Health Equity Research in Population Health: Building the Necessary Workforce

Civil rights and health equity advocates in the allied fields of population health have worked for decades to get more funding and attention for health equity research in population health. While these efforts need to continue and funding remains behind that of biomedical research, the growing level of awareness of health disparities in population health now affords numerous opportunities for action. With this expanded interest across fields allied with population health, there is a growing workforce issue that has two components to it.

First, with increased interest and research funding available for health equity research, there is an undersupply of individuals trained to do this work. This has led to concerns regarding the quality and productivity of research that is now being funded. Lett and colleagues have argued that newcomers to health equity research lack the research skills to do work in this area. As health equity researchers, we need to engage with newcomers through an open and practical set of guidelines and conversations for how someone can become part of the health equity research community. Multiple types of formal training in population health equity are needed. This, however, should no longer be confined to traditional coursework at universities for matriculated students. Open-access short courses and online training have advantages for being more accessible to a range of students wanting to learn how to do population health equity research. The National Institute of Minority Health and Health Disparities has led many of these efforts, with a focus on a key period of training—early career investigators—and with programs that do not require tuition or fees. There remains, however, an incredible imbalance between interest in training and the research capacity needed with training opportunities. At Stanford, we recently started an undergraduate summer program to do this type of training and received over 1,000 applications for 12 positions. In many cases, training on health equity could also be integrated into training in other domains, as has been suggested with changes to medical school curricula or has been done with integration into training involving core principles of translational science.

The second workforce issue is that there is a lack of individuals in the field who come with personal histories and life experiences of having been impacted by factors that affect population health equity. Much of the lack of diverse perspectives in research is rooted in structural racism, along with classism and other forms of discrimination. The NIH has defined its interest in diversity based on those factors, with a focus on individuals from underrepresented racial and ethnic groups, individuals with disabilities, and individuals from disadvantaged backgrounds. There is reason to be hopeful, given the increased recognition of the lack of diverse perspectives in population health, but there is an incredibly long way to go. Population health equity research is a field poised to attract more individuals from affected communities, owing to the applied, action-oriented nature of the work. Yet, training opportunities are limited and often do not focus on personal knowledge and experience as critical components of research teams, devaluing this knowledge. Master’s degree programs are a key entry point into the research workforce, but there is typically less funding for these programs as compared to undergraduate education and doctoral programs. Programs need to emphasize the value that the lived experience brings to the research team and recognize this as a bidirectional part of training in health equity work, including curricula that focus on “lessons learned” and practical applications.

What is critical is that both issues continue to be addressed if we are to make progress in health equity. To avoid a “ravaged landscape,” we should think about the composition of our research teams in population health, in terms of both factors—expertise in health equity research and being from the community of the work. We can think of these as two axes of what one brings to research, and each of us can reflect on where we fit. Each of these aspects is very specific to the population health equity project of focus. I may be an expert in some areas, and I may be part of the community for some projects, but not for many others. The idea here is that we want to see more people who are part of the community be central to the work, and we want to include people who don’t yet have expertise in health equity research by bringing them into these research teams. We need to value the “community cultural wealth” that individuals might bring to research teams. In the short term, the ideal choice to be part of a research team would be an individual with health equity experience and from the affected community, working with individuals from the other three quadrants. This is essential for building the capacity to do impactful health equity work. The one caveat, though, is the initial assessment of this capacity in the research team. If most research team members fall into the quadrant without health equity research experience and are not from impacted communities, the makeup of the team should be reassessed. Teams can reach out to colleagues for ideas for collaborators with direct experience or prioritize relevant experience when hiring new staff for the project.

The value of inclusive and well-trained research teams is universally accepted as important for doing high-quality science, and the need for these types of teams in population health equity research is essential. To address these two health equity workforce issues together, we need to think more clearly about the composition of population health research teams. A focus on race and power dynamics in mentoring training is key, and there should be focused funding to support work that demonstrates what types of program components are most effective. The issue is capacity and the difficulty of achieving this. It is difficult for anyone to be able to do all of this well, from theory to methods, to data, and to building teams.

The development of programs to support these efforts almost always needs support and collaboration among institutional leadership, faculty, and staff, but programs can be initiated successfully by any of these groups. Several recent programs at my institution that focus on building a diversity of perspectives in mentorship and research capacity have come from the Dean’s office (the REACH initiative and the Propel program) or the Provost’s office (the IDEAL program), and these efforts have engaged with the faculty for support for sustainability and development. On the other hand, we have also seen success here with faculty-initiated programs (the AHEaD program) that have worked to integrate undergraduates interested in health equity work into faculty-led research teams.

In addition to thinking about bringing new people into health research, we need to think about keeping people in the workforce as well. Successful examples of this that could be broadened or replicated in population health include the NIH MOSAIC Program to build a diverse biomedical workforce and the NIH loan repayment program, both of which help with research support during the challenging transition time between graduate training and faculty positions. More fundamentally, NIH funding priorities have meant less funding for research topics of interest to diverse researchers in population health, with historically more funding going to biomedical research than to health disparity research, with impacts on the ability to have a stable research career in health equity research. Foundation funding for workforce development, for example, the Robert Wood Johnson Foundation’s Health Policy Research Scholars Program, has also been critical in meeting these gaps. These programs allow scholars to do work that is high risk and not typically rewarded within biomedical research funding, and to have the space and time to do this work.

Health equity research is challenging, and it takes time and great effort to bring people together. But I am very optimistic that this is not only worthwhile but critical for achieving health equity. There is much work to be done, and if we want equity at the center of social policy and health care policy changes and implementation, there just aren’t enough people in the health equity community right now to do that important work. But there are clear successful paths forward that we can learn from for changing that and building the research workforce that is needed for health equity.

Acknowledgements

I would like to thank members of the Social Policy and Aging Lab and Terrance R Mayes for feedback on this commentary.

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