Description
Background
In December 2022, the National Heart, Lung, and Blood Institute (NHLBI), of the National Institutes of Health (NIH), convened a workshop to discuss “Promoting Inclusive Excellence in Career Development for Social Determinants of Health and Implementation Research.” The goal of this workshop was to bring together experts with interest in the areas of social determinants of health (SDOH), implementation science (IS), and career development to discuss the current state and potential future strategies for expansion and integration of inclusive excellence. As NHLBI approaches its 75th anniversary, its leaders acknowledge that the intersection of implementation science and social determinants of health is increasingly central to the organization realizing its mission. Promoting a culture of equity and inclusive excellence that recognizes the importance of SDOH in training and career development will ensure these essential guiding principles extend to the research itself and further ensure that the latest evidence-based heart, lung, blood, and sleep disorder interventions reach the individuals and communities who need them most.
Objectives
- To explore opportunities for promoting inclusive excellence in training and career development at the interface of social determinants of health and implementation research.
- To identify areas of dissemination and implementation research across heart, lung, blood, and sleep science that represent promising and innovative avenues for early-stage investigator-initiated research at the interface of implementation research and social determinants of health.
- To highlight opportunities for refining and contextualizing theoretical and conceptual frameworks to guide innovative research in social determinants of health and implementation research for advancing health equity.
Summary:
Over the course of two days, participants explored opportunities for promoting inclusive excellence in training and career development at the interface of SDOH and implementation research, identified areas of dissemination and implementation research across relevant NHLBI disciplines that represent novel avenues for early-stage investigator-initiated research at the interface of IS and SDOH, and described opportunities for refining and contextualizing IS and SDOH theory for future trainees.
Session 1: Inclusive excellence in training and career development
Session 1 opened with an engaging presentation from Desiree Salazar, DEI coordinator for Extramural Programs at NHLBI, who spoke about “Inclusive Excellence in Training and Career Development at NHLBI.” She underscored that NIH has a strong commitment to diversity and is working on programs to address structural racism and champions programs that improve research workforce diversity including the Diversity Supplements Program, the Short-Term Education Program to Enhance Diversity in Health-Related Research, the Program to Increase Diversity Among Individuals Engaged in Health-Related Research (PRIDE), and Maximizing Opportunities for Scientific and Academic Independent Careers (MOSAIC) program. The next presentation from Dr. Fernando Bruno and Dr. Dave Clark discussed capacity building in implementation science. Rapid growth in the field of implementation science has increased the demand for implementation scientists. The NHLBI’s Center for Translation Research and Implementation Science (CTRIS) has shown its commitment to capacity building in IS by supporting career development and identifying opportunities to advance career excellence.
The subsequent discussions covered a wide range of topics related to inclusive excellence in training and career development at the intersection of SDOH and IS. To effectively accomplish the integration of social determinants into IS frameworks will require intentional collaboration among investigators in the two disciplines. There is recognized overlap between the IS, SDOH, and health equity so ensuring that interdisciplinary teams contain experts in these domains, as well as mentors is essential to addressing the challenge of integrating SDOH into IS frameworks.
Workshop participants focused on challenges to and opportunities for improvement. Several barriers to capacity-building were identified, including mentor stress and burnout due to insufficient time and resources and lack of recognition or compensation for mentoring activities. IS training, mentorship, and credentialing opportunities are limited by the small number of credentialed implementation scientists and dedicated training programs. Mentees struggle to navigate career paths in a discipline that remains underrecognized and undervalued. Attendees noted there is an opportunity to increase visibility of formal IS training and improve the trajectory for persons interested in IS careers by creating common core curricula across institutions.
Ideas expressed by workshop participants to address challenges in capacity building included expanding the cohort of recognized implementation scientists beyond the “badge-carrying, IS-credentialed cadre” to eligible researchers in areas that employ IS principles and practices. Additionally, targeting training opportunities to the needs of a diverse trainee pool, employing more accessible terminology, and demonstrating the value of IS to interested trainees and institutional leaders will build a more fertile research pipeline. Tapping into efforts at institutions, encouraging trainees to publish, as well as engaging the global public health community could also grow the IS pipeline. Furthermore, the importance of engaging community stakeholders (patients, social service providers, and others with lived experience in the community) in IS research involving SDOH, and including them on study teams, was stressed repeatedly. Strong alliances between research institutions and the broad communities they serve are needed to effectively implement evidence-based practices.
