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Taking Action to Address Structural Racism at Health Services Research

Austin Frakt, PhD, Editor In Chief
Monica Peek, MD, MPH, Senior Associate Editor
January 17, 2022

Acknowledgement: We thank those listed in Appendix A for their recommendations and feedback.

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1. Introduction

Consistent with a broader goal to be inclusive in all areas, the purpose of this document is to report on progress to date in addressing structural racism at Health Services Research (HSR).

In early 2021, in collaboration with the Health Research & Educational Trust (HRET) that owns HSR, the Editor in Chief (EIC) established preliminary goals to proactively identify and evaluate tactics to address equity, including potential issues of structural racism within the control of the HSR editorial team. Our broad concern is that there may be parts of the health services research community to which HSR is not equitable and accessible.

The preliminary goals were discussed with Senior Associate Editors (SAEs) and presented at the 2021 Editorial Board Meeting. They were reviewed and revised by a diverse and multidisciplinary Working Group to arrive at the goals in Section 1.1.

1.1 Goals

  1. For HSR to be equitable and accessible to the entire health services research community – from editorial positions to reviewer roles to publication in our journal.
  2. n reviewing and publishing manuscripts, for HSR to be consistent, fair, and objective in how it handles “race” and “ethnicity” however they arise (e.g., as a control variable, a main focus, etc.).
  3. For HSR to be intentionally and transparently receptive to scholarship on structural racism as an underlying driver of inequities.

2. HSR Structural Racism Working Group Meeting

To refine goals and identify action items, we held a Working Group Meeting described below.

2.1 Invitees

All HSR Editorial Board Members, SAEs, and Managing Editors were invited to the Working Group Meeting held on August 30, 2021. In addition, leaders of the team from HRET that manages the business and contracting for the journal were invited to attend the meeting and assist with recording the discussion. Attendees of the meeting and their affiliations are listed in Appendix A, along with others providing feedback on an earlier draft of this report.

2.2 Meeting Agenda

The process of the meeting followed the agenda listed below. Slides for the meeting are included in Appendix B.

  1. Why we are here
  2. Introductions
  3. What we have done so far (last 8 months)
  4. Longer term goals
  5. Action items (breakout groups)
  6. Next meeting

Most of the discussion centered on items 3-5. Since most of the “what we have done so far” content is subsumed in discussion of action items (below), they are not separately described in this document.

2.3 Meeting Outcomes

The meeting outcomes included revision to the preliminary goals (Section 3) and a list of potential action items to further them (Section 4). Next steps, including publication of this report, were briefly discussed. Additional next steps are found in Section 5.

3. Revising Goals

Attendees of the Working Group Meeting suggested revisions to the wording of the preliminary goals. The goals were originally worded as follows. Final wording is provided in Section 1.1, above.

  1. For HSR to be equitable and accessible to the entire health services research community – from editorial positions to reviewer roles to publication in our journal. This recognizes that there may be parts of that community to which we are not equitable and accessible today.
  2. In reviewing and publishing manuscripts, for HSR to be consistent, fair, and appropriate in how it handles “race” however it arises (e.g., as a control variable, a main focus, etc.).
  3. For HSR to be receptive to scholarship on structural racism as an underlying driver of disparities.

The final goals in Section 1.1 differ from the preliminary ones above in the following ways:

  • The second sentence of preliminary goal #1 was deleted.
  • “Objective” replaced “appropriate” in preliminary goal #2.
  • “Ethnicity” was added to goal #2.
  • “Intentionally” was added to goal #3.
  • “Inequities” replaced “disparities” in goal #3.

4. Action Items and Implementation Plans

Twenty-one discrete recommendations arose from Working Group Meeting participants during the action items breakout groups. These are listed in the following sections, along with progress to date or proposed implementation plans.

4.1 Actions Currently in Process

Three recommendations were general suggestions and six were about activities already underway at HSR.

Recommendation 1: Pick one thing and do it well. We agree with the spirit of this recommendation in the sense that HSR should pursue strategies at which it can succeed given its mission and resources. Keeping this Recommendation in mind helped us determine which suggested action items we will defer (Section 4.4). However, we believe HSR can pursue more than one action item at a time. In fact, it already is, as discussed in Recommendations 4-9.

Recommendation 2: Identify what is different about HSR in this space. Similar to Recommendation 1, keeping the journal's strengths in mind helped to sort action items into those that would allow HSR to make a unique, meaningful difference and those that were best achieved by or with other organizations.

Recommendation 3: Ensure that HSR papers that conclude that racism causes disparities have sufficient supporting evidence. This caution is well received and in the spirit of HSR's foundational mission to publish rigorously1 conducted scholarship, both quantitative and qualitative, as well as work that illuminates the theoretical underpinnings of issues in our field. To our knowledge, HSR has not deviated from this mission and has no intention of doing so as it pursues an agenda of addressing structural racism.

