Increasing representation of racial minorities in business media obscures ongoing racial inequities in Corporate America

Introduction

As principles of diversity and inclusion become more explicit within Corporate America, there remains a discrepancy between commitments to and actualization of racial parity in corporations, particularly among corporate leadership. In this article, the authors evaluate corporate policies and contrast legally enforceable Affirmative Action policies that acknowledge the history and disparate impacts of slavery and Jim Crow era with “diversity” programs that narrowly celebrate the presence of differences, including and beyond race. This shift toward “diversity” initiatives co-opted the language and moral imperative of redistributive efforts while abstracting from the enforceable policies and actions necessary to address the systematic roots of racial inequity.

To understand the impact of diversity programs on corporate culture, the authors examined minoritized representation within Forbes, Fortune, and Money magazines. These 3 popular business magazines publicly reflect ways corporations think about race, while also reflexively informing corporate beliefs, and thus practices, related to race. The authors conclude that the features of minoritized representation across these magazines demonstrates the lip service of corporations about racial equity and set the bar at simply diversity, rather than inclusion or equity. This makes visible diversity a significant strategy to meet “sufficient” racial progress metrics.

Crystal L. Jackson received her PhD in Sociology from Loyola University. David G. Embrick is an Associate Professor of Sociology and Africana Studies and Director for the Sustainable Global Cities Initiative at University of Connecticut. Carol S. Walther is an Associate Professor of Social Science Research, Learning Lab Coordinator, and Honors Faculty Fellow at Northern Illinois University.

Methods and Findings

To study minoritized representation in Corporate America, the authors analyzed patterns of minority representation in Forbes, Fortune, and Money magazine between 1997 and 2007. The authors examined patterns quantitatively (e.g., frequency of certain words or subjects) and qualitatively (e.g., how racial minorities were represented in images). Analysis revolved around non-white representation variation across time, page type (editorial, advertisement or front page),  and content (e.g., the presence of a dedicated diversity or international focus within an issue).

Quantitatively, using negative binomial regression analysis, the authors found that minoritized representation differed between editorials and advertisements. For editorials, minoritized representation increased significantly when there was representation on the magazine cover (56% – 70% increase) and when the issue had a dedicated diversity section (21% – 56% increase). For advertisements, minoritized representation increased significantly over time (3% – 3.5% per year) and when the issue had a dedicated diversity section (49% increase). This study positions Fortune as most closely aligned with corporate culture based on its readership, followed by Forbes and then Money, which this study considers least reflective of corporate culture. When controlling for the presence of a dedicated diversity section, the level of representation of racial minorities mirrored this relationship. Fortune is significantly more likely than Forbes to have greater representation of racial minorities, and both magazines significantly ahead of Money in frequency of representation.

Qualitatively, the authors noted although non-white representation has increased in business media over time, these images infrequently show racial minorities in positions of power. When a non-white leader is featured in an editorial, the authors also find that the content centers on their presence as evidence of “diversity” rather than on their impact as a corporate leader. The authors propose this difference in leadership versus ancillary representation is particularly relevant in light of previous research. Previous findings show that whites consider numerical representation reflects full realization of diversity objectives, while non-whites more heavily weigh the level of inclusion that racial minorities actually experience, particularly within decision-making positions.

Conclusions

The authors conclude that featuring racial minorities in business media is more likely when “diversity” is the topic of focus, and is more prevalent in depictions of ancillary roles, rather than leadership. The authors note that the increased frequency of any minoritized representation in Fortune, Forbes, and Money magazines subtly reinforces a prevailing view that “diversity” has already been achieved, thereby diverting substantive discussion of the  racial inequality that persists in Corporate America. 

The authors also contextualized the increasing importance of “diversity” in Corporate America within a broader political and social shift away from legal enforcement of Affirmative Action. On the surface, the focus on “diversity” signaled a broadening of focus from race to all forms of social exclusion; however, this rhetorical shift dilutes attention from the incomplete work of achieving racial parity. Altogether, these findings show that minoritized representations in these public media may serve to produce confirmation bias that “diversity” has been achieved and short circuit deeper analysis of persisting racial inequality in corporate America.

Though compelling, this research is now almost 15 years old. Thus, further research should be done over the current time period. That research could also expand on this analysis by including the broader range of business media, both print and digital, available today.

