Discussion

THE FUTURE OF
DIVERSITY AND
INCLUSION IN HEALTH
SERVICES AND
POLICY RESEARCH:
A REPORT ON THE ACADEMYHEALTH
WORKFORCE DIVERSITY 2025 ROUNDTABLE

SEPTEMBER 2015

Margo Edmunds, Ph.D., AcademyHealth; Clem Bezold, Ph.D., Institute for
Alternative Futures; Charles Cinque Fulwood, MediaVision USA; Beth Johnson,
M.P.H., AcademyHealth; and Hassan Tetteh, M.D., M.P.A, M.B.A., Uniformed
Services University of the Health Sciences and Howard University

2

First, the authors would like to thank all of the participants in the
roundtable discussion who contributed their valuable time and
ideas and helped to develop the recommendations in this report.
They are listed in Appendix B.

The authors also would like to thank several people who reviewed
earlier drafts of this report and provided helpful comments and
guidance. They are:

Jameta Barlow, Ph.D., Assistant Professor, Department of
Women and Gender Studies, Towson University

*Anne Beal, M.D., M.P.H., Chief Patient Officer, Sanofi

*Timothy S. Carey, M.D., M.P.H., Sara Graham Kenan Professor
of Medicine and Social Medicine, University of North Carolina at
Chapel Hill

Marshall Chin, M.D., M.P.H., Associate Professor of Medicine,
University of Chicago

Deena J. Chisolm, Ph.D., Program Director, Patient-Centered
Pediatric Research Program, Nationwide Children’s Hospital

*Jose Escarce, M.D., Ph.D., Professor of Medicine, UCLA School
of Medicine

*Darrell Gaskin, Ph.D., Associate Professor, Health Economics,
Johns Hopkins Bloomberg School of Public Health

*Don Goldmann, M.D., Chief Medical and Scientific Officer, The
Institute for Healthcare Improvement (IHI)

Carmen R. Green, M.D., Associate Vice President and Associate
Dean for Health Equity and Inclusion, University of Michigan
Health System

Rachel Hardeman, Ph.D., M.P.H., Assistant Professor, Research
Program on Equity and Inclusion in Health Care, Mayo Clinic

Emily R. Holubowich, M.P.P., Senior Vice President, CRD
Associates

*Elizabeth McGlynn, Ph.D., Director, Kaiser Permanente Center
for Effectiveness and Safety Research

Felicia Mebane, Ph.D., M.S.P.H., CEO, Mebane Media
Communications

Ernest Moy, M.D., M.P.H., Medical Officer, Center for Quality
Improvement and Patient Safety, Agency for Healthcare Research
and Quality

*Eduardo Sanchez, M.D., M.P.H., Deputy Chief Medical Officer,
American Heart Association – National Center

*Karen A. Scott, M.D., M.P.H., Vice President for Quality and
Patient Safety, New York Presbyterian Hospital

*Shoshanna Sofaer, Dr.P.H., Director of Strategic Research
Planning for Health and Social Development, American Institutes
for Research

*Paul Tang, M.D., M.S., Vice President, Chief Innovation and
Technology Officer, Palo Alto Medical Foundation

*Joseph W. Thompson, M.D., M.P.H., Director, Arkansas Center
for Health Improvement,  Professor in the Colleges of Medicine
and Public Health at the University of Arkansas for Medical
Sciences, General Pediatrician

*Craig Thornton, Ph.D., Senior Vice President and Managing
Director of Health Research, Mathematica’s Health Services
Research Division

Pamela Thornton, Ph.D., Program Director, National Institute of
General Medical Sciences

Reginald Tucker-Seeley, Sc.D., Assistant Professor, Dana-Farber
Cancer Institute, Harvard School of Public Health

*Paul J. Wallace, M.D., Chief Medical Officer and Senior Vice
President for Clinical Translation,Optum Labs

Several AcademyHealth colleagues contributed to this report:
Ellen Albritton; Bonnie Austin, J.D.; Dawn Ferdinand; Michael
Gluck, Ph.D.; Erin Holve, Ph.D., M.P.H., M.P.P.; Tamika King,
M.B.A.; Terry Mackey, Ph.D.; Enrique Martinez-Vidal, M.P.P.; Kate
Papa, M.P.H.; Treva Pierre; Teasha Powell; Kristin Rosengren; Raj
Sabharwal, M.P.H.; and Lisa Simpson, M.B., B.Ch.,M.P.H, F.A.A.P.