Recommendation 4: Partner with AcademyHealth in anti-racism efforts. HSR is already in discussions with AcademyHealth to find overlap between their efforts in this area and ours. Our next step will be to reconvene after this report is finalized.

Recommendation 5: Broaden diversity on the Editorial Board and among SAEs and involve more junior researchers. Beginning in January 2021, HSR began a conscious and ongoing effort to diversify its Editorial Board and SAE team. Diversity is multidimensional, including race and ethnicity, gender, sexual orientation/gender identity, ability/disability, socioeconomic status, and other lived experiences with social marginalization, as well as age/career stage, geography, institutional affiliation, discipline of study, and other factors. HSR will strive to broaden diversity in a way that takes all these dimensions into consideration.

Recommendation 6: Clarify in author instructions what we are looking for regarding the incorporation of race and ethnicity into research findings and/or discussion. Revised author instructions are now online and include reference to the AHA/ASA Journals Disparities Research Guidelines and JAMA guidance on reporting race and ethnicity for guidance on what we expect in submitted manuscripts.

Recommendation 7: Allow authors to raise points about structural racism and people will start to study them. This is already allowed by HSR. Some action items below will explicitly invite scholarship on structural racism.

Recommendation 8: Identify articles in each issue that are consistent with the goal of addressing structural racism. HSR organizes articles in each issue thematically and designates the themes with subheadings. As the journal publishes articles on structural racism and health equity it will designate them as such, as it has in the past.

Recommendation 9: Publish a special issue to invite young scholars of color and perhaps have them partner with others with more experience to bring topics on structural racism to HSR. Such a special issue is in in progress. The call for abstracts was posted in January 2022, with an issue publication date in mid-2023.

4.2 Actions to be Taken by End of 2022

The recommendations in this section are not yet in process but will be undertaken by the end of 2022.

Recommendation 10: Issue call for papers to show that HSR is a place to submit on racial equity. This will be accomplished in several ways. First, the December 2022 special issue on Health Care Equity, sponsored by the Catholic Health Association of the United States invites articles on racial equity in health care. Second, as mentioned in Recommendation 9, we are planning another special issue with papers led by scholars that are underrepresented in specific doctoral disciplines and/or with historically marginalized backgrounds, with a mentorship component, that will include topics on structural racism. Finally, in 2022, we posted on our website an open call (not tied to any organizational sponsorship) that invites manuscripts that empirically document relationships between structural racism and the financing, organization, delivery, and outcomes of health services.

Recommendation 11: Identify data for and methodological guidance on how to address the study of structural racism (e.g., invite papers to provide surveys of data sources on structural racism and methods for handling race in analysis and discussion). The calls for abstracts and manuscripts mentioned in Recommendations 9 and 10 will be receptive to scholarship about data and methods for addressing the study of structural racism, as well as about theoretical/conceptual guidance and terminology.

Recommendation 12: Make sure reviewers know about HSR expectations, through training and/or a link in the reviewer invitation. We will amend our reviewer invitation email to point to our expectations about scholarship on or referencing race and ethnicity, as articulated in our revised author instructions (Recommendation 6). In addition, when this report is published, we will link to it and/or the associated HSR commentary in reviewer invitations (see Section 5).

Recommendation 13: Explicitly ask reviewers: Does this paper give adequate attention to structural racism where it can? We seek to raise SAEs’ awareness of the need to do this and to provide them with the skills to do so — both to ask reviewers to adequately attend to the issue and to do so themselves. To do this, we will continue the process already underway in educating SAEs about how to handle papers that address or should address structural racism. That education currently includes facilitated discussions about structural racism issues in monthly meetings. To be determined is the extent to which those will be augmented by externally facilitated workshops.

4.3 Actions to be Considered over the Next Five Years

While all of the recommendations above will continue beyond 2022, action on some recommendations will not be feasible to initiate in the next 12 months, because of the effort or resources involved. The need to delay consideration for some actions is consistent with the spirit of Recommendation 1, which is to pursue only those actions that can be done well.

Recommendation 14: Evaluate every paper for structural racism goals. It is our ambition that this becomes reflexive for all SAEs. We believe that this recommendation will be accomplished through continued training (Recommendation 13) and continued diversification of the SAE team (Recommendation 5). Making this top of mind for all SAEs through those processes is likely to take beyond 2022. However, in the interim, all papers on structural racism or health equity will be assigned to SAEs who can appropriately evaluate them consistent with our goals.