Organizational behavioral modification should be used to make social justice a professional norm

Introduction

The professional field of evaluation plays an integral role in creating the results, measurements, and evidence that guide the worldviews and decisions of businesses, educational institutions, philanthropies, public health agencies, and governments. Given this influence, it is paramount for evaluators to understand the practice of evaluation as a tool to reinforce and enable or conversely to challenge the unequal, inequitable access and outcomes that minoritized communities experience. For example, evaluative standards have been manipulated at various points in an attempt to validate Black intellectual differences as evidence of deficiency.

Like other social science fields, the profession of evaluation must reckon with the ways that its norms, history, and practices are built upon and perpetuate structural racism and injustice. In this study, the authors argue that the field of evaluation cannot be reformed without addressing the structural racism embedded throughout. Instead, the field must not only identify and acknowledge its own structural racism, but also take concrete action to eradicate ingrained structural racism from its theories and practices.

Dr. Leon D. Caldwell, PhD, is the Senior Director of Health Equity Strategy and Innovations at the American Hospital Association and Founder and Managing Partner of Ujima Developers. Dr. Katrina L. Bledsoe, PhD, is a Senior Evaluation Specialist and Research Scientist at the Education Development Center, Principal Consultant at Katrina Bledsoe Consultancy, and Partner at Strategic Learning Partners for Innovation.

Methods and Findings

The authors first review the history of the field of evaluation’s struggle to reckon with both its partiality and role as an intentional political tool for maintaining Eurocentric structures of power and authority. Because the field presents itself as the authority on measurement of various relevant, consequential outcomes, acknowledgement of this reality is necessary to understand how its approaches to hypothesis generation, definition of data, and interpretation of findings are inherently limited and insufficient. The authors point to publications and conference addresses dating from the late 1970s to late 1990s as seminal statements on the field’s complicity in structural racism. Although several authors have advanced more equitable evaluation methodologies since the 2000s, these methods are far from universally accepted best practice.

Next, the authors make distinctions between individual and systemic racism as significant to eradicating systemic racism from the field. Although individual evaluators should interrogate and address their internalized and interpersonal racism, they also have the power to collectively deconstruct systemic racism in the field by advocating for legacy organizations like the American Evaluation Association to establish and enforce social justice oriented norms. For example, the authors point to the potential normalization of frameworks such as Patton’s Seven Questions Concerning Race in the Field of Evaluation as an opportunity to move the field forward on eradicating systemic racism.

Ultimately, the authors leverage organizational behavioral modification, otherwise known as reinforcement theory, to make recommendations for lasting change. Organizational behavioral modification requires consistent consequences following antecedents to reinforce desired behavior and extinguish undesired behaviors. In this vein, the authors recommend incorporating social justice concerns into mandatory selection criteria for professional awards, publications, and promotions to positively reinforce social justice as an industry standard. Similarly, the authors recommend that the American Evaluation Association and individual funders make institutional accreditations, grants, and contracts contingent upon consideration and fulfillment of equity priorities as an additional tool.

Conclusions

In this article, the authors argue that members of the evaluation field must push the field’s institutions to recognize their histories of promoting and amplifying structural injustices through both their norms and pedagogies. Those institutions should then take steps to establish consequences to reinforce social justice-oriented transformation and to extinguish attitudes, behaviors, and outcomes that reinforce systemic oppression. 

The authors contend that evaluators not only participate within inherent structural racism of all US systems, but that they have the power to change both the perception and material outcomes of minoritized populations. Thus, the field must commit to deconstructing former best practices grounded in European traditions and reimagining the field with leadership from BIPOC evaluators. This review highlights the need for additional analysis and experimentation to determine social justice-oriented best practices and to measure their rates of implementation across the field.

Scrutiny, visibility, and social norms motivate organizations to meet – but not exceed – diversity thresholds

Introduction

As institutional Diversity, Equity, Inclusion and Justice (DEIJ) efforts have become increasingly prevalent, public scrutiny (critical attention paid to particular behaviors) has increasingly been recognized as an effective tool to encourage such efforts. The #OscarSoWhite critique of the Academy of Motion Picture Arts and Sciences is one such example. Although previous scholarship has shown that “diversity” is interpreted differently across individuals and contexts, this study aims to understand how groups concerned with diversity-related reputational threat identify thresholds for “sufficient” diversity and respond to external scrutiny.

