Setting the course to high impact, equitable health services research

1. INTRODUCTION

The outbreak of the COVID‐19 pandemic requires those of us working in health services research to reassess our work to improve health and health care for all. Long‐standing challenges in our field, while all too familiar to many of us, were thrown into sharp relief and given sudden new urgency as the virus spread.

In the midst of this pandemic, another ongoing public health emergency came into the spotlight with the murder of George Floyd in June 2020, a tipping point in a series of murders of Black people at the hands of the police, and prompting what Professor Daniel Dawes has called the fourth great racial awakening; ¹ and, while AcademyHealth has worked for years to advance diversity, equity, and inclusion (DEI) in our field, the 2020 Annual Research Meeting (ARM) felt like a turning point as we gathered virtually and examined the many ways systemic racism dramatically and negatively impact health delivery, outcomes, and our collective scholarship. Health services research produces the evidence base that—at its best—informs decision‐making by policymakers and health system leaders, among others. If our evidence is flawed by inattention to the many ways that racism shapes each step of the research life cycle, then we are contributing to the policies, processes, and structures that perpetuate racism. Who our community includes and welcomes, the questions we ask, the funding we can secure, the data and methods we use, how we interpret our results, and where we publish, all reflect a knowledge base shaped by the failure to address the impact of racism.

This commentary will outline what AcademyHealth has learned from our prior work in DEI and our response to the events of 2020, summarize the recommendation of an External Advisory Group on Diversity, Equity, and Inclusion, and share our approach to charting a course for higher impact, more equitable health services research.

2. WHAT WE HAVE LEARNED

For years, we at AcademyHealth have acknowledged the lack of diversity in our field and prioritized its advancement. Building on prior work, we established the Center on Diversity, Inclusion, and Minority Engagement (DIME) in September 2015, which houses our Diversity Scholars Network, and released five recommendations ² that have served as the AcademyHealth roadmap for our activities since that time:

• Make a public commitment to diversity

• Communicate clearly about the commitment

• Promote accountability through data collection and reporting

• Learn from and promote best practices

• Focus on diversifying the pipeline of future health services researchers

As a result of that 2015 report, AcademyHealth began requiring completion of demographic data on all members and registrants to events (with the option to “choose to not respond”); engaged student chapters and diverse fellows and junior faculty in social and programmatic events; held annual breakout sessions to feature different aspects of workforce diversity; and regularly reported to the AcademyHealth Board of Directors on these and other activities to promote diversity and inclusion. It should be noted that discussions of racism were not prominent in these conversations, nor the role racism plays in limiting diversity in our institutions and community.

Despite the goal of diversifying the workforce, Black, Latinx, and American Indian researchers are still underrepresented in the field. ³ Several studies, most recently the Wellcome Trust study on research culture, ⁴ have identified hostile environments for women and BIPOC (Black, Indigenous, and People of Color) as a barrier in retaining diverse and marginalized members of the research enterprise. Health services research is not immune. In late 2019, a team of doctoral students and faculty members developed a survey examining workplace culture among attendees at the 2020 ARM. They presented preliminary findings a year later indicating that sexual harassment and racial/ethnic discrimination had been experienced or observed by more than 40% of respondents, a simply unacceptable result.

It is abundantly clear that collectively, individuals and institutions in health services research must go beyond past inadequate attempts to provide opportunities for a small number of diverse individuals, as well as ineffective and insufficient efforts to adjust our methods on the margin. Instead, we must embrace a more fundamental examination of the cultures, structures, and incentives of the health services research ecosystem and the organizations in which we all work. Racism, sexism, ableism, gender discrimination, and the power differentials that often accompany and operationalize exclusionary policies and processes require our concerted attention. As Hardeman and Karbeah so wisely pointed out in their October 2020 commentary, “We cannot build a more equitable and just culture using the same white supremacist tools that were used to create the systems of disadvantage that we seek to dismantle.” ⁵

At the same time, our field continues to struggle in both measuring and achieving the impact that ultimately improves health and equity. Thus enhancing impact has been a central focus of the Paradigm Project, an ambitious initiative funded by the Robert Wood Johnson Foundation, to reorient and reimagine health services research for greater impact. Through the Paradigm Project, volunteer “design teams” worked to generate and test innovations in how health services research is conducted and used. A key insight from the Paradigm Project is that the lack of diversity in who receives funding, who is engaged in research, and who is consulted during each step of the research process is too often a core design flaw in our field. This flaw is intrinsically connected with all dimensions of the health services research enterprise and limits our research findings' impact on policy and practice.