AcademyHealth acknowledges the Robert Wood Johnson
Foundation for its support of this work on diversity.

*Indicates a member of the AcademyHealth Board of Directors

The views expressed in this article are those of the authors and
do not necessarily reflect the official policy or position of the
Department of the Navy, the Department of Defense, or the U.S.
Government.

ACKNOWLEDGMENTS

3

Recognizing the persistence of systemic, institutional, and historical
factors that work against diversity and equity in health services and
policy research (HSR) and the larger health and health care workforce,
the AcademyHealth Board of Directors provided funding for a new
Center for Diversity, Inclusion, and Minority Engagement in January
2014 http://www.academyhealth.org/Programs/ProgramsDetail.
cfm?ItemNumber=6086. To date, Center programs support training
and mentoring for under-represented racial/ethnic minority (URM)
students and junior faculty; promote resource exchange with well-
established, more senior researchers in HSR programs; and provide
information on diversity to the HSR field.

We recognize that aspects of diversity may include age, country of
birth, disability, ethnicity, gender, gender identity, language, national
origin, race, refugee status, religion, culture, sexual orientation, health
status, community affiliation, and socioeconomic status. For purposes
of our first report, we focused on URM to align with the current
programs and funding of the Center.

In June 2014, AcademyHealth and the Institute for Alternative
Futures (IAF) convened a multidisciplinary group of experts
to develop actionable recommendations to increase workforce
diversity and inclusion in HSR. The invited group included
health services researchers; representatives of a variety of health
professional organizations; government officials; and experts
in disparities, change management, strategic communications,
and mentoring programs for under-represented racial/ethnic
minorities (URM), including diversity officers.

During a one-day roundtable discussion in Washington, D.C.,
the group analyzed and discussed the implications of four
future scenarios and their potential impact on HSR workforce
diversity by 2025, roughly 10 years in the future. Following the
IAF aspirational futures approach, the scenarios incorporated
drivers at three levels: (1) the macro level of the U.S. economic,
social, and policy environments; (2) the health and health care

ecosystem, focusing on implementation of the Affordable Care
Act (ACA) with an emphasis on trends in health coverage, access
to care, and use of electronic health records (EHRs) for research;
and (3) micro-level factors specific to the field of HSR, including
the availability of research funding, public awareness and support
for HSR, and the career pipeline for URM researchers.

After discussion, the group’s overarching recommendation for
AcademyHealth was to provide national leadership by taking
five visible steps to promote workforce diversity and inclusion in
the field of HSR. These steps include: (1) developing a diversity
and inclusion plan for the field and sharing it publicly; (2) clearly
communicating about our own commitment to diversity in
goal statements, programmatic language, graphic images, and
events; (3) collecting better data and publicly reporting on our
progress in achieving diversity and inclusion goals; (4) promoting
best practices for diversity and inclusion in the current HSR
workforce; (5) and creating a more racially and ethnically diverse
pipeline for the future HSR workforce.

AcademyHealth believes it is vitally important to continue its
URM scholarships, fellowships, and mentoring programs. The
organization must also take additional steps to promote diversity
and inclusion in the HSR workforce, including URM researchers
at all career stages. The imperative for diversity stems not only
from the need to reflect the changing demographics in the U.S.
population, given the shift in the proportion of minority and
majority populations, but also from a need to ensure that the best
talent from all backgrounds feels at home in HSR, contributes
to a vibrant community of evidence producers and users, and
advances the production and use of the evidence we need to
improve health and the performance of learning health systems.

