're here with Dr Carlos Rodriguez-Diaz to discuss a recent editorial in the journal Annals of Epidemiology that we worked on together, titled From Equality to Equity Increasing the se in Reporting of Equity-Based Approaches in Epidemiology. You can read the full editorial online in the journal's special issue on health equity Novel Equity-Based Approaches in Epidemiology at wwwanalystofepidemiologyorg. So now let me welcome our guest.

Patrick Sullivan: 1:03

Dr. Carlos Rodriguez-Diaz is an academic activist- and I love that term. His professional work focuses on engaging the social determinants of health to address health inequities among populations made vulnerable by factors such as race, ethnicity, incarceration status, gender identity, sexual orientation and HIV status. He conducts community-based participatory research in Puerto Rico, the continental United States and the Caribbean region and has several funded projects to improve primary care HIV prevention services and interventions to improve HIV prevention services with sexual minority men, to enhance the continuity of care for justice-involved people and to promote primary care for Latinx and transgender populations. Dr. Rodriguez-Diaz, thank you so much for joining us today. Thanks for the invitation.

Patrick Sullivan: 1:54

So I'm excited to get to talk to you about this, because sometimes you work on writing something and it raises a bunch more questions. You know, it's almost like we rarely sit down and have something we understand fully and then put it on paper, but rather the process of working with colleagues and writing leads us to more questions and great discussions. So I'm excited to get to talk a little bit about this, and I wonder if we could start out just by asking you we hear a lot about health equity in the field today, and I wonder if you can just think a little bit about this concept of health equity and how you think that differs from health equality. Are these really talking about the same thing, or what additional dimensions do you think equity might hold for us?

Carlos Rodriguez-Diaz: 2:38

Sure, and thanks for the question. I agree that it's lovely to have the opportunity to think about what we've been thinking and writing about and share further thoughts. First, health equity and health equality is not the same, although both have a meaning and unfortunately, often we misuse both terminologies. And I would like to start by talking about health disparities, which I think is the most common way of talking about the differences in health outcomes among different groups. And in fact we have health disparities. Some of those health disparities are expected because we have differences in the populations that can help us understand that we will see a different health outcome because something that exists in the community or in the population. Health equity is the goal. Health equity is what we want everybody to enjoy and it refers to the ability of having what is needed based on the population or individual characteristics. Based on the population or individual characteristics From a system perspective and from the research that we do, he's addressing those structural factors that create unjust differences in the populations that we work with.

Carlos Rodriguez-Diaz: 3:58

And then health equality it may sound like an ultimate goal but in fact might not be, because health equality speak of everybody having the same health outcome, which is, for the most part, we want positive health outcomes, but the challenge with speaking of health equality without understanding equity is that we may think that we should do the same with every population to achieve health equality, and that's not the case. So we need to understand the differences within groups and in the different populations that we work with in order to address the disparities, achieve health equity and, in fact, having health equality in our groups and the people that we work with.

Patrick Sullivan: 4:50

Yeah, I think this is such a good point and, as you were talking about it, it sort of made me think that another way into this equity discussion is the idea of setting up the circumstances around us and the opportunities so that everyone can sort of reach their optimal state of health-a nd what it takes to do that. Like what we as public health, you know people and what clinicians and what people who run programs need to think about is that, if the goal is for everyone to be able to obtain their highest state of health, that what is between me and my highest state of health may not be the same needs as what's between another person and their state of optimal health, so that some groups may start further ahead on that journey because they have access to health insurance, because they live in a place where healthcare facilities are more proximate, because they're served by providers who speak the same language or who have different tools at their disposal, and some folks may start further away from that state of their optimal health, again because of some of these structural and social determinants of health that can sit between where our health is today and that optimal state of health. That can sit between where our health is today and that optimal state of health. And so I think the way that you talk about it really sets us on a path of thinking in deeper ways and asking different questions. That if we're just sort of looking at the percent of people who are vaccinated for hepatitis, you know, for example, and is it the same in all these groups?

Patrick Sullivan: 6:20

But to me health equity asks us to think about what that gap is between where someone sits in our society, in the city, in the health insurance scheme, in health literacy, and where that highest state of their personal health is for them. Like, if we start taking that framework, what are the consequences of that? Like, how does it lead us to different questions? Or, you know, in your own work, how do you, what range of things are you thinking about and assessing that come about? Because we're talking about a health equity framework rather than the proportion of people who you know got a vaccine. So where does that take, your own work, when you think about it in that way?