Paradigm design teams leveraged the tools of human‐centered design, an approach selected for its focus on the needs of people experiencing a given challenge and on generating innovations that are implemented in the real world. ⁶ For example, one design team focused specifically on using empathy to empower researchers to address the impact of racism on investigators of color in their own institutions. This “day of action and impact” has already been tested with four institutions, and we plan on making the program available to other partnering organizations.

Over the course of the Paradigm project, we learned that health services researchers are motivated to make a difference, change is possible, and we do not have to reinvent the wheel. ⁷ The project's commissioned “horizon scans” and workshops highlighted new approaches to rewarding university faculty, ⁸ allocating research funds, ⁹ and creating a more diverse, inclusive workforce. ¹⁰ One workshop we convened demonstrated how the lack of meaningful DEI perpetuates inequitable access to funding, tenure, and opportunities for younger researchers of color and women and the questions they would study. As noted by one workshop participant,

Those of us who are of color … in this system as it currently exists, I think, often find it so hostile that you have two choices: You either change and completely conform … go get a white co‐ [principal investigator], and that's how you get your first RO1. That's not a sustainable system and that's not right, and so you either make that choice or you leave … . I don't know how you fix that system without first acknowledging that it is a system that has truly systemically disadvantaged a slew of really bright, brilliant, energetic people over the course of history. ¹¹

3. HOW WE HAVE RESPONDED

Innovating is challenging under the best circumstances but faced with the large societal problem of racism in all its forms—internalized, interpersonal, structural—it seemed especially so. Fortunately, our leadership, staff, and colleagues were committed to making a change. We worked with our Board of Directors and other outside advisors to shape a sustainable, action‐oriented strategy to address DEI. We began with a self‐assessment process and are now expanding to include our relationships with our members, partners, stakeholders, the field, and the larger research community, including its funders (Figure 1).

FIGURE 1.

AcademyHealth's Diversity, Equity, and Inclusion (DEI) strategy [Color figure can be viewed at wileyonlinelibrary.com]

3.1. Model

We started by looking at our identity as an organization and staff. AcademyHealth's executive team is predominantly White (as are the authors of this commentary). Among its 20‐person board of directors, 65% self‐identify as White, 15% as Black, and 20% as Asian. Two members of the board, or 10%, list their ethnicity as Hispanic/Latino. In early 2020, staff participated in a series of sessions led by external facilitators over 5 months to increase awareness of our own personal assumptions, values, biases, and identities as they relate to the organization's diversity and inclusion efforts. These sessions were co‐developed by staff from all levels across the organization and were offered in direct response to staff survey results showing strong interest in training and discussions about DEI.

AcademyHealth's strategic plan explicitly names diversity and inclusion as a core value. ¹² We are integrating this value into all of our programmatic activities, policies, and procedures. A key aspect of this work has been seeking external and independent expertise to help guide our DEI efforts. In January 2021, AcademyHealth convened a panel of highly accomplished external advisors to inform a sustainable, action‐oriented strategy to address DEI in health services research. The Advisory Group members ¹³ represented a variety of lived experiences, racial/ethnic identities, gender identities, geographies, organizational settings, areas of professional expertise, career stages, and perspectives on DEI. All brought a familiarity with research culture and a track record of innovation, and they reflected a range of experiences with AcademyHealth activities and the field of health services research. Early in their deliberations, they adopted the following Statement of Principles to guide their work:

Health services and policy research (HSR) generates timely evidence about what works, for whom, at what cost, and under what circumstances to improve health and health care for all. As the professional home for HSR, AcademyHealth is committed to enabling an equitable future where the field of HSR is diverse, representative, inclusive, and trusted by a variety of stakeholders, including researchers, policymakers, system leaders, clinicians, communities, and individuals. AcademyHealth will address the power dynamics of structural racism and increase support for the production, dissemination, and use of evidence to achieve a more just, equitable, and healthy society.

In an effort to increase both transparency and community input, a draft version of the Advisory Group's preliminary recommendations was presented at the 2021 ARM and finalized in July. The release of a full set of recommendations in August ¹⁴ was accompanied by an online survey requesting feedback from the community. Survey results validated the recommendations and helped prioritize which should be acted upon first.