SUMMARY

AcademyHealth believes the moment is
right for a different kind of conversation to
find new solutions about race, privilege,
and equity in HSR

Roundtable Recommendations for AcademyHealth Actions

• Make a public commitment to diversity and inclusion

• Communicate clearly

• Collect better data and report it publicly

• Promote best practices

• Improve the pipeline

4

I: DIVERSITY PRODUCES
BETTER EVIDENCE
The multidisciplinary field of health services and policy
research (HSR) studies organizational, economic, social,
and technological factors that influence health and health
care systems and inform health policy and clinical decision-
making. As the professional society for HSR, AcademyHealth
works to improve health and the performance of the health
system by supporting the production and use of evidence
to inform policy and practice. One of the principles in our
strategic plan is that “diversity of opinion and perspective
produces better evidence.”

As part of its efforts, AcademyHealth is committed to
promoting diversity and equity among its members and the
field at large in terms of race, ethnicity, disability, sexual
orientation, gender identity, and other backgrounds that are
historically underrepresented in HSR and biomedical research.

AcademyHealth has been concerned with diversity and
inclusion in HSR for several years. In 2004, with funding from
the W. K. Kellogg Foundation, we conducted a qualitative
study that explored ways to increase racial and ethnic diversity
in HSR.1 The study recommended a national strategy to
promote HSR as a viable career option and also recommended
a fellowship program for under-represented racial/ethnic
minority (URM) researchers.

In 2007, AcademyHealth convened an invitational summit
Health Services Researcher 2020, with support from the
Robert Wood Johnson Foundation (RWJF) and the Agency
for Healthcare Research and Quality (AHRQ).2 The summit
recommendations for improving the size and composition
of the field called for mentoring minority students and
junior faculty, as well as improving awareness among URM
researchers about opportunities to pursue HSR careers.

The first minority fellowship program at AcademyHealth was
launched in 2010 with support from the Aetna Foundation and
is still continuing. As of late 2014, nearly 75 URM researchers
at more than 32 institutions in 21 states had participated as
fellows, which included activities such as attending national

AcademyHealth has been concerned
with diversity and inclusion in HSR for
several years

5

conferences; making presentations to a variety of audiences at
academic and professional webinars, meetings and conferences;
and meeting with a wide range of senior professionals from the
field. Mentors come from many different areas of professional
expertise and represent a variety of racial and ethnic backgrounds.
The program is being evaluated by mentees, mentors, and
program staff during the summer and fall of 2015.

In 2013, AcademyHealth confirmed that African American,
Hispanic, and American Indian researchers were still
underrepresented in the HSR field.3 Notably, HSR is not the only
research field in which this is the case. A significant discrepancy
in success rates has been reported for National Institutes of Health
(NIH) research grant applications between White applicants and
Black applicants, even after controlling for numerous observable
variables.4 That finding led Dr. Francis Collins, the NIH director,
to call for a Workgroup on Diversity in the Biomedical Research
Workforce to develop recommendations for improving the
number of URM scientists, which included a focus on mentoring,
career preparation, and retention, as well as appointing a Chief
Diversity Officer, re-evaluating the grant review process, and
developing diversity/implicit bias training (see Appendix E). 5

Recognizing the persistence of systemic institutional and
cultural factors that work against diversity and equity in the HSR
workforce as well as the larger health and health care workforce,
the AcademyHealth Board of Directors provided funding for a

new Center for Diversity, Inclusion and Minority Engagement in
2013 (http://www.academyhealth.org/Programs/ProgramsDetail.
cfm?ItemNumber=6086.). The Center supports training and
mentoring for URM students and junior faculty, promotes
resource exchange between them and well-established, more
senior researchers in HSR programs, and provides information on
diversity to the HSR field.

The Center sponsored the Roundtable discussion on which this report
is based in order to develop actionable recommendations to increase
future diversity and inclusion within the HSR field. AcademyHealth
plans to use these recommendations to expand its mentoring activities
and take additional steps to build a more diverse HSR community by
promoting workforce inclusion and equity.

Heckler Report Recommendation on Professional Development

“[HHS] discussions with the non-Federal sector should … identify
implementation strategies to address critical health professions
educational issues, such as: increasing minority participation in
the various training areas; strengthening training program curricula
by making them more culturally sensitive to minority patients and
minority health problems…; and providing continuing education
programs for training on minority health issues. “

— Report of the Secretary’s Task Force on Black
and Minority Health (“The Heckler Report”).