The authors theorize that when forming “diverse” groups, individuals aim to match the average levels of diversity among peer groups to avoid associated scrutiny – particularly for highly visible groups. Additionally, the authors highlight findings that individuals find lofty goals highly motivating but pause their efforts once salient goal thresholds are reached, suggesting that peer groups will coalesce around a similar threshold. Thus, intuitively, additional underrepresented members within the group will be added at lower rates once the peer group diversity threshold is met. Further, groups will not act on their diversity goals unless there is risk of scrutiny and visibility. If these hypotheses are accurate, there should be an overabundance of highly visible peer groups with identical levels of diversity. To test these hypotheses, the authors conduct six analyses. This study demonstrates the significance of external factors such as peer group social norms and external scrutiny in setting – and expanding – expectations for diversity in hiring and group composition. In a time of increasing DEIJ investment, this study offers critical insight into implicit barriers and potential accelerators to this effort.

Dr. Edward H. Chang, PhD, is an Assistant Professor of Business Administration in the Negotiation, Organizations, and Markets Unit at Harvard Business School. Dr. Katherine L. Milkman, PhD, is the James G. Dinan Professor of Operations, Information, and Decisions at the Wharton School and Professor of Medical Ethics and Health Policy at the Perelman School of Medicine of the University of Pennsylvania. Dr. Dolly Chugh, PhD, is an Associate Professor of Management and Organization at New York University Stern School of Business. Dr. Modupe Akinola, PhD, is an Associate Professor of Management and Faculty Director of the Sanford C. Bernstein & Co. Center for Leadership and Ethics at Columbia Business School.

Methods and Findings

The authors first test the hypothesis that group diversity levels will coalesce around the peer group average (the descriptive social norm), and that this effect will increase for high visibility companies, by examining gender diversity among companies boards within the S&P 1500 and higher profile S&P 500 companies in 2013. This analysis found that there were significantly more (+12%) boards with exactly two women and significantly fewer (-8%) boards with no women than would be expected if gender diversity was randomly distributed across all boards. This pattern of statistically significant cluster of boards around the contemporary descriptive social norm held true across 12 years of historical data. Among higher visibility S&P 500 companies this effect was exaggerated, with 45% more boards with two women and 45% fewer boards with zero women than would be expected in a random distribution. More specifically, an ordinary least squares regression showed that the level of media attention received among S&P 1500 companies in 2012 significantly predicted the overabundance of exactly two female board members in 2013. Notably, the authors did not see any clustering effect for race – a diversity trait not publicly scrutinized during this time period.

Second, the authors test the hypothesis that additional diverse members would be added to groups at a slower rate once the group has reached the peer group diversity threshold, and whether this varied based on the visibility of the group, by analyzing additions to company boards among the S&P 1500 from 2004 to 2013. The authors found that company boards that already included at least 2 women were less likely to add an additional female member – and this trait was the primary predictor for that behavior. This pattern was exaggerated among the more visible S&P 500 companies and those that received greater media attention in the previous year. Notably, the authors did not find a clustering effect for racial diversity – a diversity trait that was not scrutinized – in this time period. The authors also created an online experiment (N=479) to replicate the conditions of this study in a controlled setting, where they could vary the number of women already on a board and control for the quality of potential new candidates. They found that individuals were less likely to add additional female candidates to boards with two existing female members, regardless of the quality of the candidate.

Next, the authors created an experiment among 556 business students to test the salience of social norm thresholds and threat of scrutiny in a controlled setting. They asked students to select an additional speaker for a hypothetical conference and experimentally varied the gender diversity threshold and level of scrutiny. When gender was scrutinized, participants significantly preferred female candidates if they believed they had not met the social norm for gender diversity. However, when gender was not scrutinized, participants displayed no preference for female candidates, regardless of whether they had achieved the social norm for gender diversity. The authors also replicated this experiment in an online setting (N=200) and added monetary stakes for participants. They found that the online results mirrored the in-person study: when gender was scrutinized, participants significantly preferred female candidates if they were below the diversity threshold, even though the female candidate was more expensive to recruit. When gender was not scrutinized, participants displayed no preference for female candidates, regardless of the social norm.

