Resilience & Racial Inequity in Preterm Birth

Drs. Allyson Redhunt and Heather Burris discuss their article, "Resilience as a potential modifier of racial inequities in preterm birth,” published in the July 2023 issue (Vol. 83) of Annals of Epidemiology. In this study, the researchers investigate the potential protective effect of individual resilience on preterm birth risk.

Read the full article here:
https://www.sciencedirect.com/science/article/pii/S1047279723000753

Episode Credits:

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

Transcript

Patrick Sullivan: 0:10

Hi, you're listening to EPITalk: 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 publications featured in our journal. Today, we're joined by Dr Allyson Redhunt and her mentor and co-author, Dr Heather Burris, to talk about their article "Resilience as a potential modifier of racial inequities in preterm birth." You can find the full article online in the July 2023 issue of Annals at www. annalsofepidemiology. org. I want to introduce our guests. Dr Redhunt graduated from Tufts University School of Medicine and will begin her internship in Obstetrics and Gynecology at Albany Medical College in July. Dr Burris is an attending neonatologist at the Children's Hospital of Philadelphia and Associate Professor of Pediatrics at the University of Pennsylvania Perelman School of Medicine. She studies social and environmental factors that contribute to perinatal health inequities. Welcome, Drs Redhunt and Burris.

Heather Burris: 1:22

Thank you. We're happy to be here. Thank you.

Patrick Sullivan: 1:25

So we're going to talk some about your paper that recently came out, focusing on racial inequities in preterm birth, and I wonder if you could start out just by talking a little bit about the question that you wanted to ask and how you came to that research question.

Heather Burris: 1:41

Sure. So I think for a long time you know, maybe decades ago folks thought that some of the differences in preterm birth outcomes by race and ethnicity were somehow innate. And I think the last several decades have kind of disproven that hypothesis and really highlighted that a lot of the lifetime exposures that folks have in the United States that can differ by race and ethnicity, as well as socioeconomic position and other factors, really contribute to differences in birth outcomes, including preterm birth. And recently there's been a real focus on, you know, are there ways to kind of buffer some of these adverse exposures that lead to differences in birth outcomes? And for a little while there was a focus on individuals' ability to be resilient to these exposures.

Heather Burris: 2:37

So I'm going to refer to Dr. Redh unt as Allyson. Allyson came to us first as a college student and then did a few years working as a research assistant in our group up in Boston when I was there with our colleague Dr. Michelle Hacker, another epidemiologist who focuses on reproductive epidemiology, and Allyson really was asking the question could individual level resilience modify the association between race or ethnicity and preterm birth? And with the hypothesis that potentially folks with a higher level of resilience might be able to kind of overcome those adverse exposures. Yeah, so I think that's the main way in which we came about this question.

Patrick Sullivan: 3:22

Then you had access to this prospective cohort study that actually had some of the data elements that you needed. Was that planned in the study or was that just a fortunate availability of data?

Heather Burris: 3:34

Great question. The primary purpose of the spontaneous prematurity and epigenetics of the cervix project, which I was one of the two principal investigators of that study with Dr. Michelle Hacker, was to look at the cervical epigenetic biomarkers and whether they could predict spontaneous preterm birth. And we enrolled nearly 1200 women or pregnant people into that study and followed them and waited to see if people ended up having spontaneous preterm birth or term births. And then we did a matched nested case control study and those results were recently published in a different journal. But when a student comes to us looking for a project we think, ok, what data are available in this data set? And because Dr. Hacker and I were so focused on social and physical environmental determinants of spontaneous preterm birth, in addition to these biomarkers we had also proposed to look at some psychosocial measures and partway through the study we added resilience, and so you can see in Dr. Redh unt's flow chart that for a little while we didn't collect any resilience measures and then partway through the study we started to offer the resilience scoring to participants.

Patrick Sullivan: 4:42

Thanks for the information about the context for the study, and now I wonder if you could just summarize what are the major findings of the paper in your analysis.

