Health Equity Blog Series: Speaking with Dr. Aisha Langford about health decision making during COVID-19 (and beyond)

Health equity is at the core of our work here at the City Health Dashboard. But when we talk about health equity, what exactly do we mean? Starting this month, Black History Month, we will be exploring issues impacting health and health equity in diverse communities around the country in a new, regular feature, our Health Equity Blog Series. For the first blog in the series, we are very excited to invite you into a conversation with Dr. Aisha Langford from the Department of Population Health at NYU Grossman School of Medicine, also home to the Dashboard. Dr. Langford’s insights help shed light on the importance of health communication and shared decision making in ensuring that everyone has the same opportunities to be healthy, at this critical time of COVID vaccination uptake and in all actions we take that impact our health.

CHDB: Tell us a little about yourself, your research interests and how you became interested in health decision making and health disparities.

Dr. Langford: I’m from the San Francisco Bay Area originally and held roles in public relations, adult literacy, and community outreach before transitioning into academic research. I became interested in health decision making when I started my PhD program at the University of Michigan and decided to focus my dissertation research on clinical trial participation and decision making. Unlike some health communication approaches that use persuasion as a way to change behavior, informed decision making is about providing people with the right amount of balanced information needed to help them make a decision that is right for their situation. With informed decision making, the focus is on supporting a good decision making process (e.g., knowledge, confidence, certainty) and not the actual behavioral or biomedical outcome (e.g., quitting smoking, lowering blood pressure). Regarding health disparities, I’ve always been interested in health and wellness, particularly in communities of color and older adults – although it should be noted that there are many types of health disparities (e.g., by sex, geography, physical and cognitive disabilities). Looking back, my interest in health disparities was sparked when I worked as an adult literacy specialist for San Mateo County Reads in East Palo Alto, California. Many of my adult literacy students were reading at or below an 8th grade reading level and having difficulty navigating the health care system for themselves and their children. One of my first adult learners ended up in the emergency room because he could not read well enough to know how to properly take his blood pressure medication.

CHDB**: How has COVID-19 impacted your research?**

Dr. Langford: COVID has reinforced the importance of clinical trials and ensuring that all people have equitable opportunities to participate in clinical trials if they are interested. My dissertation research was about ways to enhance minority participation in clinical trials across health conditions. During the pandemic, I’ve had the privilege of working with the NYULH Vaccine Center on ensuring diversity in their various COVID-19 vaccine clinical trials. I also was a participant in Pfizer’s COVID-19 Vaccine Phase 1 Clinical Trial, and have been able to share my story as a Black woman, researcher, and clinical trial participant.

CHDB: How do you see racism and distrust of the medical system impacting vaccine hesitancy, and how is that playing out in communities?

Dr. Langford: Many people are asking, “Why now?” That is, why is everyone so concerned about Black and Brown communities all of a sudden when health

disparities and health inequities have always been a problem? These are fair and very important questions.  And for some people, that feeds into distrust and vaccine hesitancy because the current concerns do not feel genuine. For other people, they see this time – including the pandemic and social unrest – as an opportunity for change. And for that, they are hopeful and cautiously optimistic. In my personal opinion, the only way for real change to happen is for health systems, researchers, and health care professionals to change the way they operate and to do a better job with how they handle vulnerable communities (vs. being so laser focused on “changing the attitudes” of patients).  People trust institutions and professionals that behave in ways that are respectful and genuine.

It's also important for health care professionals to listen to and partner with patient and community groups to understand the concerns and opportunities to address vaccine hesitancy. "Trusted messengers" may not always be scientists - they may be community health workers, barbers, clergy members, and the person who makes their coffee every day at Starbucks. It's also important to normalize people feeling confused and hesitant. The news and information about COVID (and the vaccines) over the last year has been exhausting and sometimes very confusing. We should avoid guilting people for not wanting to get the vaccine right away. Instead, we should ask "how can we help?" and be ready to provide trusted sources of information when asked.

CHDB: What are some ways cities, health departments and researchers can improve health communication around COVID-19 and vaccines with residents, specifically Black communities?

Dr. Langford: First, we should all be mindful about painting populations with broad brushes. For example, there is indeed medical mistrust and vaccine hesitancy in the Black community. There are also data that show that Black adults participate in clinical trials when asked and eligible, and many Black adults are willing to get COVID-19 vaccines, especially those who are older and with underlying health conditions.

Cities, health departments, and researchers should acknowledge these real and important issues, but they should not spend all their time focused on mistrust and vaccine hesitancy. That paints a false narrative that these are the only issues and concerns in Black communities. Instead, we should take an expansive view of the various factors that affect COVID-19 transmission (e.g., social determinants of health) and ensuring access to vaccination for people who want it – which is a logistical challenge, not an attitudinal problem with patients.

Moreover, access to high quality health care was a persistent problem before the COVID-19 pandemic. Cities, health departments, and researchers should continue to be involved with health care policy to help ensure that people can get medical care, vaccines, and screenings when they need such services.

CHDB: The stress of this year on communities of color cannot be understated. What does this mean for health/mental/behavioral health, and how can cities best support community needs?

Dr. Langford: To best support community needs, we need to listen to communities and then commit financial and human resources to help address some of those needs in practical ways. Otherwise, such conversations can come across as performative, which can be perceived as being worse than doing nothing.

 **CHDB: How do you think the pandemic will change people’s health behaviors and connection with public spaces and community engagement moving forward?**

Dr. Langford: I’m guessing that many people may have let some health goals go by the wayside because the pandemic has been so stressful. That makes sense because many people are just trying to cope in the best way that they can. It’s hard to be disciplined in a lot of areas while also being worried about losing jobs, juggling remote learning if they have children at home, and dealing with anxiety and depression.

That said, some people have found new ways to cope and change health behaviors. For example, some people are cooking at home more and others are learning new ways to exercise without having to go to a gym (e.g., taking walks outside, watching free workouts on social media or apps, or doing yoga at home). We’ve all had to be creative with community engagement and reimaging our relationship with public spaces. Luckily, we’ve been able to maintain relationships and, in some cases, build new relationships with community groups during the pandemic via technology. I look forward to being together outside when the weather breaks and inside once we can get most people vaccinated (and they feel confident that we can do so safely).

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We are also excited to gather safely with friends and family as vaccinations rise and cases fall! Thanks to Dr. Langford for talking to us about how the pandemic has spotlighted concerns that have been around much longer than COVID-19, as well as the importance of good communication, trust, AND resources in fighting back against inequities in vaccinations and beyond. We look forward to continuing the conversation around health equity in future posts of this blog series.

Aisha Langford, PhD, MPH, is an Assistant Professor in the Department of Population Health. Under NYU Langone Health's Clinical and Translational Science Institute (CTSI), she co-directs the Recruitment and Retention Core (RRC). Broadly, Dr. Langford's research explores how health communication can improve individual decision making and reduce population health disparities for conditions or behaviors that lead to preventable mortality and morbidity.  Historically, she has done work in cancer prevention and minority clinical trial participation in community-based settings. Her current work has expanded to include cardiovascular disease broadly, with a particular interest in hypertension-related decision making and patient-physician communication. Dr. Langford earned her BA in English from the University of Virginia, MPH in Behavioral Science from Saint Louis University, and PhD in Health Behavior and Health Education from the University of Michigan. Prior to transitioning to a career in academic research, Dr. Langford held professional roles in public relations, adult literacy, and community outreach.