Among the many lessons shared during the workshop was the need to increase awareness of IS research as an attainable career path and provide clinical researchers with foundational training. Finally, a systematic approach to growing the field will demand a persistent focus on advancing diversity throughout the process.
Session 2: Training and career development at the intersection of SDOH and implementation research
Creating career pathways for under-represented minorities (URM) trainees requires a non-traditional approach that acknowledges their diverse backgrounds and the unconventional and indirect paths they may take to achieve their professional goals. Dr. Charles Muiruri from Duke University provided perspectives from his personal experiences to describe challenges and opportunities for training experiences in IS at research institutions. Additional insights into mentoring and training at the intersection of SDOH and IS came from Dr. Susan Ewart at Michigan State University College of Veterinary Medicine. Biomedical trainees interested in research at the intersection of SDOH and IS need mentors with expertise in diversity, equity, inclusion, and accessibility (DEIA)-focused research. When paired with mentees in cross-race, cross-ethnicity relationships, mentors feel ill-equipped to understand the URM student perspective, recognize or defuse microaggressions, or engage in difficult conversations.
Following the examples from university professors, Dr. Victoria Spruance, of the NIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) introduced the extensive work they undertook to understand their trainees’ needs and the tailoring done to create a new program for trainees. They introduced the Institutional Network Award (INA), a cooperative agreement that funds a networking core, a professional development core, and an administrative core, each of which is linked to a U2C training core. The INA program is advancing inclusive excellence through voluntary collaborations between research-focused institutions and neighboring ones with more diverse student bodies that might otherwise not be competitive for T32 funding.
Following Session 2, the discussants addressed barriers to and facilitators of change in existing pipelines and frameworks that affect progress in fostering inclusive excellence in education and research. Opportunities identified included changing the mindset of seasoned researchers and administrators to a more trainee-centric one. Shifting the focus of the conversation from the institution and its representatives to URM trainees and their changing needs provides a convincing argument. Additionally, establishing scientific and social networks that build community and facilitate connections within the research community was repeatedly proposed as a means of promoting inclusive excellence.
Session 3: Training Needs
Session 3 opened with a perspective on developing and teaching a Diversity Equity and Inclusion curriculum in a health care system from Dr. Nancy Denizard-Thompson, of Wake Forest University Medical Center. The Wake Forest health equity curriculum translated into students reporting more confidence in their ability to understand and service medically underserved populations, more familiarity with available community resources, and a deeper understanding of the social, economic, and historical factors that influence the health of underserved populations. Community service partners who participated in the project also reported benefiting from having volunteers and from knowing they had accomplished a part of their mission by helping students to better understand their community’s needs and SDOH.
Next, perspectives on best practices for teaching implementation science to address social determinants of health outcomes were introduced by Dr. Justin Moore, of Wake Forest University School of Medicine. SDOH considerations (i.e., the total environment in which an intervention will occur) are integral to any health related IS framework. Rather than hiding social, cultural, and psychosocial factors within the IS framework, participant characteristics and their SDOH should be central to the intervention design and implementation.
Dr. Meghan Lane-Fall, of the University of Pennsylvania, gave the final presentation of session 3 on the intersection of ethics and equity in implementation science. She described how ethics, equity, and IS are distinct but interrelated. Increasingly, IS research is engaging historically marginalized populations and examining evidence through an equity lens. Progress in integrating equity into IS frameworks is complicated by barriers that still need to be overcome. IS has the potential to advance or undermine equity and best practices for the ethical integration of equity into IS have yet to be defined.
