Moving From Documenting Disparities To Reducing Them

Editor's Note: This is one of several posts Health Affairs Blog is publishing stemming from sessions at the June 2015 AcademyHealth Annual Research Meeting (ARM) in Minneapolis. Watch Health AffairsBlog for additional posts on topics raised at the ARM, including a related post by Margo Edmunds.

AcademyHealth recently hosted a panel focused on Disparities, Diversity, and Inclusion: Building a National Platform for Engagement in Health Services Research (HSR), which complements a newly released AcademyHealth publication on the same topic. The panel and the large, diverse audience had a spirited discussion that went beyond strategies for engaging underserved minority students and professionals in HSR. It quickly turned to an exploration of the root causes of the glaring inequities in US health and health care, including the influence of racism and other biases on workforce recruitment, retention, and the nature of HSR itself.

The discussion was remarkably frank, even blunt, compared to the questions from the floor that characterize many HSR panel sessions. Participants seemed eager to initiate a constructive dialog that would build trust in the HSR community. It was, at the very least, a step in the right direction. The panel and audience discussion validated AcademyHealth's recommendations for improvement (see box), while pushing the HSR community to reflect deeply on the factors, including intrinsic biases, that create barriers for minorities seeking to enter the field and advance their careers.

There was also evident impatience with the nature of research on equity and disparities, which continues to emphasize documenting disparities rather than studying promising approaches to addressing and reducing disparities. How long, the audience asked, will we continue to publish papers that document disparities in virtually every aspect of health and health care, in disease after disease, treatment after treatment, without offering effective solutions? Despite decades of research and good will, tangible progress in improving minority health and wellbeing remains distressingly slow.

AcademyHealth's recommendations urge the group to

1. Make a public commitment to workforce diversity, through reports and online forums;
2. Communicate clearly about our commitment through goal statements, programmatic language, graphic images, and special events;
3. Report publicly about progress in improving diversity through keeping current workforce statistics;
4. Train and prepare the current HSR workforce in best practices in diversity; and
5. Create a more racially and ethnically diverse pipeline for research careers, beginning with high school students and undergraduates.

In this post, we consider what we really mean by diversity and inclusion in HSR and identify three areas in which solutions will be needed to advance equity.

What We Mean By 'Diversity And Inclusion'

Improving diversity and inclusion requires fundamental cultural change. It does not mean simply adding minorities to work and research environments. Many organizations, including those related to HSR, were founded and developed by those who had access to higher education and medical training. Historically, this meant primarily white men. The cumulative impact of this fact is lasting in direct ways (the underrepresentation of minorities in degree programs and HSR career paths) and indirect ways (nuances of office culture, including micro-aggressions). Minority researchers will not thrive, nor will an organization, in a climate predominantly managed by white men who are comfortable with the status quo, where people continue to speak from privilege, and where racism has not been confronted actively and openly.

Yes, it is important to set measurable goals for workforce diversity, but this is not about meeting a check-box goal. Intentional efforts must be made to create spaces to understand new, outside perspectives. This is about building an organization and a field where previously marginalized voices lead and shape the work.

Increase The Representation Of Minorities In HSR

Because specific racial and ethnic minority groups are underrepresented in HSR, particularly at the highest academic levels, their perspectives are not brought to bear optimally on research questions, study design and methods, and interpretation of results. According to a 2011 AcademyHealth survey, 6.9 percent of the HSR field is Black and 3.7 percent Hispanic or Latino, while the US population is approximately 13.2 percent and 17.1 percent respectively. This challenge has been recognized for at least a decade and has led to increased outreach to students, minority recruitment programs, and efforts to improve the number and quality of mentors. Yet, we are still not where we want to be: diversity in health services research that better reflects the diversity in our population.

We are unlikely to succeed only by increasing outreach, recruitment, and mentoring. Underrepresented minority students will be reluctant to enter a field that remains rife with implicit bias, where the path to promotion seems unfair and discriminatory, where the great majority of attendees and presenters at meetings do not look like them, and where role models do not understand the importance of white privilege and intrinsic bias in perpetuating racism. For those underrepresented students who see the promise and take the risk, their exit from the field will be precipitous if their worst fears are reinforced from the outset.

Prioritize Solution-oriented Research To Reduce Disparities

As noted above, much of HSR remains mired in "first-generation" research, in which disparities are documented with monotonous regularity. Health services researchers have at least begun to move towards "second-generation" research: the investigation of the causal mechanisms of inequity, such as social determinants of health; unequal access; failure to engage patients with cultural competency, sensitivity, and humility; and unequal use of evidence-based diagnostic testing and treatment. It is time to leverage the knowledge accrued in first- and second-generation research to design, test, and evaluate solutions. This will involve developing promising ideas, seeing where they work by testing them in a range of contexts and conditions, implementing proven solutions at scale, and disseminating learning each step of the way.

Research funders, including Federal agencies, can help by moving beyond requests for proposals that simply require that the population under study be representative and inclusive. As standard practice, applicants should be asked to describe how they will identify disparities and what they will do to address them. Over the next decade, we should expect a dramatic increase in research presented at the Annual Research Meeting of AcademyHealth that rigorously evaluates programs designed to improve equity.

Provide HSR Training To Address And Speak Up About Racism In Health Care

As we say at the Institute for Healthcare Improvement (IHI), "Every system is perfectly designed to get the results it gets." We know that our health care system results in predictably worse outcomes for minority populations, particularly people of color and the poor. Regardless of the good intentions of the individuals operating within the system, the results speak for themselves. Racism is due not just to the intrinsic biases or bigotry of individuals; it is a property of the systems that govern health and health care in the US.

Given this reality, HSR training should provide the language, knowledge, and skills to address racism. In addition, we have an obligation as leaders to speak up about racism and inequity and to share the results of the actions we are taking to address these issues.

Moving forward, we need to build learning and research environments in which minorities are equitably represented, their opinions and perspectives are heard and respected, and their careers are nurtured. We must encourage and fund research that will not just accelerate our understanding of the causes of inequity, but develop and evaluate potential solutions, and implement and scale up those that prove to be effective.

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