20 RESEARCH QUESTIONS: OLD vs New PARADIGM

CARDIOVASCULAR HEALTH

OLD PARADIGM

RQ1: Do Black Americans have higher rates of hypertension than White Americans?

NEW PARADIGM (Williams)

RQ1: Does cumulative exposure to interpersonal and structural racism (measured via validated discrimination scales + neighborhood ICE indices) predict hypertension incidence after controlling for SES, healthcare access, and environmental stressors?

DIABETES

OLD PARADIGM

RQ2: What explains racial disparities in Type 2 diabetes prevalence between Hispanic, Black, and White populations?

NEW PARADIGM

RQ2: How do food desert proximity, chronic economic insecurity, occupational exposures, and healthcare quality interact to predict Type 2 diabetes incidence across neighborhoods with varying racial composition and historical redlining patterns?

MATERNAL MORTALITY

OLD PARADIGM

RQ3: Why do Black women have 3x higher maternal mortality rates than White women?

NEW PARADIGM

RQ3: Does provider implicit bias (measured via IAT), insurance adequacy, facility resource level, and previous experiences of medical discrimination predict quality of prenatal/delivery care and maternal mortality risk?

COVID-19 OUTCOMES

OLD PARADIGM

RQ4: Are racial/ethnic minorities at higher risk for COVID-19 hospitalization and death?

NEW PARADIGM

RQ4: Do occupational exposure risk (essential worker status), household density, insurance status, comorbidity burden, healthcare access barriers, and neighborhood air quality predict COVID-19 hospitalization and mortality?

MENTAL HEALTH

OLD PARADIGM

RQ5: Do African Americans underutilize mental health services compared to Whites?

NEW PARADIGM

RQ5: How do historical trauma exposure (for descendants of enslaved populations), cultural stigma around mental health (measured via validated scales), provider availability, insurance coverage, previous negative healthcare experiences, and cultural competency of available services predict mental health service utilization?

CANCER SCREENING

OLD PARADIGM

RQ6: What accounts for lower colorectal cancer screening rates among Hispanic populations?

NEW PARADIGM

RQ6: Do language concordance with providers, health literacy levels, insurance navigation barriers, work schedule flexibility, transportation access, and clinic cultural competency predict colorectal cancer screening adherence across immigrant generation status and country of origin?

PAIN MANAGEMENT

OLD PARADIGM

RQ7: Are Black patients prescribed fewer opioids than White patients for similar conditions?

NEW PARADIGM

RQ7: Does provider implicit bias regarding pain tolerance (measured experimentally), patient self-advocacy behavior, patient-provider communication quality, insurance type, and facility opioid prescribing protocols predict adequacy of pain management across patient populations?

ASTHMA

OLD PARADIGM

RQ8: Why do Black children have higher asthma rates than White children?

NEW PARADIGM

RQ8: Do residential proximity to industrial facilities, traffic density, housing quality (mold, pest exposure), air pollution (PM2.5, NO2), healthcare access, and controller medication adherence predict pediatric asthma incidence and severity across census tracts with varying historical environmental racism patterns?

OBESITY

OLD PARADIGM

RQ9: What explains higher obesity rates among Black and Hispanic populations?

NEW PARADIGM

RQ9: How do neighborhood walkability scores, supermarket access, fast food density, green space availability, chronic stress exposure (measured via cortisol), sleep quality, work schedule predictability, and food security status predict BMI trajectories over time?

INFANT MORTALITY

OLD PARADIGM

RQ10: Why is infant mortality 2x higher for Black babies than White babies?

NEW PARADIGM

RQ10: Do maternal weathering (measured via allostatic load), prenatal care quality and timing, delivery facility resource level, neighborhood safety perceptions, social support networks, doula access, and breastfeeding support predict infant mortality across maternal stress exposure profiles?

SUBSTANCE USE TREATMENT

OLD PARADIGM

RQ11: Do racial disparities exist in substance use disorder treatment access and outcomes?

NEW PARADIGM

RQ11: How do criminalization history, insurance coverage for SUD treatment, treatment facility availability within 10 miles, stigma experiences (measured via validated scales), employment stability, housing security, and medication-assisted treatment access predict SUD treatment entry, retention, and recovery outcomes?

ALZHEIMER'S DISEASE

OLD PARADIGM

RQ12: Are Black Americans at higher genetic risk for Alzheimer's disease?

