Methodology for Promoting Equity-informed Research in Sport and Exercise Medicine: Recommendations from the AMSSM Collaborative Research Network

Abstract

Background:

Limited guidance exists for conducting research on health disparities within the field of sport and exercise medicine (SEM). This review aimed to identify and summarize existing best practices for conducting equitable, diverse, and inclusive research within SEM.

Methods:

A narrative review with evidence synthesis was conducted using electronic databases, reference lists, manual searches, and relevant publications from other organizations. Search terms associated with steps of the research process were used in tandem with “equity”, “inclusion”, and “health disparities”.

Results:

We developed a research roadmap for SEM researchers with methodological recommendations to develop and conduct equity-informed and equity-focused research. This roadmap serves as a tool for SEM researchers and clinicians to design, execute, and disseminate research with a health disparities lens. We recommend SEM researchers should: build an equitable, diverse, and inclusive research team and include community members; apply a multilevel, intersectional framework; minimize and acknowledge potential biases in the study design and incorporate qualitative or mixed methods approaches if appropriate; apply multiple inclusive strategies for recruiting and retaining diverse populations; collect accurate and representative data using inclusive data collection methods and tools with validity and reliability in the populations of interest; apply measures with evidence of validity and reliability in the populations of interest; implement a data analysis plan that reflects the conceptual and theoretical frameworks; and promote broad dissemination and interventions that ultimately address and reduce health inequities.

Conclusion:

SEM researchers should consider these methodological recommendations to conduct equity-informed and equity-focused research to address health disparities in SEM.

Introduction

Physical activity, exercise, and sports participation have numerous physiological, psychological, emotional, and social benefits (1–3). However, these benefits are not equally experienced across populations. Individuals who experience inequitable exposure to negative aspects of the social determinants of health, such as financial precarity, exposure to racism, and neighborhood socioeconomic deprivation, are less likely than their peers to be physically active and participate in organized sports (4) and less likely to receive a prompt diagnosis and appropriate follow-up care after a sports-related injury or illness (5). Health equity “is achieved when everyone can attain their full potential for health and well-being” and is an important consideration for future equity-informed and equity-focused research designed to address health disparities (6). The National Institute of Minority Health and Health Disparities (NIMHD) framework emphasizes that health inequities occur over time and at multiple, intersecting levels (individual, interpersonal, community, and societal levels) (7). Thus, it is important to consider how exposures at different levels may exacerbate or ameliorate health inequities.

Scientific research is a key driver in the identification and measurement of health outcomes and the factors that influence these outcomes, and research can provide a critical foundation for equitable and evidence-based patient care. Across many medical disciplines, there have been substantial advances in how research on health inequities is conducted, with particular emphasis on improving the volume and quality of research investigating the impact of racism in perpetuating health inequities (8). Extending and adapting this progress to sport and exercise medicine (SEM) is critical to ensure that further scientific advances in our field ultimately promote equity—both within the research community and for the patients and athletes impacted by SEM research. Importantly, research practices related to equity, diversity, and inclusion should be addressed by research teams striving to practice equity-informed research.

In April 2023, the American Medical Society for Sports Medicine (AMSSM) Collaborative Research Network (CRN) hosted a research summit, ‘Sports Medicine for All: A CRN Research Summit on Justice, Equity and Inclusion’ to shed light on existing health disparities research in SEM and identify knowledge gaps (9). As part of this summit, a working group was developed to conduct a review with two purposes: (1) identify and summarize existing best practices for conducting equity-informed and equity-focused research, and (2) provide a roadmap to guide SEM researchers in performing equity-informed research with a focus on important methodology to promote equity, diversity, and inclusion. The group focused their work on North American literature and context, however noting that these best practices and the corresponding road map may be a useful starting point for similar work in other settings. It should be noted that meaningful improvement and sustained establishment of equity in a research setting is inherently linked to an understanding and recognition of the systemic oppression of marginalized groups and individuals, as well as to dominant systems of power and privilege that have perpetuated existing biases and inequities. This manuscript aims to provide a pragmatic framework as a starting point for researchers to integrate these considerations into all SEM research.