Washington, DC: HHS, 1985. pp. 22-23.

6

II: BUILDING A DIVERSE
WORKFORCE
Previous approaches to diversifying the workforce in HSR and
the health professions have involved individual recruitment,
mentoring, and scholarship programs as well as organizational
diversity programs to build awareness and support for
diversity within an academic or organizational culture. While
it is beyond the scope of this report to provide an exhaustive
review, the next section highlights some examples of
approaches and what is known about these efforts.

Recruiting, Mentoring, and Retention
Programs for Individual Researchers

Successful efforts to promote diversity have focused on
individuals at different phases of the research career pipeline,
including K-12 education; mentoring and supportive
interventions at the college and graduate school levels;
mentoring and minority fellowships for postgraduate and
postdoctoral professionals; and faculty development programs
for junior faculty. Some are supported by national organizations,
and others are specific to an individual institution.

The STEM (Science, Technology, Engineering, Mathematics)
programs initiated by the U.S. Department of Education
may be the best example of these pipeline programs for
K-12 (http://www.ed.gov/stem). College and postgraduate
programs are also available across the country. Some of the
best-developed mentoring programs are at Historically Black
Colleges and Universities (HBCUs), such as Morehouse,
Meharry, and Howard, where active mentoring is embedded in
the organizational culture.6

In academic medicine, there is some evidence that multi-
component URM faculty development and mentoring
programs increase retention, academic productivity, and
promotion rates.7,8 There is anecdotal information from
AcademyHealth’s own experience that these programs make a
meaningful difference in the lives of the people who participate,
particularly junior faculty, and also have a positive impact on

Successful efforts to promote diversity
have focused on individuals at different
phases of the research career pipeline.

7

their mentors through expanding their professional networks
and deepening their understanding of the value of diversity.

However, URM faculty retention is still a challenge. A recent
study using the Association of American Medical Colleges
(AAMC) Faculty Roster database found that the percentage of
URM faculty in medical schools increased by only 1.2 percent
over the 10 years between 2000 and 2010. In part, this was
because only one out of three schools had minority faculty
development programs as of 2010, and of those schools, only
those that had been in existence for longer than five years and
also had multiple program components showed a significant
increase in URM representation.9 While change takes time,
this finding suggests that mentoring programs alone will not
be sufficient to diversify the workforce enough to reflect the
demographics of the U.S. population, and that programs will
have a greater impact when they include additional components
such as networking and cultural events, organizational diversity
strategies, and changes in promotion and tenure processes.

Organizational Diversity Initiatives

Mentoring programs are an important first step toward diversity,
but they do not directly address racial bias or the discrimination
mentees may encounter in or from predominantly white
institutions (PWIs). Thus, individual-focused programs need
reinforcement from organizationally-based programs to build a
culture of diversity and inclusion across the institution, which may
be defined as valuing diverse perspectives and backgrounds as an
asset and making all participants feel engaged and respected.10

In the larger biomedical research community, after uncovering
a systematic bias against funding URM researchers,11 the NIH
director called for a complete review of all NIH grantmaking
and review functions by an internal working group. The group
recommended many strategies relevant to HSR, ranging from
a focus on mentoring, career preparation and retention to
appointing a Chief Diversity Officer at NIH, which occurred in
2014 (see Appendix E).

In another example from the research community, the National
Science Foundation (NSF) now provides training to reduce
implicit bias among grant reviewers and senior faculty as one
strategy to directly address bias and provide more opportunities
for women and people of color to enter the STEM fields.12
Broadening participation and promoting diversity was one
of the performance areas NSF needed to improve under the
Government Performance and Results Act (GPRA), making the
agency accountable for creating opportunities and innovation to
help maintain the US position of “world leadership in science and
technology.”13

Mentoring programs will have a greater
impact when they include additional
components such as networking and
cultural events, organizational diversity
strategies, and changes in promotion and
tenure processes.

