Navigating Hostile Workplaces and Educational Spaces Within Health Services and Policy Research
PMCID: PMC11671308
PMID:
Abstract
Introduction: The representation of ethnoracial minoritized individuals in health services and policy research (HSPR) has increased in recent years. However, previous literature has exposed a need to acknowledge and attend to inequities within the HSPR workforce. Methods: To describe educational and workplace experiences that characterize diversity, equity, and inclusion (DEI) within the HSPR profession. In this qualitative study, six focus groups were conducted virtually via Zoom with 27 individuals who reported working or pursuing higher education in HSPR from December 2020 to January 2021. We sought HSPRers perspectives on DEI initiatives, work and educational environments, experiences, and climate, and recommendations for improving DEI in HSPR. We developed a structured codebook and applied a deductive approach to conduct thematic analysis. Results: Of the 27 participants, nearly half of participants identified as Black/African American (44%); most were women (81%). Three major themes emerged: (1) HSPR work and education spaces subject minoritized HSPRs to a range of exclusionary and harmful practices; (2) DEI initiatives fail to address the need for institutional change; and (3) by working with and for policymakers, HSPRs are uniquely subjected to shifting political contexts that reinforce racism. Discussion: Despite an increasing commitment to increasing the diversity of the HSPR workforce and improving equity and inclusion in the HSPR workplace, the findings suggest that more intentional and action-oriented work is needed, especially work that emphasizes inclusion and equity across various levels of the workplace. Health Equity Implications: The findings offer critical insight on necessary workplace and educational reform to develop the workforce necessary to advance population health equity and equity-oriented policy making.
Full Text
We conducted a codebook thematic analysis using a deductive approach, as we conducted this study with key research questions, and they guided our analytic approach. T.R. and K.G. created a structured codebook prior to analysis, using references and survey findings as source material from A.B. and C.D. The codebook consisted of 46 codes, and their definitions can be found in Table 2. The transcripts were coded by T.R. and K.G.; T.R. and K.G. recoiled the coding and created the themes. C.M., T.C., and M.K. checked and verified the thematic analysis.
We recruited 27 participants total across six groups. Nearly half identified as Black and/or African American, and most were women (Table 1). Two-thirds were aged 35–64 (66.6%) years old, and approximately one-third of participants were early career academics (students, postdocs, and assistant professors). In the Supplementary Data S1, we list positions and organizational types and assign pseudonyms to protect participant identities. Qualitative analysis of the focus groups identified three major themes (Tables 2–4).
Participants shared adverse experiences, which can be broadly categorized into subthemes: (a) discriminatory policies and practices, both local and national; and (b) interpersonal harms, including exploitation and abuse. Participants described how the cumulative impacts of these types of experiences led to deterioration in their mental and physical health, exiting organizations, and/or considering leaving the HSPR field entirely (Table 2).
For subtheme (b), participants described repeated interpersonal harms, manifesting as abuse, exploitation, harassment, and retaliation (Table 2). Postdoctoral fellow Cameron described how their PhD advisor had leveraged fear, particularly via the exploitation of Cameron’s status as a child of undocumented immigrants with financial precarity, to ensure Cameron’s compliance and maintained a verbally and emotionally abusive relationship. Similarly, in Memphis’ prior position as an assistant professor, the health system chief executive officer subjected Memphis to sexual harassment, verbal abuse, and physical aggression. When she attempted to report these harms, both her abuser and other senior leadership threatened her professional reputation and work—from publications to grants—to instill fear of speaking out and then to enact retaliation.
When queried about DEI initiatives, participants reported that organizational DEI efforts were frequently ineffective or actively counterproductive (Table 3). Participants characterized these efforts as “window dressing,” i.e., publicity without substantive reform or support; reactive to social movements, rather than proactive and systematic, thus contributing to the observation of this work as cyclical and impermanent.
Participants explained that they were skeptical of DEI initiatives that did little to acknowledge existing problems. They noted that efforts were often rushed and emphasized simple, quantifiable outcomes, rather than intentional processes that focused on quality and democratic decision-making. Those with more professional experience referenced past reform efforts that had also been short-lived and ineffective. A few spoke more positively of their organization’s DEI work as promising, particularly in the overdue recognition of structural racism—but noted they had not yet observed significant investment in implementation and sustainability (Table 3).