Methodology

Focus of Review

The overarching objective of this review was to identify and summarize existing best practices for conducting equity-informed and equity-focused research and frame them within the common steps of the scientific research process. This objective was developed through an iterative process during monthly working group meetings leading up to the AMSSM CRN research summit (April 28, 2023), with the goal of producing recommendations for the conduct of scientific research in SEM. This review is grounded in a critical multiculturalist theoretical framework which emphasizes critical reflection, resistance to oppression, and social justice in an attempt to address the root causes of inequity and exclusion (10,11).

Formation of Working Group

The working group consisted of two co-chairs of the AMSSM research summit (CB, KR) who have experience and leadership in the health equity space, the AMSSM diversity sub-committee chair (MB), a community leader (JR), two AMSSM staff researchers (MA, SK), a non-AMSSM PhD researcher (EK), and 5 additional at-large AMSSM members (MA, CD, JD, CN, NS) selected based on content area expertise, affiliations with peer medical groups, and demonstrated research experience. At large members were selected via an open call to all AMSSM members. The call specifically sought applications from underrepresented and early career researchers. The community leader represented an American non-governmental organization whose mission is to increase access to sports for adaptive athletes.

Equity, Diversity, and Inclusion Statement

The working group was purposively selected to ensure representation of individuals from diverse training backgrounds, geographic locations across the United States, and representation of the populations they serve. Specifically, the working group included individuals representing diversity related to gender, race, disability status, sexual orientation, primary medical specialty, level of experience, and region of the U.S. The working group also included a community member from an organization focused on improving access to sport for all, with the goal of ensuring outcomes of this process were relevant and accessible to a non-clinician and non-researcher audience. The social, environmental, and socioeconomic context was intentionally considered in developing these recommendations. However, we recognize that our recommendations may not be directly generalizable to areas outside of the U.S.

Patient and Public Involvement

Patients and the public were not involved in the design or conduct of this research study.

Search Strategy

Although the working group considered conducting a systematic review, a narrative review with evidence synthesis was chosen due to a lack of research publications meeting the review objectives (12,13). The group sought to identify precedents from other fields and provide recommendations within the following steps of the scientific research process (Figure 1):

1. Forming the research team

2. Identifying equity-related, theoretical frameworks

3. Choosing a study design

4. Selecting study measures

5. Recruiting and retaining participants

6. Collecting data

7. Developing and executing a data analysis plan

8. Publishing and disseminating study results

Figure 1.

Research Road map.

Study Selection

Separate literature searches for each defined research step were conducted using a combination of electronic databases (PubMed, Google Scholar), reference lists, and manual searches that included relevant publications from other organizations. All published studies written in English that fit the research objectives were considered for inclusion. Types of research included peer-reviewed articles, book chapters, reports, position papers, editorials, and professional society statement publications. Studies were excluded if they primarily focused on health outcomes rather than methodological processes. Each search included methodological keywords specific to the research step being investigated (e.g.: “study design”, “dissemination”) in tandem with the words “inclusive” and “equitable” and “health disparities”. Additionally, citations were utilized from an AMSSM CRN scoping review on the topic of equity, diversity, and inclusion (EDI) in SEM to include SEM-specific examples that exemplified these proposed best practices where appropriate (9). Search results were reviewed and the content of relevant literature was summarized in each of the recommendations. Results were organized by the steps of the research process.

Results

Conducting Equitable, Diverse, and Inclusive SEM Research Along the Research Continuum

1. Forming the Research Team

Assembling a diverse research team is critical for representing diverse perspectives in research; however, diversity alone will not ensure equity and inclusion within the team (14). Involving collaborators with different backgrounds and attributes (e.g., age, gender, race/ethnicity, geographic location, disability status, and/or sexual orientation) from the outset will allow the research team to draw on a variety of lived experiences to conduct more equitable and inclusive research ideally incorporating perspectives of the study’s target population. Diverse teams strengthen trust and increase participation rates when research is conducted with underrepresented populations (15).