Finally, the authors created an online experiment (N=603) to test whether diversity thresholds also applied to race and group visibility had a similar effect as scrutiny. Participants were significantly more likely to prefer Black candidates if they believed they were below the diversity threshold, even though they received lesser financial compensation for selecting the Black candidate. Further, participants were significantly more likely to prefer Black candidates if they believed their decision was highly visible.

Conclusions

This study demonstrates the relevance of peer-defined diversity thresholds,  visibility, and anticipated scrutiny to realize group diversity. These findings explain the clustering of group diversity around diversity thresholds (a phenomenon they term “twokenism”) and variance in the degree of clustering by group visibility and threat of scrutiny. Practically, this research identifies conditions in which minoritized individuals are more or less likely to be selected for groups and points toward potential strategies to encourage continued diversification. 

These strategies could include employing public scrutiny or idealized social norms to motivate group diversification as an alternative to emphasizing individual behaviors like hiring bias. However, the authors also note several important caveats to their proposed strategies, such as the greater effectiveness of positive attention for high performing groups rather than punitive reinforcements for poor performers. To overcome the tendency to stall diversification once the peer-defined threshold is met, scrutiny should be maintained until more ambitious goals are reached. Relevant social norms should also be shifted from peer group averages (descriptive norms) to ideals (injunctive norms) in order to establish more ambitious diversity targets. 

The authors point to two limitations of this study. First, they only examined the behavior of individuals, and it’s reasonable to expect that group decision-making is more complex. Secondly, it is possible that their findings do not translate to all external settings. The authors also identify several potential areas for further research to extend the current study, including: investigations about ways in which diversity-related norms (including processes for shifting descriptive norms)can hurt rather than help minoritized groups; relevance of these findings for other organizational contexts; the specific psychological mechanisms underlying the effect of descriptive norms and scrutiny; and interventions that decrease the salience of descriptive norms in favor of injunctive norms.

Scientists must recognize social inequality as a foundational ecological concern

Introduction

Cities are important ecosystems shaped by dynamic and interdependent biological, physical and social influences. However, Schell et al. note that few studies link research on urban ecological and evolutionary studies to that of social inequality. They argue it is integral to integrate these disciplines as human-created systems of power create uneven impacts on non-human ecosystems. And, ultimately, unequal distribution of green spaces and “blue spaces,” in addition to harmful practices, impact human health and well-being.

Historic and current social inequality is a particularly significant factor in urban ecology and evolution. Mechanisms of structural racism and classism including redlining and gentrification result from, and sustain, unequal distribution of resources and power. Unequal representation and power in decision-making impact the entirety of urban management, including development, governance, and infrastructure. The physical manifestations of these social inequalities also influence the distribution of biodiversity and evolutionary stressors, which affects the equilibrium of urban plant, animal, and microbe communities. Thus, research on ecological and evolutionary outcomes in urban settings must incorporate a social and environmental justice lens to adequately account for the drivers behind environmental change  and to advance goals of equitable urban conservation and climate resilience. 

Dr. Christopher J. Schell, PhD is an Assistant Professor in the UC Berkeley Department of Environmental Science, Policy, and Management. Dr. Karen Dyson, PhD is an urban ecologist at the University of Washington, the founder and director of Research and Design for Integrated Ecology, and Senior Scientist at Dendrolytics. Dr. Tracy L. Fuentes, PhD is a terrestrial ecologist and botanist and urban plant ecologist at the University of Washington. Dr. Simone Des Roches, PhD is a research scientist  at the University of Washington. Dr. Nyeema C. Harris, PhD is an Associate Professor of Wildlife and Land Conservation at the Yale School of the Environment. Dr. Danica Sterud Miller, PhD is an Associate Professor in the Culture, Arts and Communication division of the School of Interdisciplinary Arts and Sciences at the University of Washington. Dr. Cleo A. Woelfle-Erskine, PhD is an Assistant Professor at the University of Washington School of Marine & Environmental Affairs. Dr. Max R. Lambert, PhD is the Aquatic Research Section Manager at the Washington State Department of Fish & Wildlife.

Methods and Findings

To test several epistemological hypotheses, the authors summarize current cross-disciplinary findings on the socio-ecological implications of wealth disparities in cities, the impact of structural racism on urban structures and ecology, and the need for justice-oriented urban conservation approaches.