Recommendation 15: Collect demographic data on editors, authors, and reviewers (e.g., to provide baseline information and to support analysis of diversity and representation on the editorial team and accepted/rejected papers, in who is invited for commentaries, and in who gets reviewed by whom). We are enthusiastic about this recommendation and will begin the process of planning for it in 2022. However, obtaining the infrastructure and resources to fully implement demographic data collection will require a multiyear process. That process will likely include technical enhancement of the online system used to collect author and reviewer information, possibly developing and fielding a survey of authors and reviewers, and cleaning and analysis of demographic data, which will involve identifying and recruiting suitable scholars. Such scholars could advise on data collection and also use the data to inform diversity, equity, and inclusion metrics, perhaps leading to publication in the journal on changes over time. Since this is such an important action item — and because we have other ongoing recommendations that are easier to implement quickly — we cannot and should not rush this one into fruition. We plan to take the time to do this process well so that it is a lasting and valuable component of regular HSR operations.

Recommendation 16: Support or offer workshops for editors/reviewers/authors (e.g., supporting authors from groups underrepresented in research on the peer review process more broadly and educating all editors and reviewers in how to evaluate race and ethnicity topics in a way that is grounded in structural competency2 ). We are also enthusiastic about this recommendation and plan to offer periodic, free webinars to provide the guidance suggested. However, in light of the other actions we wish to pursue rapidly (described above), we believe it makes sense to defer this beyond 2022. (See also Recommendations 13 and 14, both of which reference SAE training.) In the meantime, as we see training and workshops of this nature, we will use our networks to circulate the information. We will also encourage other Editorial Board members and SAEs to do the same.

Recommendation 17: Develop a resource library. The papers published through the process described in Recommendations 9-11 may provide the raw material for a resource library on scholarship about how to conduct health services research on structural racism. We have the infrastructure to bundle HSR papers into online, virtual issues. When a critical mass of papers is published, which is not expected until after 2022, we will use the bundling option to create a resource library. In the interim, should we become aware of an appropriate resource library developed by another organization, we will reference it in communications to authors and reviewers and draw editors’ attention to it.

4.4 Actions to be Deferred

We are deferring plans to implement four recommendations for reasons described below.

Recommendation 18: Study of perceptions of readers. Though we are interested in how HSR is perceived by readers, we have two concerns about this recommendation. First, reaching out to readers may miss the populations we really need to hear from—nonreaders. Consistent with our first goal (Section 1.1), we strive to reach parts of the health services research community to which we are not equitable and accessible today. Those are more likely to be nonreaders than current readers. Second, considerable resources would be required to develop and field a survey and study of reader (or nonreader) perceptions. For the foreseeable future, we will prioritize resources to implementing recommendations described in prior sections.

Recommendation 19: Provide a systematic way to accept complaints. We welcome all comments, suggestions, and complaints. Anyone may send these to hsr@aha.org, which is referenced in numerous places on HSR’s website, including the Contact Us page. Given this and other priorities, articulated in prior sections, we elect not to devote resources to enhancing this approach to accepting complaints.

Recommendation 20: Develop a publication mentorship program. We are enthusiastic about mentorship (e.g., see Recommendations 9 and 16). However, the development of a publication mentorship program is a substantial undertaking and beyond the scope of HSR’s focus and resources. We welcome partnering with other organizations and journals to participate in such a program, based on interest and leadership from others. This topic will be part of our ongoing conversation with AcademyHealth (see Recommendation 4).

Recommendation 21: Do not desk reject any papers by Black authors. We appreciate this bold suggestion that would go a long way toward addressing longstanding disparities in access to publication by Black scholars in our field. However, it is not without a host of challenging issues (including increased workload for SAEs, greater demands on reviewers, identification of guidelines of when to discontinue such a program, and the ability to implement similar programs for other socially marginalized groups, such as other racial minorities and LGBTQ+ authors). We would like to continue this conversation to identify ways that we might meet some of the overall goals of this recommendation (e.g., increasing the rate of publication of socially marginalized groups) through different strategic methods. (See, for example, Recommendation 9.)

5. Next Steps

In late Winter 2022, we will reconvene the Working Group to discuss progress to date and implementation plans for specific action items to be addressed in 2022. Annually thereafter, we will report progress at the Editorial Board meeting in June and, separately for a deeper discussion, reconvene the Working Group.

Additionally, for full transparency, at least once per year we will include, in a “From the Editor’s Desk” piece published in HSR, a summary of progress and any changes to or enhancement of plans articulated in this report.

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1 What is considered “rigorous” varies across subdisciplines within health services research. HSR has historically published studies with different types of methods, varying by subdiscipline and question addressed. This is one of the reasons a diverse editorial team is essential, to reflect the diversity in the field.

2 “Structural competency” refers to the ability of health care professionals to understand how inequities in health outcomes are influenced by inequities in access to structural goods, services and opportunities.