Participants described several experiences that arose specifically due to the nature of their work in/with governmental agencies and policymakers. The actions of local, state, and federal governments, as well as the level of politicization of their organizations, impacted participants’ work environments (Table 4). Because many worked on health equity issues, several described how changes to a more conversative administration either limited or terminated their projects. For others, navigating the differing political interests of their stakeholders presented heightened challenges to accomplishing their goals and/or increased the level of work and educational tension. In summary, for minoritized HSPRers, shifting political contexts presented a unique challenge to maintaining equitable and inclusive environments.
White supremacy culture is the widespread ideology in society that teaches us overtly and covertly that whiteness holds values and whiteness is value. This ideology is reflected in the characteristics, and their definitions can be found in the online Supplementary Data S1. Many participants shared that scholarship on racism and minoritized communities was devalued, and while acceptance in this area of work is growing, scholars were continually questioned (Table 3). This phenomenon reflects characteristics of white supremacy culture, characteristics of one right way and worship of the written work. One right way is the belief that there is one right way to do things and assumes that anyone who does not adapt to “fit” is wrong. Worship of the written word is the habit of honoring what is written and only what is written to a narrow standard, even if what is written is incorrect. Our findings offer insights into the institutional mechanisms that contribute to inequities in funding and publication, including denialism and minimization within the peer-review process and overall organizational priorities.
Because HSPRers work in/with policymakers, political and policy contexts can perpetuate institutional racism, both restricting the work and fostering internal organizational racism (Theme 3). In many cases, HSPRers work in highly politically polarized environments; many participants work in places entrenched in the either/or and binary characteristics of white supremacy culture (Table 4). Similarly, participants shared experiences that resembled paternalism and perfectionism, and that fraught political context dampened appreciation for their work. These characteristics of White supremacy culture reinforce racialized organizations’ ability to diminish the agency of racial groups (e.g., the experiences of Wren, Ryan, and Drew) and legitimize the unequal distribution of resources (e.g., Drew) in HSPR workplaces and educational spaces (Table 4).
Sections
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Two-thirds were aged 35\\u201364 (66.6%) years old, and approximately one-third of participants were early career academics (students, postdocs, and assistant professors). In the Supplementary Data S1, we list positions and organizational types and assign pseudonyms to protect participant identities. Qualitative analysis of the focus groups identified three major themes (Tables 2\\u20134).\"}, {\"pmc\": \"PMC11671308\", \"pmid\": \"\", \"reference_ids\": [\"tb2\"], \"section\": \"Theme 1: Harm and Exclusion Within HSPR Workplace and Educational Settings\", \"text\": \"Participants shared adverse experiences, which can be broadly categorized into subthemes: (a) discriminatory policies and practices, both local and national; and (b) interpersonal harms, including exploitation and abuse. Participants described how the cumulative impacts of these types of experiences led to deterioration in their mental and physical health, exiting organizations, and/or considering leaving the HSPR field entirely (Table 2).\"}, {\"pmc\": \"PMC11671308\", \"pmid\": \"\", \"reference_ids\": [\"tb2\"], \"section\": \"Theme 1: Harm and Exclusion Within HSPR Workplace and Educational Settings\", \"text\": \"For subtheme (b), participants described repeated interpersonal harms, manifesting as abuse, exploitation, harassment, and retaliation (Table 2). Postdoctoral fellow Cameron described how their PhD advisor had leveraged fear, particularly via the exploitation of Cameron\\u2019s status as a child of undocumented immigrants with financial precarity, to ensure Cameron\\u2019s compliance and maintained a verbally and emotionally abusive relationship. Similarly, in Memphis\\u2019 prior position as an assistant professor, the health system chief executive officer subjected Memphis to sexual harassment, verbal abuse, and physical aggression. When she attempted to report these harms, both her abuser and other senior leadership threatened her professional reputation and work\\u2014from publications to grants\\u2014to instill fear of speaking out and then to enact retaliation.