Heather Burris: 4:52

Dr. Redh unt really did not find that resilience modified the association between race and preterm birth in our study and really then makes the case that just bolstering. Even if we knew how to do such a thing, bolstering individual level resilience may not be enough to overcome inequities or disparities in preterm birth.

Patrick Sullivan: 5:13

I want to pick up on that because I think it's a really interesting question to ask, it's a really interesting hypothesis and it's a really pretty clear answer, I think, from your data. But I think the idea and I guess maybe I'll ask if it's surprising to you that it didn't mitigate this effect or this association.

Heather Burris: 5:30

I think originally we might have been a little bit surprised, but then we started reconceptualizing. We're not the only folks to have done so. Lots of people are reconceptualizing resilience. That resilience can often be a response. We don't know that people's resilience is kind of a stagnant state or a trait that you have your whole life. But if you have experiences throughout your life, maybe some adversities and other factors that could lead to needing to build resilience, those same exposures might be the antecedents of preterm birth and they might also lead to increased resilience. And so maybe this resilience as a modifier of the association between race and adverse birth outcomes may not be as clear as we initially hypothesized.

Patrick Sullivan: 6:19

Yeah, and I think that that's so insightful because we're talking about exposures that probably happen over the life force to shape risk in biological, behavioral and sort of environmental ways. And so I think in some ways it's a great question to ask, but also maybe kind of a high bar to think that individual resilience can really overcome a lot of inequities that grow out of structural inequities, inequities in access to health care, potentially earlier in the life course, and so I think it's an important question to ask, but in that context, that these are really problems that grow out of really structural and long term inequities in our society.

Heather Burris: 7:02

Absolutely. It also highlights that race itself, and I wanted to make sure we said this in this podcast, that race itself is not some sort of construct. That is also completely it's not really a biologic factor, right it? Folks who identify with certain races or ethnicities have different life experiences and so, in this study, identifying with this particular race or ethnicity it's probably a proxy for lots of exposures that happen throughout the life course, as you say.

Patrick Sullivan: 7:30

Right, yeah, you have this note in the paper that you know resilience might only play a minor role in this relationship because really it's factors beyond individual characteristics that are responsible for the inequities. And you mentioned things like redlining access to prenatal care and employment opportunities and so I think redlining, literally speaking to that, you know, sort of structural built environment component and all the things that travel along with where people live, all those exposures. So thanks for that thought. So I want to just get one more question, in which is where do you think this leaves us? You sort of ask a question. You didn't reject your null hypothesis, which is fine. I actually love at Annals that we sort of have the perspective that sometimes null findings are as impactful as rejecting the null. But where do you think this leaves the field, or what's sort of the next question that follows on around understanding these inequities?

Heather Burris: 8:30

Yeah, well, I appreciate that the journalist is open to null findings, and I think again.

Heather Burris: 8:35

We think about mentoring, students and trainees and projects.

Heather Burris: 8:38

It's so important that either way, the answer is interesting and important, and so we hope that that would be the case for this project as well.

Heather Burris: 8:47

Most of my work at this point is focused on trying to understand the totality of exposures that lead to differences in outcome, both by finding structural interventions that can improve population health. So we have a study on green space exposure during pregnancy and hypertensive disorders of pregnancy with a colleague of mine named Dr. South, Eugenia South. She's an emergency medicine physician at Penn, so the two of us are running that study work with others focused on exposures that are highly relevant, at least in the Northeast over the last few weeks air pollution, also rising temperatures, changes in climate and so are there ways that we can bolster not just an individual's likelihood of a healthy pregnancy but a whole population right, and how can we narrow gaps? And I think it's really important and what Allyson has highlighted is that it's really important that just improving the world for all may not always work to diminish disparities, and so we need to be mindful of that as we're thinking about these interventions at the population level and keeping an eye on inequities.