Mentoring programs are an important
first step toward diversity, but they do
not directly address racial bias or the
discrimination mentees may encounter in
or from predominantly white institutions.

8

In both of these large, leading research organizations, the impetus
for systemic change came from outside the organization after
information about their patterns of discrimination and lack of
diversity was made public.

In contrast, several universities, such as Harvard (http://diversity.
harvard.edu/), University of Chicago (http://diversity.uchicago.
edu/), University of Michigan (http://www.diversity.umich.edu/),
University of North Carolina-Chapel Hill (http://diversity.unc.
edu/), University of California-Berkeley (http://diversity.berkeley.
edu/), and University of Southern California (https://www.usc.
edu/schools/GraduateSchool/diversity_programs.html) have
developed diversity and inclusion programs for an entire campus.
These programs are driven not only by recognition of changing
demographics, but also because the organizations value the variety of
perspectives that diversity brings. Many of these diversity programs
have been in place for several years, and most have dedicated websites,
sponsor and produce events, and report publicly on their progress.

Communities of Practice

While some communities are institutional or geographic, others
are virtual. For example, a professional community of disparities
researchers has developed around National Health Disparities
Summits convened by the Department of Health and Human
Services (HHS) in 2002, 2006, 2009, 2011, and 2014. Over time,
organizers hope that many connections made at these meetings
will lead to increased citations of work presented there, as well as
new collaborations among researchers with similar interests.

Similarly, the AcademyHealth Disparities Interest Group has more
than 800 members who conduct disparities research, present their
work at the AcademyHealth Annual Research Meeting, are active
in an online community, publish findings, and share information
throughout the year. The American Public Health Association
meeting also provides annual opportunities for HSR presentations
and professional networking around health disparities and
minority health. Each of these virtual communities has achieved
significant engagement by URM students and faculty.

Diversity programs are driven not only by
recognition of changing demographics,
but also because the organizations value
the variety of perspectives that diversity
brings.

Contact with a community of peers
and senior researchers in the field can
make a big difference in an individual’s
career path.

9

Based on anecdotal information from its minority scholars and
fellows, AcademyHealth knows that contact with a community
of peers and senior researchers in the field, along with the
ability to present findings at professional meetings, can make a
big difference in an individual’s career path. AcademyHealth is
currently evaluating its programs to find out more about their
career impact and relationship to institutional culture changes.
The organization is also seeking input on further changes
fellows believe would support equity in promotions and improve
retention rates at their respective institutions.

AcademyHealth is particularly interested in the impact of
building a URM community of practice where previous and
current fellows can interact and exchange ideas on their research,
and in what would encourage them to continue to be engaged
with the larger AcademyHealth community, including long-term
mentoring and networking opportunities.

Diversity in the Health Professions

In 2000, the health professions implemented National Standards
for Culturally and Linguistically Appropriate Services (CLAS
Standards) (https://www.thinkculturalhealth.hhs.gov/content/clas.
asp), which have been incorporated into continuing education
programs, Joint Commission and NCQA accreditation, and even
legislation in some states. They are intended to advance health
equity, improve [healthcare] quality, and help eliminate health
disparities. 14

In a 2006 review of evidence, The Bureau of Health Professions at the
Health Resources and Services Administration (HRSA) concluded
that greater workforce diversity improves population health by
improving access and quality of care for racial and ethnic minority
populations.15 Notably, the HRSA-funded National Health Services
Corps, a loan repayment program, has trained 40,000 primary care
clinicians over 40 years to serve in Health Professional Shortage Areas
(HPSAs), many of which are low-income communities of color. The
NHSC clinicians are more diverse than the national workforce, and
many grew up in communities similar to the ones they now serve.16

The AAMC has developed a “roadmap to diversity” to help
medical schools achieve diverse student bodies through
institution-specific, diversity-related admissions policies.17
These strategies apply to those who are interested in academic
careers, and many are clinicians who also conduct HSR and
clinical research. As another example, the Finding Answers:
Disparities Research for Change program has developed an equity
self-assessment questionnaire for medical schools to help them
identify concrete actions to address equity among students and
faculty, with an additional goal of reducing health care disparities
through advocacy and systems level changes.18

Greater workforce diversity improves
population health by improving access
and quality of care for racial and ethnic
minority populations.