An inclusive research team also actively incorporates individuals who represent the target population to ensure appropriate communication, participation, and relevance to the community (16,17). These stakeholders may take an active role in the research process by identifying important areas of study, suggesting interventions, and building trust between the population being studied and the research team (18–20). A commonly used phrase coming from an American Indian community describes this concept best as “no research about us, without us” (19). A study by Pedersen et al. (2021) discussed how the research team was developed with an academic-community partnership to understand physical activity behaviors of rural American Indian older adults (17). Community-based participatory research (CBPR), an inclusive research method, involves community members in all steps of the research process to create equitable partnerships between researchers and the community (18,19).

To ensure equity on the research team, all members should have their perspectives heard and valued. During research team formation, study leaders should guide the team in reflexivity practices (e.g. discussion of implicit bias, structural competency, and positionality) to understand power dynamics and proper management strategies (14,21). Consistent dialogue and reflection should occur throughout the research process. Study teams should be aware that inclusion, without ongoing critical reflection of power dynamics within the study team, may inadvertently perpetuate existing inequities and harm on traditionally underrepresented team members. Superficial diversity, such as adding a junior researcher from an underrepresented background without valuing their input, will not lead to high-quality equity-informed or equity-focused research. Instead, senior investigators should seek opportunities for mentorship and sponsorship in coordination with these team members (14). The voices of all research team members must have equal weight and those in the typical majority must be open to changing their top-down approach and long-held practices (14). Similarly, allies within the research team need to speak up if the perspectives of underrepresented groups are being ignored or dismissed (14). The burden of ensuring equity and inclusion within a research team should fall on those with more power than those with less and should be considered throughout the research process.

Recommendation 1: Create an equitable, diverse, and inclusive research team, ensuring the meaningful inclusion of community members representing the population of interest, with the goal of co-producing research, improving the quality of research, and elevating the experience of all team members (22).

2. Consider equity-related, theoretical frameworks

Prior to finalizing a research question, teams should consider the problem through the lens of an intersectional, multi-level, theoretical framework (e.g., equity- and/or social-focused). Theoretical frameworks are often considered in tandem with lived experience (including clinical expertise in the case of SEM clinicians) and the existing scientific literature to create a conceptual framework (23). Equity-related frameworks involve a logical connection of concepts and premises developed from existing theories (e.g. feminist, intersectionality, queer, disability justice) (24). In qualitative and quantitative study designs, conceptual frameworks can include narrative descriptions or visual displays (e.g., directed acyclic graphs) to demonstrate how important concepts are related and inform a research question. While the appropriate theoretical framework will vary based on the research question, several robust, multi-level frameworks are widely used and can be instructive in developing research questions, selecting measures, and finalizing analytic plans. The World Health Organization’s (WHO) Social Determinants of Health (SDOH) Research Framework demonstrates how non-medical factors influence health outcomes and lead to inequities, i.e. “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (25,26). This framework focuses on five domains of SDOH: (1) economic stability, (2) education access and quality, (3) health care access and quality, (4) neighborhood and built environment, and (5) social and community context (27). In Figure 2, we have included an adapted figure of the WHO’s SDOH framework with SEM-specific examples that align with each domain.

Figure 2.

SDOH framework

Another commonly used equity-focused framework is the NIMHD Research Framework which specifies domains of influence on health outcomes (individual behavior, physical environments, sociocultural environments, and the healthcare system) and levels of influence (individual, interpersonal, community/organizational, and societal) (28). In Figure 3, we adapted the NIMHD framework with specific examples to illustrate applications to SEM. Both the WHO and NIMHD frameworks challenge researchers to situate their research in a contextualized understanding of health disparities, where individual differences are rooted in exposures that precede individual differences in behavior. Other theories situate individuals in their context, such as ecological systems theory (29), and ecosocial theory (30), which also may be useful to consider for certain research questions.

Figure 3.

