Expanding the boundaries of health services research

1. INTRODUCTION

Decades of definitions of Health Services Research are broadly consistent with the definition articulated a quarter of a century ago by the National Academy of Sciences, wherein “Health services research is a multidisciplinary field of inquiry, both basic and applied, that examines access to, and the use, costs, quality, delivery, organization, financing, and outcomes of health care services to produce new knowledge about the structure, processes, and effects of health services for individuals and populations.”. ¹ This definition, and others that are consistent in intent, suggests a field that uses a range of approaches to best understand the delivery of health care, to the end of improving health. ² , ³ This general orientation and the approaches that are typically deployed to these ends have served the field—and our understanding of the questions at hand—well. Health services research can claim success through important insights that have, over time, helped advance the structure and function of health systems, particularly in the US context.

And yet, despite these successes, it is abundantly clear that there remains much where US health systems fall short. At the simplest level of stating the problem, the US health care system is by far the most expensive system in the world, with 17.7% of gross domestic product spent on health, ⁴ without commensurate success in achieving health indicators that one might hope for given this expenditure. On most measures, Americans live shorter, sicker lives than peer nations, despite our disproportionate spending. ⁵ It is difficult to think of another sector where the country vastly outspends its peers only to have worse achievement on the key markers of interest. It is not fair to lay this problem fully at the feet of health services research. It should, however, give us pause and challenge us to think about the field, to consider if there are approaches that could expand the scope and boundaries of health services research, help nudge the field forward, and lead to the improved health indicators that should be our fundamental goal. This is a particularly apposite moment for reflection on boundaries of the field. We are currently living through several once‐in‐a‐generation exogenous forces that are shaping scholarship. The coronavirus disease 2019 (COVID‐19) pandemic, its economic consequences, and long‐overdue racial reckoning have encouraged us to see differently across a range of fields. Health services research should be no exception, and it bears asking whether there are perspectives, informed both by the moment and by scholarship that has come before it, that can fruitfully inform a consideration of expanding the boundaries of health services research.

We suggest that there are three lenses and three approaches that can frame an expansion of health services research, which can both advance scholarship and help the field guide us to better health.

2. THREE LENSES

2.1. Incorporating intersecting heterogenous identities

The first lens emerges from a growing appreciation of the importance of intersectionality ⁶ that has elevated in our scholarship the role that individual experiences at multiple levels of identity—including for example both race and gender, immigrant status, and sexuality—play in shaping daily lived experience including, and certainly not limited to, interaction with the health system. Health services research's traditional concern with effects of health services for individuals and populations has typically been operationalized as inquiry into characteristics of health systems that may have an impact on individuals or populations of individuals. However, this approach is predicated, at least implicitly, on an assumption of homogeneity of individuals. Scientists and scholars have always realized that individuals are not all alike, of course, just as we recognize that in our daily lives as citizens. Yet it is often a helpful reduction to consider individuals as interchangeable, differentiated at best at the level of broad populations (e.g., the elderly or the young). However, it is also abundantly clear that this simplification limits our understanding of the processes within health systems that shape health, simply because individual characteristics matter substantially for how these processes shape health for different individuals.

Hence, for example, costs of care and processes for delivery of care matter quite differently for persons with different life experiences and can determine whether health systems achieve their desired intent—improving health—or fail to do so through a combination of practical inaccessibility and incompatibility with the reality of lived experience of different people who encounter the health system. A forward‐looking health services research may need to grapple with considering how intersecting and heterogenous identities refract the function of the health system, and how health systems must be designed to account for the diversity of lived experience of the persons who are to benefit from their function. We realized that one challenge of this approach is the risk of reductio ad absurdum, that an overly individualistic approach suggests the scholarship and function of “health systems for one.” But we do not think that this must be the case at all. It can be simultaneously true that health services research does a better job at thinking through how individual intersecting identities shape the questions of interest for the field, and the function of the systems that it studies, while also being careful to define populations in ways that are useful to the scholarship.