One of the key hypotheses is that household and neighborhood wealth – specifically median household income – correlates positively with urban biodiversity. This “luxury effect” is believed to occur because humans with greater resources available for non-essential needs have greater likelihood to facilitate growth and abundance of plant species in their neighborhoods. The luxury effect scales from the household to neighborhood and city level, with wealthier residential neighborhoods generally having more vegetation and canopy cover, plant diversity, and public park spaces than less affluent neighborhoods. Importantly, the distribution of plants within cities is inversely correlated with the concentration of heat and air pollution, resulting in urban heat islands and greater risk of exposure to air pollutants in lower-income neighborhoods. 

Wealth alone, however, does not completely predict urban ecosystem patterns. Structural racism, community norms, and local policies, are also predictors of urban socio-ecological patterns. Residential segregation policies based on racial prejudice, including redlining, have well-documented, measurable, and sustained harmful effects on urban ecological patterns that remain after official policies are dissolved. As a consequence, ecological and evolutionary stressors including heat, pollution exposure, and risk of zoonotic disease spread are not only distributed along economic lines, but also along minoritized racial and ethnic populations. Thus, the authors argue that urban conservation plans need to be tailored to the historical and contextual needs of the impacted communities, rather than applied uniformly across and within cities. 

The authors note that further research is necessary to better articulate the relationship between systemic racism, ecology, and evolution and to capture the intersectional effects of structural racism and classism on evolutionary outcomes. In addition, the authors identify a need to center Black, Indigenous, Latinx, and non-white immigrant communities in ecological and evolutionary research and justice movements due to their disproportionate vulnerability to the climate crisis and environmental exposure risk. These racialized groups experience the duality of environmental harm and social harm in public spaces including state-sanctioned police brutality. In addition, communities of color possess distinct environmental rights and relationships, cultural knowledge, and effective practices for ecological revitalization that have been historically, and detrimentally, excluded from urban environmental decision-making.

Conclusions

Ecologists, biologists, and environmentalists must expand the scope of their research and practice to include a social justice lens. Economic opportunity, public infrastructure, affordable housing, access to healthcare, and voting rights, are all powerful levers for promoting environmental justice, conservation, and local stewardship of urban ecosystems.

Centering social inequity in ecological and evolutionary research also enables equitable distribution of conservation and restoration resources and ultimately, urban biodiversity, according to community need. Researchers have a responsibility to integrate justice into their research process itself. This includes involving local communities in knowledge generation, increasing access to decision making, and eradicating practices of exploitation of community labor to produce academic discourse.

As the urgency of climate change grows, it is more important than ever to actively and radically dismantle systems of racial and economic oppression, within cities and outside their borders. Environmental and evolutionary biology research requires a thorough re-understanding and integration of the social factors impacting ecosystems to advance equitable urban resilience.

To overcome vaccine hesitancy, messaging and expertise matters

Introduction

Despite the demonstrated benefits of preventive medicine, only 45% of American adults typically get a flu shot during flu season. Vaccine hesitancy is particularly common among Black and white lower socioeconomic status men, who don’t trust doctors and are skeptical of the benefits relative to the perceived risk. For Black Americans, this mistrust is further rooted in historical and current medical racism. Given both the disproportionate impact of COVID-19 on disadvantaged communities and the need for mass vaccination, this study seeks to understand what messages will resonate or backfire among these particularly vaccine-hesitant populations and whether messaging alone is enough to induce vaccine uptake.

Previous research has shown that small interventions like prompting patients to write down the date and time of their vaccine appointment and increasing accessibility through on-site clinics at schools and workplaces are effective at increasing vaccination rates. Drawing on these principles, the authors tested whether messaging could improve vaccine uptake among Black and white men without a college education. Specifically, they tested the effect of three key variables: the race and perceived medical expertise of messengers and acknowledging historical medical injustice within the content. This study is particularly timely due to patterns of vaccine hesitancy and disproportionate risk for and impact of COVID-19 on disadvantaged communities.

Dr. Marcella Alsan, MD, PhD, MPH is a Professor of Public Policy at Harvard Kennedy School. Her research applies microeconomics to study health inequality. Dr. Sarah Eichmeyer, PhD, Msc is an Assistant Professor of Economics at the Ludwig-Maximilians University of Munich. Her research interests are at the intersection of public economics and the economics of digitization, particularly the impacts of digital technologies on political polarization, health, and education. 