Research Framework

Framework-driven research is particularly important for ensuring health disparities research is not perpetuating unfounded and potentially stigmatizing explanations for differences in health outcomes (31). Boyd and colleagues caution that race is often incorrectly identified as a risk factor in research involving health disparities (32), rather than specifically examining the pathways through which racism and other forms of oppression are impacting the outcomes of interest (32). They emphasize that research measuring racial differences should specifically use the word racism, and note the type of racism (e.g., systemic, interpersonal, internalized) that is theorized. Ideally, such potential pathways are tested analytically. For example, rather than solely describing differences in subspecialty concussion care by ethnicity, Copley et al. (2020) demonstrated that these differences were in part driven by English proficiency and insurance status (33). Knowing that differences between two racial or ethnic groups exist due to modifiable experiences in a healthcare setting because of differences in access to healthcare services provides important insights for future action. Researchers should also acknowledge there are multiple potential forms of oppression that may impact health outcomes by considering intersectional frameworks that incorporate lenses of discrimination based on race, sex, sexual orientation, gender identity, disability, and other characteristics of historically marginalized populations (34).

Recommendation 2: Identify the theoretical framework informing your research question, hypotheses, study design, and interpretation of results. To advance equity-informed and equity-focused SEM research, consider using a multi-level, intersectional framework (35).

3. Choosing a Study Design

When planning equity-informed or equity-focused research, it is important to design studies that avoid unintentional bias toward the study population who may be at higher risk of marginalization and the impact of health disparities. Importantly, inclusivity in study design involves intentional reflection on traditional and Western ways of knowing (e.g. authority, rationalism, scientific method) and embracing other ways of knowing (e.g. indigenous ways of knowing) when deciding on the best approach to answering a research question (36–38). As previously discussed, involving members of the researched community throughout the research process is critical as they provide invaluable input to all aspects of research, including study design. Incorporating CBPR should be considered for any study design, from observational studies to randomized control trials (RCTs).

Observational research (cohort, case-control, and cross-sectional studies) is common in SEM (39,40). These designs allow researchers to evaluate exposures and outcomes that occur within specific populations or at certain timepoints. Cross-sectional study designs assess exposures and outcomes at the same time and may be a good option for a relatively quick study that seeks to gather baseline data for a future, larger study (40,41). However, not all data can be quantified, and qualitative data are uniquely capable of providing contextualization for lived experiences of study participants as they relate to the research question, particularly in equity-focused research or when little previous research exists on a specific topic.

Qualitative and mixed methods approaches in health disparities research could reveal contextual information and participant-centered views and perspectives that can be used to promote equity and reduce disparities in SEM (42,43). Additionally, qualitative methodological approaches are well equipped to reveal insights from participants with intersectional identities. For example, a qualitative study from Couch et al. (2023) used semi-structured interviews with Olympic female African American sprinters to better understand how race, gender, and athletic identity impacted transitions during their competitive careers (44). To provide additional guidance, health equity researchers recently developed analytic guidance and considerations for conducting equity-informed qualitative analysis (45). Mixed-methods research involves using both qualitative and quantitative study designs either simultaneously or sequentially (41). A study by Eberman et al. (2020) provides a helpful example of a mixed-methods study using a cross-sectional survey and follow-up semi-structured interviews to investigate athletic trainers’ knowledge and experiences regarding the health care needs of transgender student-athletes (46).

RCTs, by design, lack generalizability, as researchers may exclude important populations (e.g. excluding non-English speakers from a study given that one of the survey tools is only validated in English). These exclusions may explain – in part – why these populations have been historically understudied (47). Additionally, randomization is often not feasible or ethical in health disparities research (41). Observational, qualitative, or mixed methods study designs may be more appropriate and reveal important findings to inform future research priorities.

Recommendation 3: When appropriate, use qualitative or mixed methods (both quantitative and qualitative) study designs to answer research questions. Ensure potential inherent biases are taken into consideration and addressed in the research team’s choice of study design.

4. Selecting Study Measures

Not only is the use of valid and reliable measures necessary to appropriately answer research questions in quantitative studies (48), it is also important for the comparability of research findings across studies. This helps to support future meta-analyses and systematic reviews. The National Institutes of Health has created a PhenX Toolkit, which may be useful for SEM researchers (49). This web-based resource contains a repository of reliable and valid common data elements related to social determinants of health, divided by level of exposure (e.g. individual, structural). The current sports medicine literature includes the use of many non-validated survey items and patient reported outcome measures, or those which are validated in specific populations – often adult, able-bodied males. This can lead to inequitable health outcomes in certain marginalized groups within SEM, including people with disabilities, youth, people with obesity, and pregnant people (9).