2.2. Integrating social and structural contexts

Complementary to the individual intersectional lens that can inform expansion of health services research boundaries is a second lens that focuses on the context within which the individuals live, work, and play, how that context shapes both the individual identities themselves, and how those identities intersect with health system elements that determine effectiveness of those elements toward producing better health. There are several theoretical models that explain how social and structural determinants of health, manifesting at nested levels of context—from social networks, to neighborhoods, to communities, and to policies and institutions—influence individual actions and behaviors. ⁷ Of particular interest to this comment is that it is impossible to separate individual action or consequence of access to assets such as health systems, without understanding the individual's context that may facilitate, or impede, how the individual realizes their relationship to these assets. Therefore, for example, it is difficult to understand whether—or why—a health system may succeed in a successful screening program, without understanding the role that trust in that health system may play in its success. This has never been clearer than, in recent illustration, the challenges that we have faced with delivering COVID‐19 vaccines, where trust in systems, including health systems, has emerged as a barrier, long‐present, not particularly well studied nor understood, and impenetrably challenging during a crisis.

As an important example of the role that context plays in the question of interest to health services research, it is difficult to study how quality of care may influence particular populations without asking whether structural racism, previously largely unexamined and likely ubiquitous, is influencing provider engagement. The influence of structural racism is now understood to be pernicious in many aspects of daily life. This includes the delivery of health services. Structural racism influences both differential access that persons of different racial groups—particularly black Americans—have to health‐related goods and services (e.g., pharmacies, transportation to physician appointments, health insurance, co‐pays ⁸ ) and physician attitudes and behaviors that introduce biases in management decisions leading to differential outcomes of care. Both of these can lead to different health outcomes and should pose questions of concern for health services research. To what extent, for example, do preconceived attitudes about the “compliance” of different racial groups with treatment guidance shape the likelihood of provider vigilance that treatments are delivered in a way that is likely to be well received, and hence implemented effectively, by patients? How do physician's unconscious biases influence their decision making, and how does this change care algorithms that result in poorer health for particular racial groups?

Health services research can also continue to tackle a central topic: cost and accessibility of medical care, through the lens of the contexts in which people live, shaping how they intersect with the medical system, how it is funded, and how to optimize access to care. As economic inequality continues to grow, so too will the field need to grapple with payment of medical care; with almost 74 million people enrolled in Medicaid as of 2021, ⁹ and 10 million new enrollees during the COVID‐19 pandemic alone, ¹⁰ health services research will increasingly need to address the determinants that shape lives, such as employment, education, and economic stability, in its remit. This lens calls for us to situate health services research as it is—in the real world—where system access, costs, and organization are shaped by the world around us and where the extent to which these functions influence outcomes of health systems is inextricable from these features of the same world that shapes health systems. Such a lens would allow the field to address health disparities ⁸ , ¹¹ through a holistic view, recognizing the complex and multiple layers leading to quality interactions with the health system.

2.3. Taking a lifecourse perspective

A third lens that can fruitfully push the boundaries of health services research forward is a historically grounded lifecourse perspective, one that recognizes that health is the product of both the immediate individual intersection with the health system and their exposures and experiences throughout a lifetime and often of historical legacies that shape that lifetime. ¹² Building on a recognition of the role of intersecting personal identities influenced by nested levels of context, inquiry into the role of historical and lifecourse context can lead to more granular questions in the field that better reflect lived experience. For example, going back to the example of trust in health systems, trust is accumulated over a lifetime. Patients who have been connected to effective, caring health systems since childhood are much more likely to be willing to engage with health systems in adulthood, to their benefit. Similarly, persons whose families have long felt safe engaging health systems are much more likely to do so than those who inherit a legacy of distrust in the same systems. It is difficult to consider, for example, how to optimize health system functioning without considering such legacies of marginalization that can be borne by immigrant families or by persons of color in neighborhoods that may have been long served by institutions that were not responsive to community need. This nests our appreciation for health system functioning within a historical frame, asks us to consider the role that history plays in the processes and effects of health systems, and pushes us to study health system approaches that, with intentionality, are designed to overcome the historical and lifecourse forces that may make health system effects different for persons with substantially different life experiences. The antiracist scholarship agenda, for example, ¹³ , ¹⁴ , ¹⁵ offers a perspective that encourages active effort to counter historical racism as experienced by individuals and that requires the deliberate building of systems that counter these historical legacies. An health services research informed by this perspective would consider this history, how it is experienced by individuals with intersecting identities, and how that is informed by present context, to better understand how we can optimize system functioning toward producing health.

3. THREE APPROACHES

The lenses we proposed represent, to some extent, a tall order, a stretch for any field, but one which we suggest health services research is well suited to embrace, building on a rich multidisciplinary past and a clarity of intent to study and design health systems that can improve health for all. These lenses can also be complemented by three approaches, all extending work that is currently part of health services research, but centered and brought to a fore in an expanded health services research repertoire.