Methods and Findings

The researchers surveyed 2,893 non-Hispanic Black and white male adults with no college education who had not yet received the flu vaccine during the 2019-2021 flu seasons. Participants were asked about their baseline attitudes and beliefs about the flu vaccine, then randomly assigned to watch videos with one of 10 messengers reading text about vaccine safety and effectiveness. Messages were identical, except some included a mention of historical racial injustices and others did not. Messengers also varied by race and their perceived medical expertise, signaled by their clothing. 

After viewing the video, participants reported their perception of their messenger’s trustworthiness and qualification, perception of the effectiveness and relevance of the message, level of attention they paid to the statement, their belief in the safety of the flu vaccine before and after the statement, interest in free flu shot coupons,  intent on getting the flu vaccine before and after the message, and intent to get the COVID-19 vaccine. Participants then received a trackable coupon for a free flu shot. Finally, participants described their actual vaccine uptake behavior and vaccine safety beliefs in a follow-up survey at least two weeks later. 

Key Findings:

• Black participants rated messenger and message effectiveness higher for Black messengers, but this racial concordance did not affect content recall, safety beliefs, or flu vaccination coupon interest. When white “expert” messengers acknowledged historical medical injustice, Black participants also perceived their message to be more effective and had higher rates of COVID-19 vaccine intent, but not flu vaccine uptake. The race of the messenger had no impact on any of the outcome measures for white participants, but only white participants listening to Black messengers exited the survey without completing the study. 
• Overall, participants who watched videos with “non-expert” messengers rated them substantially less qualified to give medical advice, but remembered more of the message content, were more willing to get the COVID-19 vaccine, and more likely to follow through with actually getting the flu vaccine. White expert messengers had significantly lower flu vaccine uptake and COVID-19 vaccine intent among Black participants, a particularly alarming figure given that 75% of Black patients have a racially discordant doctor.
• Participants’ past vaccine-seeking behaviors also influenced the relative effectiveness of different message interventions. Only Black participants who got a flu vaccine within the last two years were influenced by race concordance and acknowledgment of historical medical injustice. Black participants who never received a flu vaccine rated “non-expert” messengers as significantly more effective.  They also reported substantially higher flu vaccine intent after seeing “non-expert” messengers than those who had a vaccine in the last two years.

Conclusions

These findings provide a roadmap to design effective campaigns and change vaccine beliefs and behaviors among specific demographics. For audiences who previously used vaccines, race concordant and empathetic “experts” are likely the best messengers. However, for audiences that have historically not been vaccinated, peer figures such as community health workers or citizen ambassadors may be the most effective messengers. Based on these findings, an effective vaccine messaging campaign should include messengers from various racial backgrounds and levels of expertise. 

Implicit organizational bias for efficiency impedes mental health care for Latinx and Asian patients

Introduction

BIPOC communities face many structural barriers to accessing mental health care. To reduce this health disparity and better serve multicultural populations, many providers are turning to person-centered care. Person-centered care is intended to improve quality of care by centering the patient’s values, preferences, and goals in collaboratively designed care plans. Although this approach has the potential to improve upon disease-centered models and expert-driven care,  its emphasis on the individual may still create barriers for patients from community-centered cultures. Recognizing the limits of “cultural competence” in improving care, mental health scholars have suggested scrutinizing health provider culture and its relationship to broader structural and sociopolitical issues. 

This study aims to better understand the sources of these barriers to care for Latinx and Asian patient populations by examining shared themes across providers’ descriptions of their encounters. The authors choose to focus on Latinx and Asian patient populations for three key reasons: they represent the two fastest-growing subgroups in the US; they face unique challenges of xenophobia, harassment, and invisibility; and their cultures tend to be more community-centered.