The selection of specific measures depends on the research group’s underlying theoretical framework and research question. For example, if neighborhood characteristics are the outcome of interest, this could be measured at different levels. The Area Deprivation Index (ADI is a well-established, U.S. census-based measure that gives a synthesized view of socioeconomic disadvantage within census block groups. It has previously been used to demonstrate the relationship between neighborhood context and health outcomes; for example, higher readmission rates among Medicare patients living in the most disadvantaged neighborhoods (50,51). Within the SEM context, the ADI was used to demonstrate that Black athletes with sudden cardiac arrest come from neighborhoods with greater socioeconomic deprivation than white athletes or athletes of other race with sudden cardiac arrest (52). These findings suggest that racialized disparities in SDOH, via structural racism in the U.S., may influence cardiovascular risk in young athletes. Another composite measure of area level deprivation is the Social Deprivation Index (SDI) developed based on seven demographic characteristics collected in the American Community Survey and used to quantify levels of socioeconomic disadvantage and their association with health outcomes (53). Other examples are tools that evaluate the impact of racism at multiple levels and in different ways. This may include measuring individual experiences of racism or racial trauma with the use of a validated self-report scale (54,55) or using a community-level proxy for systemic racism such as racial inequities in policing or unemployment.

Alternatively, in a qualitative context, theoretical frameworks and existing theories are useful to guide the development of interview or discussion guides. For example, Pedersen et al. (2021) used an ecological model of health behavior to investigate individual, social/cultural, and environmental influences on physical activity behavior among rural American Indian older adults, a group prone to health disparities (17).

Recommendation 4: To perform high-quality equity-informed SEM research, select reliable and valid study measures based on the research question(s), study design, and underlying research framework. Quantitative measures and/or qualitative inquiry of socioeconomic deprivation or discrimination should be considered to explore social determinants and health inequities.

5. Recruiting and Retaining Participants

Recruitment and retention of participants is an essential part of many research studies. The inclusion of a diverse study population is necessary to ensure an accurate and comprehensive assessment of the research question. Equitable, diverse and inclusive recruitment and retention strategies must begin from the inception of a research study. At this stage, research teams should once again engage in reflexivity practices to evaluate unconscious biases in participant recruitment and retention practices, to approach this process with a more inclusive lens.

An essential component of successful recruitment and retention is building trust and connection with the target community from the beginning of the research process and regularly examining this relationship throughout the study (56–59). Common practices in participatory research approaches (e.g. Action Research, Community-Based Participatory Research, Participatory Action Research) prioritize genuine and meaningful participation among stakeholders (60). This can include empowering and training community members to be part of the research team and assist with participant recruitment. Recruitment of diverse populations can be challenging due to the legacy of unethical research involving underrepresented communities, including abuse and deception as well as withholding treatment for research purposes (61). This has resulted in mistrust, apprehension and hesitancy to participate in research (56). Research teams must actively work to address barriers related to research mistrust by engaging directly with the community, including community members as participatory and active members of the research team, and facilitating open communication and collaboration. This collaboration must include opportunities for feedback and an open-mindedness to modify the study design, if indicated, based on input from the community (57,62). Inclusive practices to promote retention of diverse participants could include accommodations for caregiving responsibilities, evening and weekend data collection, and addressing accessibility of study materials for people with disabilities.

Recruitment approaches should be multimodal (62) and inclusive of both proactive and reactive strategies (56). Proactive strategies include direct contact with potential study participants in order to share study information and to request their participation. This may include face-to-face interactions with community members at events such as community centers, fitness facilities, sports practices, interscholastic events, and street fairs (56,63). These interactions provide opportunities for community members to engage in dialogue, discuss concerns for potential harm, address cultural values, express expectations, ask questions, and build connection and trust with the research team (56).