Carlos Rodriguez-Diaz: 7:04

Yeah, I want to follow your analogy and take it a little bit further. What is the baseline for different people? Right, I think of the root causes, right? What are causing those baseline not to be at the same level? So those are the reasons or the factors that we should be considering as we are aiming for health equity. If we don't understand what are the drivers of the differences for the baselines, then we would not be able to answer questions or come up with solutions to achieve health equity. So that inspired my work.

Carlos Rodriguez-Diaz: 7:42

We have multiple scientists, including epidemiologists, who are helping us identifying how certain factors affect specific health outcomes and, fortunately, we have moved from only looking into health factors. We know that there are social factors and besides, of course, the biological factors that are drivers of health outcomes, and those are existing simultaneously, or interact or are additive to a specific health outcomes. And because we have that knowledge, that is what we need to use in order to achieve health equity, either by describing what are the problems and what are the pathways from the root to the difference, or to, if we already understand what are the differences and we know where do we need to intervene, then to intervene in those areas that we know are going to help us close in the gap and the difference of those who can achieve health equity with certain intervention or resources and those that need more resources or a different kind of intervention to achieve the same health goal.

Patrick Sullivan: 8:51

Yeah, and I think that's such the key point that you end on, which is that we need to think about individuals. Maybe as clinicians, we would think about individuals, but as epidemiologists or public health people, we think about groups of people. And what is that recipe, which may be, you know? We talk about like providing information to people, providing rides to service centers, to offering low copay services or free services, to what language is their office? Those are sort of the ingredients and it's that deeper understanding of why people are situated where they are. So the idea that for me, I put things in epi terms, but like the observational epidemiology, of just describing things like where the service points are and where the communities in most need of those services are Are they close, are they far away? You get there by car. Do you get there by public transportation? How long does that take? Is that different for different parts of town? It may be health insurance coverage, it may be language that services are provided in, or other elements of cultural competence. So I think I really like your framework and I really like thinking about what's in the roots you know what are the roots and following that all the way through and that suggests you know ways to make things better.

Patrick Sullivan: 10:05

So you know, I think sometimes is the work that both of us do.

Patrick Sullivan: 10:08

We talk to colleagues and we shortcut sometimes and use terminology to talk about disparities or this or that group you know has twice the burden of this disease, and like we have a lot of language that helps us communicate as people who are interested in improving health. But I just wonder, you know, is how we talk about health inequities? How should we be talking about health inequities as we communicate this information, so that we're not further stigmatizing or using language that might suggest that communities share some part of the blame? And I'll just say up front my thought is that when you look at a community within a city and they have a worse health outcome, that's almost certainly related to some kinds of historical racism, you know, marginalization of populations, some parts of cities not being served as well, with good roads and public transportation and grocery stores proximate and walking distance, like all those things. But how do we think about using language that really helps us focus on those underlying causes and not further stigmatize groups of people by race or age or neighborhood?

Carlos Rodriguez-Diaz: 11:18

Well, yeah, I agree with you that often when we work with communities, populations, we often already know that there are some structural factors that have influenced their lived experience and therefore have caused negative health outcomes, and the community also knows that. So sometimes we try to do research to explain things that the community knows very well and that can hurt the relationship of scientists with the community and also science overall. And I would say that the best approach that we can have, or based on my experience as a community-based scientist, is to listen to the community and, instead of looking at what has not been working, why don't we pay more attention to the things that are actually working? Let's have a more asset-based approach to the solutions.

Carlos Rodriguez-Diaz: 12:16

I have heard more than once recently from community partners the phrase 'Carlos, we know what the problem is, but we need to solve the problem.

Carlos Rodriguez-Diaz: 12:26

Why do we continue to describe the problem and to describe the things that are not working to address the problem?'

Carlos Rodriguez-Diaz: 12:34

So to me, what I'm listening is hey, we have assets, we have good things that are happening. Why don't we tap on those and see how that can help us achieving the goals? And sometimes they might not have enough of that goodness that helps solving the problem, but part of the solution could be enhancing, bringing resources or improving the way those resources can be used, and public health, health sciences and epidemiology our fields can contribute with communities in order to get there. And another aspect of this that I think can make it, you know, useful to the goal of achieving health equity is that then we will be basing our work on what the community knows. Their language, and the likelihood of having engagement and ownership of the community in the process will help research and will help the solution and the sustainability of the work that we do. So we have great opportunities here if we start listening to what is working, to the people that we're working with, and engage from that asset-based perspective.