The 17 recommendations from the Advisory Group can all be categorized under the final two sections of AcademyHealth's DEI strategy: Lead and Influence. The recommendations included strategies to catalyze structural change in the field; elevate the importance and visibility of health equity research and researchers; promote and develop the careers of health equity researchers; promote quality and transparency of health equity and research methods; and increase support for health equity research. Below we summarize the recommendations and, where relevant, describe how we have already begun to take action.

3.2. Lead

Ten of the 17 recommendations in the report related to ways AcademyHealth can be a catalyst for changing the field of health services research to address racism and promote equity.

Many actions are centered on the creation and curation of resources from standards, for the collection of workforce diversity data to providing mentoring models and increased access to training and professional development for minoritized groups. Other recommendations focused on facilitating important change‐making processes such as a Truth and Reconciliation ¹⁵ process for health services research to publicly acknowledge past injustices and the scale of the physical and emotional harms they caused.

We look forward to acting on these recommendations and have already made progress in some areas of resource creation. For example, AcademyHealth has released its first version of a DEI glossary, ¹⁶ which we hope will be useful in defining essential DEI terminology and core concepts, particularly as they relate to the HSR field. This glossary will be updated every 6 months as terms and their definitions evolve. We are now working to identify other resources that are most needed by our members, and will also provide an opportunity for our members to more broadly disseminate their efforts and lessons learned in addressing diversity and/or racism in their institutions.

3.3. Influence

Seven of the report's recommendations outlined ways AcademyHealth could act as an influencer to spur change across the field. For example, by leveraging our conferences and relationships with official journals, we can model best practices for increasing the representation of minoritized and historically excluded individuals in each step of our work, from the abstracts submissions to review panels and in peer‐reviewed publications. We are, therefore, encouraged to see our official journals acting independently in pursuit of this goal and read with interest the plan put forth by Drs. Frakt and Peek in this issue. ¹⁷

In June 2020, AcademyHealth began requesting abstract submitters and registrants to self‐identify according to racial/ethnic identity, gender identity, and sexual orientation. We then compared the distributions of demographic data for submitted abstracts and acceptances for ARM 2022 and found that they were substantially the same, suggesting a lack of systemic bias among reviewers. We are now building on this to prepare an annual dashboard on our DEI efforts to share with our members.

Other recommendations related to the setting of antiracism criteria or standards for everything from journal submissions and conference presentations to contracting and use of partnerships and to addressing promotion and tenure criteria within academic institutions. We began our work on antiracism methods and data this past July with a workshop ¹⁸ and are now working with our Methods and Data Council to develop ARM 2022 breakout sessions on measuring structural racism, standardizing racial/ethnic data, and using culturally responsive research methods.

The Advisory Group also recommended that we develop a coordinated funding strategy with accountability metrics aimed at advancing DEI in the funding process. Similarly, one recommendation centered on our advocacy agenda, ¹⁹ suggesting that we encourage member organizations and partners to engage in local, place‐based equity efforts. We have since discussed this with our Board Committee on Advocacy and Public Policy and have worked with members to submit several recent comments to federal agencies on the topic of DEI, including to the National Institutes of Health, ²⁰ the Office of Management and Budget, ²¹ and the Patient‐Centered Outcomes Research Institute. ²² We are also actively advocating that the proposal to establish an ARPA‐H focus squarely on equity. ²³

Finally, to ensure that our partners represent the diverse perspectives and needs of the field, we are conducting an audit to assess the diversity represented across all these groups—from our Board of Directors to the vendors we work with. This audit will inform adjustments to our policies and nominating criteria to reduce structural barriers and engage more diverse voices on our advisory councils, interest group leadership, conference and program committees, abstract reviewers, and others.

4. WHERE WE ARE HEADING

AcademyHealth understands that helping our field become more diverse, inclusive, and equitable is a long journey that will take concerted focus and sustained effort. We are committed to this and will coordinate this new work to advance high‐impact, equitable research with the activities of our Center for DIME. We will build on the recommendations of the Advisory Group on DEI and launch a suite of activities to promote and develop the careers of health equity researchers, including new awards and mentoring models. We will also engage our networks and partners to promote quality, accountability, and transparency of data and research methods. A full plan of these activities will be released in winter 2021. We invite your ideas as we craft our next steps. Please reach out to Dr. Edmunds at Margo.Edmunds@academyhealth.org.

FUNDING INFORMATION

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Simpson LA, Adams L, Edmunds M, Gluck M. Setting the course to high impact, equitable health services research. Health Serv Res. 2022;57(1):7‐11. doi: 10.1111/1475-6773.13927