First among these approaches must be the engagement of the persons who are the intended beneficiaries of health systems in both health system thinking and design. At its simplest level, this means engaging the community members whose health systems aim to help and inviting them to be a part of designing health systems and improving their efficient functioning. The idea of community engagement is not in any way new, and many health systems include community advisory groups and community committees whose role it is to bring community voices to the table or to extend the health systems' reach into communities themselves, outside of the walls of the formal systems. However, the failure of health systems to achieve health outcomes that would be commensurate with our spending and with our investment in the excellence of our systems seems prima facie evidence that somewhere along the line we have disjunctures between what health systems are intending to do and what they achieve. It is hard to argue that this would not be helped by having stronger input from voices—systematically, routinely, and comprehensively—to bridge the gap between what we may think should work and what, on the ground, does work. An argument for more formal engagement of community voices is not an argument against expertise and the role of those who spend lifetimes studying the organization and delivery of health systems. It is, however, a call for humility on the part of all involved—from community members to experts—and a call for clearly structured partnerships that bring insights to guide both scholarship and action informed both by present lived experience and by a deep understanding of what has worked, and has not worked, in other systems that can point to the right questions that can lead to better solutions.

Second, and perhaps canonical to the field, is the need for transdisciplinarity. It is one of the hallmarks of health services research that academic disciplines as far flung as anthropology and epidemiology, as biostatistics and economics, all have made and continue to make contributions to our understanding of delivery, organization, and function of health systems. This has served the field well and will continue to do so. Taken together with some of the other suggestions in this comment, this multidisciplinarity becomes even more clearly a cardinal feature of the future of the field, calling for the emergence of scholarship at the interstices of disciplines far beyond what has been the case over the past several decades. It is impossible to imagine scholarship that meaningfully engages intersecting individual identities and the context that shapes these identities over a lifecourse, outside of scholars who have dexterity both with these ideas and with the approaches that can meaningfully add insight into how to translate these ideas into better health systems in practice. This places a premium on training programs that can produce scholars with facility both across disciplines and merging disciplinary approaches, on funding streams that facilitate and encourage transdisciplinary work and on journals that have the intellectual flexibility to publish across disciplines.

Third, and relatedly, expanding the boundaries of health services research to include more transdisciplinary approaches must also, by definition, make space for methodological heterodoxy, the embrace of approaches that transcend typical disciplinary methods, grounded in a recognition of the heterogeneity of effects that one must expect in the delivery of care to heterogenous individuals through complex systems. It is almost certainly unreasonable to expect that the quality, delivery, organization, financing, structure, and processes of health systems will have a linear effect on the health impact of these same systems, for example. If we recognize that to be the case, approaches that comfortably accommodate a multiplicity of methods, including, for example, nonlinear system dynamics, need to become commonplace within health services research. Similarly, the reduction of complex historical processes that excluded populations from health systems to binary variables will likely provide insufficient insight into these processes. This means that qualitative approaches need to complement quantitative data as we aim to better understand optimal structure of health systems. Perhaps, more boldly, this requires the emergence of new methods that allow us to better understand the role of complex processes that have heterogenous expression for different persons, over time. It is unreasonable to expect that all health services research scholars are fluent in all the methods necessary, just as it is not reasonable to expect all scholars to have familiarity with the breadth of disciplinary approaches. It does, however, call for team science approaches and the ready cross‐fertilization of scholarship with inputs from across disciplinary spaces. That would, we suggest, make for a more interesting, and more useful health services research scholarship.

4. CONCLUSION

Health services research has made critical contributions to the development of the health systems that have substantially improved the health of populations. We are in a moment that calls for a re‐examination of much of what we do in science and scholarship. Health services research can, if suitably self‐reflective, emerge from such a moment stronger and making an ever‐better contribution to our collective health. We offer here three lenses—a fuller embrace of heterogenous and intersecting identities, of structural and social context, and of a lifecourse perspective—and three approaches—the inclusion of community voices, more transdisciplinary perspectives, and embrace of innovative methodological approaches—that can do just that. We note that we focus here on domestic US‐based health services research, recognizing that a richer field will extend its lens of inquiry globally, and that such an agenda would require a different comment by authors outside the United States. We look forward both to other ideas about how the boundaries of health services research can expand in coming decades and to seeing how these ideas can contribute to what fundamentally should matter most: improvement in the health of populations.

Galea S, Ettman CK. Expanding the boundaries of health services research. Health Serv Res. 2021;56(5):747-750. 10.1111/1475-6773.13716