Dr. Miraj U. Desai, PhD is an Instructor at the Program for Recovery and Community Health of the Yale University School of Medicine, Department of Psychiatry. His research interests include cultural, community, anti-racist, and social justice perspectives on mental health. Nadika Paranamana is a Doctoral Candidate in Clinical Psychology at the University of Hartford and a clinical trainee at the Yale University School of Medicine, Street Psychiatry Program. Maria Restrepo-Toro, BNS, MS, is an Educator at the Yale University, Department of Psychiatry, Program for Recovery and Community Health. She is a nationally recognized expert in the field of Latinx psychiatry and the Project Director of the New England Mental Health Technology Transfer Center. Dr. Maria O’Connell, PhD is an Associate Professor of Psychiatry and Director of Research and Evaluation at the Yale Program for Recovery and Community Health. Dr. Larry Davidson, PhD is a Professor of Psychiatry at Yale University, Senior Policy Advisor in the Department of Mental Health and Addiction Services, and Director of the Yale Program for Recovery and Community Health. Dr. Victoria Stanhope, PhD, MSW, MA is an Associate Professor and Director of the PhD Program at New York University Silver School of Social Work. Her professional interests are in mental health services research and policy, with specialization in recovery, person-centered care, and primary and behavioral healthcare integration.

Methods and Findings

Researchers conducted 12 qualitative interviews with providers about their experiences of implementing person-centered care, shared decision-making, and cultural engagement during patient visits. Interview techniques were explicitly designed to elicit participants’ concrete descriptions of their experience, devoid of judgment or opinion about the events. The provider was asked to describe recent work with both a Hispanic or Latinx and an Asian patient, if possible. After collecting and transcribing the interviews, two research team members transformed each interview into a one-page summary of essential moments of the interaction focusing on culture, person-centered care, and social supports. Then, the summaries were reviewed to discover key shared themes and general structures of provider-client engagement. The entire research team reviewed these findings for verification, elaboration, and refinement.

This study found that provider embeddedness in their organizational culture was the primary determinant of care across practice models. Providers implicitly preferred patients who were most aligned with their organization’s clinical norms, thereby making the visit and system run efficiently (e.g., patients who are verbal, admit there is a problem or illness, accept services, are proactive, and are individually oriented). As identified in providers’ own narrations of “noteworthy, challenging, or incongruent” features of care visits with Latinx or Asian patients, this preference became a highly conspicuous determinant of care from the provider perspective. 

Providers revealed an acultural understanding of their purpose as interpreting patient needs and goals to connect patients to a “menu” of mental health services so that patients can learn the skills needed to become “independent” and “empowered.” This prevalent perspective translates into an understanding of cultural competence as a tool for translating their preferred format and mode of care — which they genuinely believe to be best practice — into terms the patient can understand, rather than designing a truly appropriate model of care for culturally diverse BIPOC patients. Some providers are able to recognize and subvert the norms of their field, primarily by drawing on personal experiences of incongruence. However, they may still face friction with their organization’s structures when incorporating alternative practices. 

Conclusions

Provider narratives of interactions with Latinx and Asian patients in a community mental health clinic illustrate that the mental health field’s organizational culture and hidden norms are a major determinant of quality of care and a potential source of institutional bias. Providers’ lack of awareness of their field’s hidden norms — which are often rooted in Euro-American cultural ideals and archetypes — limits their ability to offer “alternative” practices that may better serve their patients, even when those providers believe they are applying a patient-centered approach. In the vast, diverse context of the US, it is critical that mental health professionals unearth their own implicit biases while also taking action to diversify the mental health field’s broader assumptions, structures, and practices.

Provider implicit bias in healthcare settings produces health inequities for Black, Indigenous and people of color

Introduction

Existing research indicates that Black, Indigenous, and people of color have worse health outcomes than white people, including incidence, prevalence, severity of disease at diagnosis, rates of mortality, and lower quality of care, despite efforts to close these gaps. The health disparity gap begins at birth and persists throughout one’s life course. Though these disparate outcomes are evident, their causal mechanism is not yet clearly understood. Based on previous research, the authors suggest that implicit bias among healthcare providers is at least part of the answer.

This systematic review examines the bulk of literature published to date about the role of implicit bias among healthcare providers in racial and ethnic health disparities. In addition, the authors examine interventions intended to reduce bias in healthcare. 

Dr. Ivy W. Maina is a Resident Physician in Otolaryngology at the University of Pennsylvania affiliated hospitals and a Medical Writer for Buoy Health. Tanisha D. Belton is a Clinical Research Project Manager at the Children’s Hospital of Philadelphia. Dr. Sara Palazzo Ginzberg is a General Surgery Resident at the Hospital of the University of Pennsylvania and an Assistant Instructor in Surgery. Dr. Ajit Singh is a primary care provider and Resident at the Philadelphia College of Osteopathic Medicine. Dr. Tiffani J. Johnson is an Attending Physician in the Emergency Department and a Faculty Scholar at PolicyLab at the Children’s Hospital of Philadelphia.