Patrick Sullivan: 13:48

First, I love the way you started, which is that the community knows, and I think sometimes as scientists we spend a lot of time with data and prove things mathematically or a significant effect or whatever. But again it's the cultural humility of starting with those discussions and there are things that the community already knows. They may sort of see what we come up with and say, yeah, we could have you know, could have told you that. So I think there's an efficiency in having those conversations. And then I think, you know, because the readership of the journal and I think maybe folks who listen to podcasts do sit more in that epi skill set, and so I think this is just moves us ahead, you know, further down the road.

Patrick Sullivan: 14:29

So do you want to take those issues that are identified?

Patrick Sullivan: 14:33

And maybe, instead of describing these associations which, again, like the community might just be able to tell us, one could ask a different question which is like can we model what the impact would be of several different alternative solutions to that problem that the community identifies, working with the community to ask which ones would be acceptable?

Patrick Sullivan: 14:53

So we don't, you know, model things that like wouldn't be feasible or acceptable and really stair step on the knowledge of the community and I just want to acknowledge your own work because there's also a real scientific basis and a professional skill set to accessing that information and to working with the community so that we can make those sort of faster, smarter steps, instead of a traditional epi approach which sometimes is, like you know, let's start by describing the problem. But do we need the epi skills or do we need the listening skills to get through that phase, or some of both? So I really appreciate like hearing your perspective and the kind of work and knowledge that you have working with communities and holding that up to how my epi brain might take a first stab at this.

Carlos Rodriguez-Diaz: 15:37

But the beauty is that we work together and I encourage our listeners to remember that if you are training epi or you're training in public health, we are in a transdisciplinary field and we need to work with people that have a different set of skills. That makes our work so much more meaningful and, let me tell you, it's also fun because we get to learn from each other, we get to nurture the experience and if we are in academia, then that also helps our students, it helps our scholarly work in general, and the community also benefit from people that have different skills and different experiences, and we are leaving something good behind when we work with the community from different disciplines and with different skills.

Patrick Sullivan: 16:28

Yeah, well said. And when I look at the colleagues that we work with, even on this editorial, we've got physicians, we've got physician epidemiologists, we've got PhD epidemiologists, we've got folks with behavioral research, community-based research, and I do think and hope that the way this turned out really called on all the different backgrounds of even just the authors. But I agree with you, it's the richest part of even just the authors. So, but I agree with you, it's like it's the richest part of our work when we put our skills together with someone who has, you know, complimentary approaches. So I'm just going to move us ahead to the call for papers, and I will-w e'll post up in the show notes the link to the call for papers.

Patrick Sullivan: 17:08

But Dr. Rodriguez-Diaz and I are, you know, working with a number of other colleagues and really inviting papers to Annals of Epidemiology that get at some of the issues we've been talking about.

Patrick Sullivan: 17:18

There'll be a link in the show notes to a call for papers where we're saying like we're really interested in this stuff and so if you have papers that are related, you know, we'd like the chance to, you know, to work with them.

Patrick Sullivan: 17:31

So we lay out in the end of the editorial seven ideas for how you know things that would be of interest for this special issue, and one of them, just from everything you've been talking about, to me just sort of rings true. So I'm going to share this with you and let you maybe just talk a little bit about how you think about this. So, actually, the first one of these bullets is to use appropriate methods to illustrate and deconstruct the role of social determinants of health that are giving rise to inequities. So you've already talked some about the humility of learning from communities but, like in the work that you do, what is this process of trying to go from? Like, well, here's a gap in health, access to health services, and we know that that's not somehow inherent to this community. How do you get to deconstructing down to what those root causes are, maybe those social determinants or structural determinants that are really the underlying causes?

Carlos Rodriguez-Diaz: 18:24

Well. So we can talk for hours about just this one item. So I would share two examples. So one would be the methodological approach to understand the problem right, because we still have to understand certain problems that have not been described well enough. And something as simple as using a cross-sectional design or using a longitudinal design can lead us to understand the problem differently and perhaps will also provide information to know how to intervene and how certain factors could change over time, and that improve our ability to integrate that knowledge into how the intervention may look like.