Patrick Sullivan: 9:54

Yeah, I think. I mean, I think it's going to have to be a both and approach doing what we can in ways that raise all boats and then recognizing that there may be particular interventions or different kinds of resources that are needed to address historical and current inequities that rise above that level of individual behavior or genetics or, you know, that shape the environments in which our health is formed. Great. So I want to turn a little bit into a section that we call Behind the Paper, because I think it's fascinating how papers come to be, and I think it's especially important here to hear both of your voices about this sort of mentor-mentee relationship, which are so special for all of us. We've all been mentored and we all grow into mentors, and so it's a critical part of our academic process. So I might start, Dr. Redhunt, by asking you just about you know how you came to work with Dr. Burris on this and what that mentoring relationship was like during the course of doing this analysis and writing the paper.

Allyson Redhunt: 10:53

So when I was a college student I was searching for a summer internship working in research and I at the time really didn't know that much about what my future would look like or what my future interests would be, just kind of had this concept but I thought I might be interested in like maternal and child health and outcomes, and so I went with that and I was fortunate enough to be interviewed by Dr. Burris as well as Dr. Hacker and some other people up in Boston, and so I started working as a research student, mostly doing enrollment for the study, and then that is how I met Dr. Burris and then, in terms of mentorship, I really felt like she not only was a wonderful supervisor for that internship but also really just had so much insight about how to start a career as a physician and researcher.

Allyson Redhunt: 11:50

And we have continued this relationship now not quite 10 years, maybe eight years, so it's been a long time and she's really helped me kind of through all these different transitions that I've had from college to working to medical school and now as I begin residency.

Patrick Sullivan: 12:04

What a wonderful story and I think these long-term relationships between mentees and mentors are so rewarding for both, on both sides. Dr. Burris, you just want to maybe reflect on. You know from your perspective. You met an enthusiastic eager, you know, earlier I say earlier career colleague and you know what's the experience been really being a mentor through these stages and seeing where Dr. Redhunt has landed and what she's doing now?

Heather Burris: 12:31

Yeah, well, clearly I was the lucky one in this relationship, but when you have a summer student who is so outstanding, you just hope that they might consider coming and working with you for a few years before going on to the next phase, whether that be a PhD program or a medical school program or any other future life that folks want to do, and so we were really excited when Allyson wanted to take a couple of gap years and work with us in Boston on the study, and so it is really satisfying, as I'm sure all the mentors on this call can understand or on this podcast can understand.

Heather Burris: 13:03

When you have a student start a project enrolling the same participants, that then at the end of the study she then analyzes the data, writes the paper and gets it over the finish line, that's really winning. And then when your mentees can teach you something that you don't maybe know upfront I mean again, most people on this podcast would understand that the landscape around studying inequities in health generally has really changed in the last few years and our language has changed over time. The way in which we consider variables has changed over time, and so Allyson was really up and reading all of the latest and greatest guidance on how to thoughtfully consider asking and answering this question, which I think you know, if we had started the project 10 years ago, we specifically on resilience and analyzing resilience we may not have used exactly the same methods that Allyson brought forth in this study.

Patrick Sullivan: 13:59

Yeah, thank you so much for that, and just this. I really want to pick up on this idea that when we mentor, if we go into that with humility, then we learn as much as we share. Just because you know mentees come, I think it even works at the level of mentees have been in school. You know, in my case you know 20 years more recently than I have and things change. So I think there is this real mutuality about what later career mentors can share and what earlier career mentors bring to that relationship and in the best of cases it really is a two-way street as far as you know, as far as learning. So thanks for reflecting on that. Back to Dr. Redhunt, I just wonder, like having been through this process yourself and having the opportunity to work with great mentors and landing where you are now, what advice would you give to current and future students about mentorship or about the idea of integrating some research experience into your training pathway?

Allyson Redhunt: 14:58

In terms of integrating research experience. I think probably especially talking to my medical classmates like research is not something that everyone's super excited about, but I found that, although it is something I want to continue to do for my career even if I didn't have that plan working on a research study and understanding the way that data is collected and the way that it's analyzed and all the people who go into that and the ways that you're asking the questions and reconsidering your questions, makes me a much more critical consumer of medical information and it makes me think a lot more carefully. When there's a new study, is this something that I would want to integrate into my practice? Does it apply to only part of my practice? And it really helps me bring that critical lens, and so I have found it really invaluable. I think that, in general, medical schools are moving towards also emphasizing that as part of the curriculum, and it's something that I really appreciated in my curriculum.