Reactive strategies involve indirect contact with potential participants. This may include indirect contact between the research team and participants through collaboration with key community leaders, snowball or word of mouth, printed and broadcasted material, or referrals from health care providers (56). Encouragement from trusted community members, family and friends helps build confidence and ease apprehension and distrust (56,59,64,65). Mindful development of recruitment materials is imperative to ensure they are culturally sensitive, available in different languages and strategically placed in a variety of locations to help reach a diverse population (56,59,63). Broadcast recruitment strategies should focus on locations with high accessibility to ethnically diverse populations to capture a wide audience of participants.

Recommendation 5: To recruit and retain diverse study participants, investigators should cultivate a diverse and inclusive study team, carefully consider the study design, build trust with the community, have them involved in the research from the initiation of the study, and use multimodal recruitment strategies.

6. Collecting Data

For researchers to identify causes of health disparities, the collection of representative and accurate data is paramount. Without appropriate measurement of factors influencing health outcomes, researchers cannot examine why those outcomes occur, or hypothesize ways to intervene (66). Many current standards of care are rooted in norms established from data of white, English-speaking, non-disabled, cis-gendered males (66). While there has been recent dialogue on how to improve EDI in research, data instruments have not kept pace with societal and demographic changes in the U.S. and globally (67). In quantitative studies, selection biases, information biases, and measurement errors can lead to biased results and conclusions (68). Determining ways to avoid and minimize these potential biases prior to data collection is critical.

To improve the breadth and depth of demographic data collected, SEM researchers should consider collecting data on the following characteristics: race, ethnicity, preferred/primary language, gender, disability or functional status, geographic location, sexual orientation, and gender identity, amongst others (69). Moreover, considering the intersection of these characteristics may reveal important associations and outcomes in equity-focused research. Qualitative methods are well-equipped to examine the intersectional dimensions of human experience as mentioned previously in the study by Couch et al. (2023). The SDOH are another important component of data collection. Examples of SDOH relevant to SEM are safe housing, socioeconomic deprivation, access to protective sporting equipment, access to transportation, job opportunities, exposure to pollution, and literacy skills (Figure 2).

There is often a lack of standardization in data collection methods, which can lead to missing data, making it difficult to combine and compare datasets across studies. Guidance on the collection of data on race and ethnicity has been developed and acknowledges that researchers should use inclusive language, provide comprehensive categories and subcategories for participants, and report on how this data was collected (70). The reflexivity of the researcher should be considered and discussed to examine how one’s own lived experiences and assumptions may influence the data collection and analytic processes. Appropriate data collection methods in both quantitative and qualitative studies should be prioritized, and scientific journal editors and reviewers should hold authors to these standards. Validated assessment and screening tools of social drivers of health should be identified and disseminated to researchers so that best practices are known (71–73).

Addressing structural barriers to research participation in data collection is also essential. Special consideration should be given to ensure that data collection methods offer opportunities for flexible assessment times, such as evenings and weekends, and at convenient sites to reduce potential barriers to transportation, meals and/or childcare (56,58,63). Factors related to universal design and access for study participants with physical, sensory, communication, or cognitive disabilities should also be considered (74). Appropriate compensation that covers expenses related to travel, loss of pay from work, childcare, and participant time should be provided to promote participation (56,59,63). Ongoing communication, and proactively seeking feedback from participants is essential to minimize participant burden and address barriers to participation as they arise.

Recommendation 6: Ensure accurate and representative data are collected by minimizing potential barriers to data collection; consider the unique needs of study participants and reduce barriers to their participation.

7. Developing and Executing a Data Analysis Plan

Data analysis plans are a critically important aspect of the research journey. Authors Light, Singer and Willet astutely stated, “you cannot fix by analysis what you bungled by design” (75). In short, any data analysis is only as strong as the thought put into the study design. A data analysis plan should be developed during the initial study design phase and in close alignment with the study aims and hypotheses, target study population, interventions, and outcomes. Choices made during this stage will impact what outcomes can be evaluated from the collected data.

A data analysis plan should include analyses that evaluate both the impact of a specific participant characteristic/factor on the outcome of interest and (when feasible) any intersections that may lead to inequities. Each individual characteristic may have a different association with the outcome when paired with other characteristics/factors. A SEM-focused example of utilizing an intersectional lens in data analysis is the cross-sectional survey of parent-reported youth sports participation by Hyde et al. (2020) which examined differences in participation by demographic factors, finding that household income level had a pronounced impact on participation among younger age groups (76).