Carlos Rodriguez-Diaz: 19:09

And another example is the use of qualitative methods in combination with quantitative methods that are the core of epidemiology. Sometimes we can use extraordinarily good methods, epidemiological methods and describe very well and achieve the goals and test the hypothesis. But what that means when we were to intervene with a community, and qualitative methods help us understand what that means and it could be. The qualitative methods can be applied with the community, with the population that we are working with, but also with other stakeholders, including the scientists, how we can make use of this knowledge. And I'm mentioning qualitative methods as a companion of quantitative methods, but with that I also want to acknowledge that mixed methods are extremely useful and that is also linked to a very popular approach nowadays with implementation science, on how we can describe a problem, how can we understand the problem and then scale up the intervention or the strategy that we know can work to solve the problem within a group.

Patrick Sullivan: 20:23

Thank you so much for that. So one of the things that is a great pleasure in my professional work and I know in your professional work is getting to work with earlier career people that might be students or master's students or doctoral students or earlier career. You know faculty and I wonder what advice you might have for students you know master's students, say who are really excited about this kind of work, interested in doing this kind of work. What advice would you give for someone who really wants to move their career in this direction, around using these tools to improve health equity?

Carlos Rodriguez-Diaz: 20:57

I will encourage the person to first read a little bit of the history of public health and how we have engaged with people to better their health.

Carlos Rodriguez-Diaz: 21:07

And the history of public health is important because we have made mistakes in public health and if you don't know about those mistakes, we are at risk of repeating those mistakes. So that would be my first advice. Second, surround yourself by peers and mentors who are aligned with your values on how you see the practice of public health and the public health professional or scientist that you want to be. Nowadays, it's extremely important to know not only the methods that help us achieving goals in public health, like the epidemiological methods, but also to understand the social sciences and behavioral science that is the foundation of the observations that we make. That will help us being better when we apply different methods. And lastly, as we have talked so much about community, always remember that you might be working with numbers, with data, but that information comes from humans, and keep in mind how relevant the information that you have in your hands can be for either clinical interventions, social behavioral interventions or to better the health of our communities. Never forget that our work is to better public health.

Patrick Sullivan: 22:24

Wow, that seems like a great place to wrap this up, because that is the bottom line, but I just want to ask you any last thoughts that you want to share with listeners of the podcast, about either this editorial, a career in public health, health equity what's sort of your closing thought here?

Carlos Rodriguez-Diaz: 22:41

Well, thanks for the opportunity.

Carlos Rodriguez-Diaz: 22:43

I would like to be thought provoking here and invite people who want to think out of the box in terms of how can we use epidemiological sciences to achieve health equity?

Carlos Rodriguez-Diaz: 22:55

What is that idea that you think could be a new way of thinking, of applying certain methods, of illustrating how is that we can achieve health equity, and that includes from describing the problems to solving the problems with interventions. I think it's time to challenge ourselves as a field and push forward. We got to where we are because in the past, other people have pushed the field. We were not talking about health equity the way we're talking about health equity nowadays, and that's because some people push the field to do so. So what's next? And if you have an idea and you can come up with a good article that is aligned with that notion, this is the special issue where you should be submitting their article and, as an editorial board, we'd be delighted to review it and provide feedback and, at the least, we will learn from the work that you're doing, and we need to nourish that work, and we are here to use this platform, such an important journal, to keep the conversation and to push the field.

Patrick Sullivan: 24:06

And, Carlos you can see, but our listeners can't see that I got a big smile on my face because I think you just really brought it right back around, saying that the reason this special issue is open is because there's lots of different articles. It's not just analyses that people can submit. You could write a commentary, you can put forward a new idea, and I just love your enthusiasm and openness, which is, I think, how all of us feel, about opening up this space for people to bring their ideas and to learn from each other. And, on that note, I feel like we talk from time to time, but I always feel like I both learn something and I leave ready to dig in and do this work. So, thank you so much for your time today, for the work that you do, for your leadership in the special issue for Annals and just for all that you've shared today. We're really grateful and that will bring us to the end of this episode.

Patrick Sullivan: 24:59

Thanks again, Dr. Rodriguez-Diaz, for joining us. It was such a pleasure to have you on the podcast. Thank you. I'm your host, Patrick Sullivan. Thanks for tuning in to this episode and see you next time on EPITalk brought to you by Annals of Epidemiology, the official journal of the American College of Epidemiology. For a transcript of this podcast or to read the article featured on this episode and more from the journal, you can visit us online at www. annalsofepidemiology. org.