Following Session 3, workshop participants discussed how to promote the intersectionality of SDOH and IS in their research training. Complexity in the intersectionality of SDOH with equity and IS constructs was emphasized. To mitigate some complexity, a common language and uniform metrics between these domains is essential. Some stressed that foundational knowledge of SDOH needs to be made a prerequisite for learning IS. Rather than being viewed as superfluous, equity frameworks are a welcomed addition to and should be an integral part of the IS toolbox. Community representation at multiple levels in SDOH and equity research training is critical. Leveraging the expertise of community organizations in choosing and conducting projects that benefit the community they serve, rather than the professional aspirations of the investigators, helps to ensure the utility, dissemination, and acceptance of the project deliverables.
In returning to the question of how to advance health equity and IS research and training, and how to grow the pipeline of IS and equity experts, workshop participants discussed several opportunities: IS training programs could benefit from training on mentoring at the intersection of health equity and IS; faculty recognition and compensation for their mentoring efforts would be welcome; and mid-career development awards focused on health equity, IS, and DEIA would support and encourage these activities.
Session 4: Defining a future state
In the final session, facilitated by co-chairs Dr. Hayden Bosworth, of Duke University Medical Center, and Dr. Hazel Tapp, of Atrium Health, workshop participants discussed how to address gaps and barriers related to integrating diversity into training programs and ways to enhance existing approaches.
There was acknowledgement that URM students interested in pursuing SDOH-focused IS research at teaching institutions encounter different barriers than their peers at research-focused universities. However, some challenges were considered more universal. Workshop attendees discussed many potential areas during the grant cycle that could help in capacity building. Contacting a program officer for technical assistance prior to submitting the application and after receiving the summary statement could help guide applicants to appropriate funding opportunities and talking through review comments respectively. At the university level, promotion and tenure committees are struggling with how to assign value to and reward community and interdisciplinary partnerships when measurable results and subsequent publications may take years.
Opportunities for expanding implementation research at the intersection of equity and SDOH include working with primary care providers in underserved communities. They understand the social determinants through their relationships with their patients and, as such, are vital resources for building community partnerships. And although they are skilled as clinicians, some local clinicians may benefit from training or other resources to build more advanced research skills. For example, the North American Primary Care Research Group (NAPCRG) supports physician training in primary care research. The Patient-Centered Clinical Outcomes Research Network (PCORNet) is exploring IS. In addition to domestic opportunities, there was discussion around international health partnerships that could elicit new insights into inclusive excellence. Altogether, discussions over the two days identified gaps and opportunities for training and career development at the intersection of SDOH and IS and left the group energized for next steps in building the field.
Workshop Co-Chairs
Hayden Bosworth, Ph.D., Duke University Medical Center
Hazel Tapp, Ph.D., Atrium Health, Charlotte, NC
Session Moderators
Karen Plevock Haase, Ph.D., M.S., NHLBI, NIH
Keith Mintzer, Ph.D., NHLBI, NIH
Desirée Salazar, Ph.D., NHLBI, NIH
Susan T. Shero, R.N., M.S., NHLBI, NIH
Session Speakers
Fernando Bruno, M.D., MPH, CTRIS, NHLBI, NIH
Dave Clark, Dr.P.H., MPH, ISB, CTRIS, NHLBI, NIH
Nancy Denizard-Thompson, M.D., Wake Forest University Medical Center
Susan Ewart, DVM, Ph.D., DACVIM, Michigan State University College of Veterinary Medicine
Meghan Lane-Fall, M.D., MSHP, University of Pennsylvania
George Mensah, M.D., FACC, FCP(SA) Hon., CTRIS, NHLBI, NIH
Justin B. Moore, Ph.D., Wake Forest University School of Medicine
Charles Muiruri, Ph.D., MPH, Duke Global Health Institute
Tracy Rankin, Ph.D., MPH, NIDDK, NIH
Desirée Salazar, Ph.D., NHLBI, NIH
Victoria Spruance, Ph.D., NIDDK, NIH
Disclaimer: The findings, knowledge gaps, and opportunities described here represent a summary of individual opinions and ideas expressed during the workshop. The summary does not represent a consensus opinion or directive made to or by NHLBI or NIH.