\"}, {\"pmc\": \"PMC11671308\", \"pmid\": \"\", \"reference_ids\": [\"tb3\"], \"section\": \"Theme 2: DEI Initiatives Fail to Address the Need for Institutional Change\", \"text\": \"When queried about DEI initiatives, participants reported that organizational DEI efforts were frequently ineffective or actively counterproductive (Table 3). Participants characterized these efforts as \\u201cwindow dressing,\\u201d i.e., publicity without substantive reform or support; reactive to social movements, rather than proactive and systematic, thus contributing to the observation of this work as cyclical and impermanent.\"}, {\"pmc\": \"PMC11671308\", \"pmid\": \"\", \"reference_ids\": [\"tb3\"], \"section\": \"Theme 2: DEI Initiatives Fail to Address the Need for Institutional Change\", \"text\": \"Participants explained that they were skeptical of DEI initiatives that did little to acknowledge existing problems. They noted that efforts were often rushed and emphasized simple, quantifiable outcomes, rather than intentional processes that focused on quality and democratic decision-making. Those with more professional experience referenced past reform efforts that had also been short-lived and ineffective. A few spoke more positively of their organization\\u2019s DEI work as promising, particularly in the overdue recognition of structural racism\\u2014but noted they had not yet observed significant investment in implementation and sustainability (Table 3).\"}, {\"pmc\": \"PMC11671308\", \"pmid\": \"\", \"reference_ids\": [\"tb4\"], \"section\": \"Theme 3: By Working with and for Policymakers, HSPRs Are Uniquely Subjected to Shifting Political Contexts That Can Undermine Equity and Inclusion\", \"text\": \"Participants described several experiences that arose specifically due to the nature of their work in/with governmental agencies and policymakers. The actions of local, state, and federal governments, as well as the level of politicization of their organizations, impacted participants\\u2019 work environments (Table 4). Because many worked on health equity issues, several described how changes to a more conversative administration either limited or terminated their projects. For others, navigating the differing political interests of their stakeholders presented heightened challenges to accomplishing their goals and/or increased the level of work and educational tension. In summary, for minoritized HSPRers, shifting political contexts presented a unique challenge to maintaining equitable and inclusive environments.\"}, {\"pmc\": \"PMC11671308\", \"pmid\": \"\", \"reference_ids\": [\"SD1\", \"tb3\"], \"section\": \"HSPR in Relation to the Characteristics\\u00a0of White Supremacy Culture\", \"text\": \"White supremacy culture is the widespread ideology in society that teaches us overtly and covertly that whiteness holds values and whiteness is value. This ideology is reflected in the characteristics, and their definitions can be found in the online Supplementary Data S1. Many participants shared that scholarship on racism and minoritized communities was devalued, and while acceptance in this area of work is growing, scholars were continually questioned (Table 3). This phenomenon reflects characteristics of white supremacy culture, characteristics of one right way and worship of the written work. One right way is the belief that there is one right way to do things and assumes that anyone who does not adapt to \\u201cfit\\u201d is wrong. Worship of the written word is the habit of honoring what is written and only what is written to a narrow standard, even if what is written is incorrect. Our findings offer insights into the institutional mechanisms that contribute to inequities in funding and publication, including denialism and minimization within the peer-review process and overall organizational priorities.\"}, {\"pmc\": \"PMC11671308\", \"pmid\": \"\", \"reference_ids\": [\"tb4\", \"tb4\"], \"section\": \"HSPR in Relation to the Characteristics\\u00a0of White Supremacy Culture\", \"text\": \"Because HSPRers work in/with policymakers, political and policy contexts can perpetuate institutional racism, both restricting the work and fostering internal organizational racism (Theme 3). In many cases, HSPRers work in highly politically polarized environments; many participants work in places entrenched in the either/or and binary characteristics of white supremacy culture (Table 4). Similarly, participants shared experiences that resembled paternalism and perfectionism, and that fraught political context dampened appreciation for their work. These characteristics of White supremacy culture reinforce racialized organizations\\u2019 ability to diminish the agency of racial groups (e.g., the experiences of Wren, Ryan, and Drew) and legitimize the unequal distribution of resources (e.g., Drew) in HSPR workplaces and educational spaces (Table 4).\"}]"
Metadata
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