10

PWIs and mainstream medical culture may have moved beyond
the shocking exploitation of African Americans by white medical
researchers that was documented by Harriet Washington in
Medical Apartheid19 and others. However, the ramifications
of such injustices play an important role in the overall health
and well-being of many African American communities. There
is a growing body of evidence that suggests implicit and often
unconscious biases about minority patients lead white physicians
to inadvertently provide poorer quality care to those patients.20,21
Despite the widespread implementation of the CLAS standards,
studies show patterns of discrimination and poor communication
about pain management, levels of care, and other treatment biases
that have a significant impact on health outcomes.22

As described by health services researchers at Kaiser Permanente
(KP) Colorado, the national legacy of overt racism and open
discrimination takes a subtle and common form of discrimination
that is often unintentional and can’t be measured with standard self-
report survey questions, precisely because individuals are unaware

they are doing it.23 As an example, the KP researchers suggest bias
might manifest as a tendency for a white male physician to perceive
an elderly African American patient with hypertension as being
non-adherent, based on implicit assumptions and stereotypes
about African Americans, rather than the physician adjusting the
medication, as he might do for a white male patient.

Thus, racism and discrimination are not always obvious either
to an observer or even to the person making discriminatory
judgments in a single incident or over time.24

The evidence shows that health disparities are not only due to
communities of color being disproportionately disadvantaged in terms
of economics and education, insurance coverage, and other social
determinants of health. Health disparities are also due to widespread
but often subtle discrimination by white people against people of
color, even against those who are well-educated and affluent.

It therefore seems likely that the same implicit biases may be at
work in admissions, promotion, and tenure decisions in HSR,
similar to most workplaces.25 Without awareness, individuals who
grew up exclusively in majority culture and its privileges are making
discriminatory decisions about people who are not like them.26

While much of the attention to diversity has been on individually
mediated discrimination and racism, the authors believe that a
more comprehensive model is needed. Perhaps the most relevant
example for AcademyHealth and the field of HSR to demonstrate

Without awareness, individuals who
grew up exclusively in majority
culture and its privileges are making
discriminatory decisions about people
who are not like them.

11

a commitment to workforce diversity comes from the diversity
section of the Accreditation Criteria for Schools of Public Health,
developed by the Council on Education for Public Health (http://
ceph.org/assets/SPH-Criteria-2011.pdf ). It requires that each
school develop a learning environment in which “self-awareness,
open-minded inquiry and assessment, and the ability to adopt to
cultural differences” are defined and evaluated (see Appendix F).

Diversity and Health Equity Research

Recommendations to increase the diversity of the HSR workforce
and health professions have been made as a strategy to help
reduce health disparities and promote health equity. In 2002, the
Institute of Medicine (IOM) report Unequal Treatment (http://
iom.nationalacademies.org/Reports/2002/Unequal-Treatment-
Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx)
presented clear evidence that differences in outcomes are related to
social determinants of health, including high rates of poverty and
unemployment, and also are related to bias, discrimination, and
stereotyping on the part of majority culture.27 That report and a
subsequent IOM report entitled In the Nation’s Compelling Interest:
Ensuring Diversity in the Healthcare Workforce (http://www.nap.
edu/openbook.php?isbn=030909125X) both called for an increase
in the diversity of the health care and research workforces as one
key strategy in an overall commitment to promoting health equity.28

In 2004, the Sullivan Commission on Diversity in the Healthcare
Workforce also called for an increase in diversity of the health
care and research workforce, noting that the workforce was not
keeping pace with changing demographics and that access to a
health professions career “remains largely separate and unequal.”29

The Commission, chaired by former HHS Secretary Louis
Sullivan, was supported by a grant from the Kellogg Foundation

to Duke University School of Medicine. Its goal was to convene
health, education, and business leaders and hold public hearings
across the country to gather testimony about the lack of diversity
in medicine, nursing, and dentistry as a means of addressing the
growing body of evidence of health …