Allyson Redhunt: 15:50

In terms of mentorship, I think that what makes Dr. Burris such a- There are many things that make her a wonderful mentor, but something that I've been thinking about is she is really fearless about kind of tackling all of the hard questions, and I have memories of her talking to me about finances in medical school and what it's like to be a friend and a family member as you grow into being a physician. Those are the things that are a little bit harder to look up online or ask classmates about, whereas the science you can sometimes pick up from your peers and from self-study. But I think that in mentorship those hard conversations that are especially hard for someone who feels young in the profession to ask I feel like Dr. Burris was always ready to bring those things up and really tackle them head on.

Patrick Sullivan: 16:38

Great. I want to thank you both for sharing about these. Mentor-mentee relationships are part of our professional world, but they're also, as you sort of alluded to, quite personal and sort of help us along our journeys. Again for both, for both the mentor and the mentee. So thanks for both of you for being open to sharing about that. I guess I'd like to just ask before we wrap up are there any last thoughts or points that you'd like to share with Annals readers and the listeners to the podcast?

Heather Burris: 17:03

Yeah, I wanted to highlight something that I think many folks probably had a shared experience.

Heather Burris: 17:07

But one of the things that made Dr. Redh unt's experience richer was having really two mentors.

Heather Burris: 17:14

So I think maybe in the traditional laboratory setting there might have been more of a single mentor of a big lab and then that's your mentor and you're the mentee, and that is a very formal relationship and I think many of us have adopted different ways in which to mentor and so, especially when you're asking medical questions using epidemiologic methods, I think it's so important to have an epidemiologist, maybe, and a physician potentially. Sure, there are many ways to do research, but I feel like that gave Allyson a way in which to analyze data rigorously, while also considering the kind of general day-to-day practice and how you enroll in the setting of an antinatal clinic, and so really kind of gave her options and some of our mentees. So Dr. Hacker and I have shared many mentees at this point. Some have gone on to do their PhDs in epidemiology or public health and others have gone on to medicine or nursing, and I think there are many paths to take, but having a diversity of mentors who can bring different professional and lived experiences can be very, very helpful.

Patrick Sullivan: 18:16

Yes, thanks for that, and the idea of sort of multidisciplinary teams to tackle these questions is key. So thanks for acknowledging that, although I will say, Dr. Burris, I know that you're a clinician, but you were talking like an epidemiologist when you talk about the sort of historical factors and the built environments, and the structural framework through which some of these inequities arise is right on the nose.

Heather Burris: 18:40

So I've learned from some of the best.

Patrick Sullivan: 18:42

I think so yeah, I mean just not to belabor the point, but the language of our disciplines. Meaning, how do you really internalize this stuff? I think we can read about it, we can read journals, but for me it's in discussions with people who have complementary expertise where we're generating ideas and in a way that's not even that tension or conscious, I think we internalize the language around these things and language is ideas, right, that kind of language that we're talking about is really reflective of the theoretical frameworks. So I think that's the reason that even in this age, we're recording over Zoom. So I shouldn't throw stones, but like, as we move more towards text messaging and messaging back and forth and platforms, that conversation, I think, develops shared vocabulary, which is the stuff that shapes our research concept.

Patrick Sullivan: 19:31

So agreed about multidisciplinary teams and sharing this language. So that brings us to the end of this episode. I want to thank you again, Dr. Redh unt and Dr. Burris, for joining us today. It was a pleasure to have you on the podcast. Thanks for the work that you do and we'll look forward to reading more of your work and maybe having you again at a later point in your careers to reflect on the work that you're doing and how you've really accomplished this piece of work together.

Heather Burris: 19:57

Thank you so much for having us.

Patrick Sullivan: 20:07

I'm your host, Patrick Sullivan. Thanks for tuning in to this episode and see you next time on EPI Talk: Behind the Paper. EPI Talk is 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.