Understanding the associations of all intersecting characteristics with the outcome is often not practical; however, ensuring diversity of enrolled participants may allow testing meaningful interactions of subgroups (i.e., the intersections of individual characteristics). Importantly, the absence of evidence that subgroup outcomes differ should not be equated to evidence of an absence of differences. Relatively novel statistical approaches to the field of SEM, such as Bayesian hierarchal methods, could be considered to assess the probabilities of meaningful differences between subgroups when sample sizes are small; however, these methods often require strong statistical knowledge. We strongly recommend partnering with statisticians/epidemiologists/data scientists/qualitative researchers early in the research process to ensure proactive and intentional use of analyses that support equity-informed and focused methods. Analyses of qualitative or mixed-methods data should involve an expert in these methodologies. Importantly, qualitative analysis involves researchers transcribing interviews and focus groups, coding the data, and mapping the data to develop rich interpretations. Given its iterative nature, sufficient time should be allocated for this part of the research process and consideration of participatory data analysis approaches, which involve community members, should be considered for analysis and interpretation (77,78). When developing a data analysis plan and reporting results, investigators should also consider disaggregating the data by various characteristics or factors when possible, while also preserving the anonymity of potentially vulnerable study participants. Oftentimes various levels of a data variable are grouped (due to small numbers) to conduct more meaningful subgroup analyses. However, this grouping makes a strong assumption that those subgroups have similar outcomes. The importance of these characteristics and their varying levels to the research question should be considered during the design phase so that sufficient data are collected to conduct meaningful analyses.

Recommendation 7: Data analysis and reporting plans should be developed a priori, with attention to methods that emphasize equity. This is best done in collaboration with experts (e.g. biostatisticians, epidemiologists, or qualitative researchers) to select the most appropriate quantitative and/or qualitative approaches and identify opportunities to assess intersectionality and disaggregate the data when possible.

8. Publishing and Disseminating Study Results

The availability, awareness, and application of equity-informed SEM research findings are dependent upon publication and dissemination of study results to a broad audience. However, as with many aspects of research, researchers must be aware of the potential for bias that limits publishing and dissemination. Gender equity is lacking in scientific journal senior authorship for women (79–82). Although racism remains a key determinant of health and a wide body of research exists detailing the relationship between race and health, a relatively small number of published papers address racialized inequities in the U.S. (83,84). Despite the increase in publications focused on identifying health disparities within specific populations, there remains a paucity of publications documenting trends towards improving health equity for marginalized groups (85). SEM journals should consider the recent work by the British Journal of Sports Medicine (BJSM) to provide EDI guidance to authors and consider incorporating similar principles into their own publication guidelines (86,87).

Current avenues for publishing equity-informed SEM research present their own challenges. In recent years, the open-access publication movement, which strives to make research more widely accessible, has favored senior male researchers at prestigious academic institutions (88) and researchers in higher resourced environments (89). As a result, women and authors underrepresented in medicine publish less frequently, and those with little or no financial means (e.g. researchers in low-income countries) may not have the same opportunity to publish in open access journals, representing a clear example of structural bias and lack of equity and diversity within publishing houses. The National Institutes of Health (NIH) has acknowledged the role structural racism plays in the scientific community broadly, while offering useful resources towards supporting EDI within SEM and medical research in general (90). Parallel work by the NIH has also acknowledged the impact for structural ableism in scientific research (91).

The last area to address regarding health equity in SEM research involves the public dissemination of research results. Given how important and challenging it can be to effectively disseminate research into communities of color, people with disabilities, non-Anglophone individuals, and other marginalized groups, alternative methods of research dissemination are important. Research teams should have conversations with communities of interest to help identify the most appropriate mechanisms for dissemination. Digitally networked technologies and the internet can be extremely valuable (92), however consideration of additional modes of communication is equally important, including potential translation of outcomes into other languages. Over the previous decade nearly all research journals, scientific magazines, and scholarly books have become available online. In addition, through digital platforms created within social media, blogs, wikis and podcasts, health research can be communicated to new audiences formerly out of reach with traditional communication methods (93). However, dissemination through digital platforms, while clearly advantageous, also creates potential barriers for those without access to these platforms (i.e., households without internet access) and those for which online platforms serve as impediments to learning. Providing multiple avenues for dissemination of SEM research, beyond digital platforms (e.g. hosting community events, holding discussions with policy makers with community member involvement, interacting with local press and media) is needed to create new opportunities for diverse investigator teams and interdisciplinary collaborations to communicate their results to diverse audiences (94) and to ensure accessibility of the research to the communities it is meant to support.

