Health equity: utopian and scientific

From Epidemiologic Knowledge to Improved Health: A Vision for Translational Epidemiology

Epidemiology should aim to improve population health; however, no consensus exists regarding the activities and skills that should be prioritized to achieve this goal. We performed a scoping review of articles addressing the translation of epidemiologic knowledge into improved population health outcomes. We identified 5 themes in the translational epidemiology literature: foundations of epidemiologic thinking, evidence-based public health or medicine, epidemiologic education, implementation science, and community-engaged research (including literature on community-based participatory research). We then identified 5 priority areas for advancing translational epidemiology: 1) scientific engagement with public health; 2) public health communication; 3) epidemiologic education; 4) epidemiology and implementation; and 5) community involvement. Using these priority areas as a starting point, we developed a conceptual framework of translational epidemiology that emphasizes interconnectedness and feedback among epidemiology, foundational science, and public health stakeholders. We also identified 2-5 representative principles in each priority area that could serve as the basis for advancing a vision of translational epidemiology. We believe an emphasis on translational epidemiology can help the broader field to increase the efficiency of translating epidemiologic knowledge into improved health outcomes and to achieve its goal of improving population health.

Commentary: Causal Inference for Social Exposures

Social epidemiology seeks to describe and quantify the causal effects of social institutions, interactions, and structures on human health. To accomplish this task, we define exposures as treatments and posit populations exposed or unexposed to these well-defined regimens. This inferential structure allows us to unambiguously estimate and interpret quantitative causal parameters and to investigate how these may be affected by biases such as confounding. This paradigm has been challenged recently by some critics who favor broadening the exposures that may be studied beyond treatments to also consider states. Defining the exposure protocol of an observational study is a continuum of specificity, and one may choose to loosen this definition, incurring the cost of causal parameters that become commensurately more vague. The advantages and disadvantages of broader versus narrower definitions of exposure are matters of continuing debate in social epidemiology as in other branches of epidemiology.

Was Mackenbach right? Towards a practical political science of redistribution and health inequalities

In 2010, Mackenbach reflected on England's lack of success in reducing health inequalities between 1997 and 2010, asserting that "it is difficult to imagine a longer window of opportunity for tackling health inequalities"; asking "[i]f this did not work, what will?"; and concluding that reducing health inequalities was not politically feasible at least in that jurisdiction. Exploring the empirics of that observation offers a window into the politics of reducing health inequalities. For purposes of future comparative research, I outline three (not mutually exclusive) perspectives on political feasibility, identify their implications for a political science of health inequalities, and explore what they mean for advocacy in support of reducing those inequalities.

Protocol for the development of a CONSORT-equity guideline to improve reporting of health equity in randomized trials

BACKGROUND

Health equity concerns the absence of avoidable and unfair differences in health. Randomized controlled trials (RCTs) can provide evidence about the impact of an intervention on health equity for specific disadvantaged populations or in general populations; this is important for equity-focused decision-making. Previous work has identified a lack of adequate reporting guidelines for assessing health equity in RCTs. The objective of this study is to develop guidelines to improve the reporting of health equity considerations in RCTs, as an extension of the Consolidated Standards of Reporting Trials (CONSORT).

METHODS/DESIGN

A six-phase study using integrated knowledge translation governed by a study executive and advisory board will assemble empirical evidence to inform the CONSORT-equity extension. To create the guideline, the following steps are proposed: (1) develop a conceptual framework for identifying "equity-relevant trials," (2) assess empirical evidence regarding reporting of equity-relevant trials, (3) consult with global methods and content experts on how to improve reporting of health equity in RCTs, (4) collect broad feedback and prioritize items needed to improve reporting of health equity in RCTs, (5) establish consensus on the CONSORT-equity extension: the guideline for equity-relevant trials, and (6) broadly disseminate and implement the CONSORT-equity extension.

DISCUSSION

This work will be relevant to a broad range of RCTs addressing questions of effectiveness for strategies to improve practice and policy in the areas of social determinants of health, clinical care, health systems, public health, and international development, where health and/or access to health care is a primary outcome. The outcomes include a reporting guideline (CONSORT-equity extension) for equity-relevant RCTs and a knowledge translation strategy to broadly encourage its uptake and use by journal editors, authors, and funding agencies.