NEW PARADIGM

RQ12: Do lifetime cardiovascular health, educational attainment, occupational complexity, social engagement levels, environmental toxin exposures, chronic stress biomarkers, and healthcare quality predict cognitive decline trajectories, controlling for APOE genotype and other genetic factors?

KIDNEY DISEASE

OLD PARADIGM

RQ13: Why do Black Americans have higher rates of end-stage renal disease?

NEW PARADIGM

RQ13: Does hypertension control quality (linked to provider access/quality), diabetes management, NSAID use patterns, environmental lead exposure, occupational nephrotoxin exposure, and early chronic kidney disease detection predict progression to ESRD across insurance types and healthcare systems?

VACCINATION RATES

OLD PARADIGM

RQ14: Why are COVID vaccine uptake rates lower among Black and Hispanic communities?

NEW PARADIGM

RQ14: How do historical medical exploitation (Tuskegee awareness), current medical mistrust (measured via validated scales), vaccine misinformation exposure, healthcare system trust, provider recommendation quality, access barriers (cost, time, location), and social network vaccination status predict vaccine uptake?

STROKE OUTCOMES

OLD PARADIGM

RQ15: Do Black stroke patients have worse outcomes than White patients?

NEW PARADIGM

RQ15: Do time-to-treatment (linked to insurance, transportation, recognition of symptoms), receiving facility stroke certification level, post-stroke rehabilitation access, medication adherence support, caregiver availability, and secondary prevention care quality predict stroke disability and mortality outcomes?

PRENATAL CARE

OLD PARADIGM

RQ16: Why do Black women have lower rates of early prenatal care initiation?

NEW PARADIGM

RQ16: Do work schedule flexibility, insurance enrollment timing, provider availability (appointments within 2 weeks), transportation reliability, childcare access, previous healthcare discrimination experiences, and pregnancy recognition timing predict prenatal care initiation and adequacy?

LUPUS

OLD PARADIGM

RQ17: Why is lupus more severe in Black women than White women?

NEW PARADIGM

RQ17: Do diagnostic delay (time from symptom onset to diagnosis), rheumatologist access, medication adherence (linked to cost and side effects), disease activity monitoring frequency, socioeconomic stability, chronic stress exposure, and comorbidity management predict lupus severity and organ damage?

PROSTATE CANCER

OLD PARADIGM

RQ18: Are Black men genetically predisposed to more aggressive prostate cancer?

NEW PARADIGM

RQ18: Do screening access and timing (insurance, provider recommendation), tumor biology (measured directly), treatment facility quality, treatment delay, clinical trial enrollment (provider bias), androgen exposure patterns, environmental carcinogen exposure, and treatment adherence support predict prostate cancer aggressiveness and mortality?

HEALTH LITERACY

OLD PARADIGM

RQ19: Do racial/ethnic minorities have lower health literacy than Whites?

NEW PARADIGM

RQ19: How do educational quality (school funding history), English proficiency, numeracy skills, previous healthcare navigation experiences, material adequacy (patient education materials at appropriate reading level), provider communication clarity, and health system complexity predict health literacy scores and healthcare navigation success?

LIFE EXPECTANCY

OLD PARADIGM

RQ20: Why is life expectancy 4 years lower for Black Americans than White Americans?

NEW PARADIGM

RQ20: How do cumulative exposures across the lifecourse—including childhood poverty duration, educational quality, occupational hazards, environmental racism (air/water quality), healthcare quality and access, chronic stress (measured via allostatic load), neighborhood safety, housing quality, and social capital—predict longevity across birth cohorts and geographic regions?

THE FUNDAMENTAL SHIFT

OLD PARADIGM assumptions:

• Race is a valid, measurable category

• Racial groups are internally homogeneous

• Differences between races are meaningful

• Race can serve as proxy for unmeasured factors

• Comparing racial averages produces interpretable results

NEW PARADIGM (Williams) requirements:

• Measure actual exposures and mechanisms

• Account for within-group heterogeneity

• Specify causal pathways explicitly

• Use validated measurement tools

• Consider historical and structural contexts

• Avoid crude categorical comparisons

• Test specific hypotheses about mechanisms

• Ensure reliability and validity of all measures

The difference: OLD asks "Do races differ?" NEW asks "What specific, measurable factors cause health differences across populations, and how do they operate?"