Recommendation 8: To enhance equity in research dissemination, SEM researchers should consider equity-informed dissemination strategies during the planning stages of their research to ensure these principles are implemented when publishing and disseminating results. Considerations should include, for example, free layperson’s summaries, low-cost or free Open Access publication, and actively campaigning for a more equitable SEM publication model.

Discussion

This review addresses a major gap in SEM research by providing best practices for conducting equity-informed and equity-focused research. We emphasize the steps of the scientific research process wherein intentionality can drastically improve how SEM research is planned and performed to increase EDI. We draw from best practices in other scientific fields to help shift the paradigm and build a new research culture within SEM.

To conduct research in an equitable and inclusive manner and limiting bias(es), a purposeful and proactive approach is necessary. In addition to the research roadmap presented here, several other examples of position statements and guidance on equity-informed research from other medical societies exist, and SEM researchers are encouraged to familiarize themselves with these and consider their recommendations (18,95–99). SEM researchers and clinicians can integrate these tools in their research and practices to improve patient care and address health disparities in the field. Encouraging broad dissemination of SEM research will lead to the development of interventions, based on recommendations from equity-informed research, that address and reduce health disparities.

Importantly, conducting meaningful and sustainable equity-informed research is an intensive and iterative process that requires intentional, consistent, and deliberate effort by study teams. The recommendations presented in this roadmap are intended to provide SEM researchers with the necessary tools from which they can begin to engage in this important and needed work. Even with altruistic intentions, engaging in equity-focused and equity-informed research may, at times, result in unexpected challenges and missteps that ultimately harm the communities and individuals we intend to uplift. To help mitigate these harms, including risks of exploitation and extraction, study teams should prioritize accountability and transparency, be committed to authentic inclusion, and engage in regular, critical self- and study team-reflection throughout the research process.

Limitations

Although this review advances the principles of EDI in SEM research, there are limitations that should be noted. First is the lack of a consistent, systematic search strategy used to identify all pertinent research relevant to the methodology of conducting equity-informed research. However, our search terms and review of relevant references should have mitigated the possibility of missing important frameworks, tools, and guidance documents related to health inequities in SEM. A second limitation is our focus on North American-centric research most relevant to AMSSM. We recognize there may be important considerations for equity-related research and practice in other contexts and geographic regions. We also acknowledge that strategies to conduct equity-informed research in the U.S. may not be feasible or relevant in other areas of the world. We hope that SEM researchers will continue to build on this work across contexts to allow for the growth of equity-informed research in our field.

Conclusion

Developing a research roadmap for SEM researchers is a pertinent first step towards the conduct of more equity-informed and equity-focused research. It is our intention that these recommendations serve as a starting point that are iteratively revised to address health disparities in SEM as this important arena continues to expand and evolve.

Summary Box.

What is known?

• Health disparities exist due to inequities in socioeconomic, sociocultural, environmental, and structural exposures within the health care system.

• Research on best practices for conducting equitable and inclusive research is growing in other scientific fields; however, recommendations specific to the field of sport and exercise medicine (SEM) are lacking.

What does this study add?

• This review provides a roadmap aligned with the steps of the scientific research process, summarizing recommendations for conducting equitable and inclusive research in SEM, as well as research focused on health disparities, based on existing best practices from other scientific fields.

• Equity-informed and equity-focused research is needed to advance evidence-based approaches to athletes and patients from underrepresented or marginalized populations across the domains of research, patient care, and advocacy in the field of SEM.

Data Sharing:

All relevant data and citations are included in this manuscript