Methods and Findings

The authors used standard protocol for systematic analyses, including defining their search terms: 1) healthcare providers, 2) implicit bias (measured using the Implicit Association Test only), and 3) racial/ethnic prejudice or stereotype activation. Next, they used these terms to search for relevant scientific articles published from 1997 to September 2016 in PubMed, PsycINFO, SCOPUS, and CINAHL. Each article was screened by two reviewers for inclusion into the meta-analysis based on standardized criteria, with a third reviewer resolving any disagreements. Of an initial 6249 articles (4934 after removal of duplicates), 29 studies passed the inclusion criteria and 8 additional studies were included from auto-search results. Two reviewers independently extracted relevant data from each study, including details about the study design, setting, participants, methods, and results, and the reported results were reviewed.

Overall, the 37 studies included 10,013 healthcare provider participants throughout the United States. The authors report four major findings:

Finding 1: Research shows that most healthcare providers — across multiple levels of training and disciplines — have implicit biases against Black, Latinx, Indigenous, and ‘dark skinned patients’ (terminology used by the researchers).

Finding 2: The level of bias differs based on provider characteristics: Black providers generally have little implicit racial bias compared to white, Latinx, and Asian providers.

Finding 3: Research about the impact of implicit bias on patient care and patient outcomes is limited; the authors identified only 7 studies that demonstrate a consistent association between higher provider implicit bias and poorer patient-provider interactions, while the rest report mixed results. Only the studies that examined real world patient-provider interactions, as opposed to simulated patients or clinical vignettes, demonstrated a clear association.

Finding 4: Only two published intervention studies tested methods to reduce implicit bias among healthcare providers, and only one demonstrated success in reducing implicit bias post-intervention.

Conclusions

Implicit bias plays a significant role in the provision of medical services. By examining a wide range of  literature, the authors demonstrate the role of provider implicit bias in healthcare and uncover significant gaps in existing research in both outcomes and reduction strategies.

Despite several limitations based on the studies included, the researchers’ systematic review and meta-analysis found that provider implicit bias contributes to health disparities, congruent with the findings of related studies. Furthermore, the authors suggest that patient-provider communication, particularly under the stresses of real-time interactions, may be the channel through which provider implicit associations lead to lower quality of clinical care and health outcomes.

The authors recommend additional research to uncover the impact of implicit provider bias on healthcare outcomes and to identify strategies to reduce provider implicit bias. Such studies would need to be more nationally representative of a wider base of patients and providers of different racial identities and lived experiences, and of geographic settings. The authors also identify several specific research areas for further exploration, including patient characteristics that impact patient-provider interactions; the impact of providers’ implicit negative stereotypes against Black, Indigenous and patients of color and their prescribed treatments; stress in healthcare provision and other system-level, setting, or specialty characteristics that may impact provider decision-making and implicit bias; how provider bias changes over time with increased clinical experience; the downstream effects of implicit bias on real world patient behavior and clinical outcomes; and successful methods to reduce provider implicit bias and sources of cognitive stress.

Review of healthcare research provides new insight in affirming common themes and findings, as well as gaps for further understanding.

Having a Black doctor statistically reduces mortality risk for Black infants, particularly those with complex cases

Introduction

Prior research has documented that sharing demographic characteristics increases a sense of understanding or empathy between two people. This in-group bias has been found to influence the decisions made by leadership teams, inspection enforcers, teachers, and judges to favor those with shared racial or gender traits (further exasperated by white racial power). Greenwood, Hardeman, Huang, and Sojourner posit that the effect of this racial concordance — a shared racial identity — may exist in medicine; yet, previous studies have been limited and have not sought to demonstrate the effect of racial concordance on actual health outcomes. By looking at the health outcomes of 1.8 million hospital births in Florida over 23 years, this study attempted to bridge this gap. Additionally, by using newborns as a test subject, the authors eliminate a possible confounder: the communication skills of the infant patient.

One of the most significant medical racial disparities in health outcomes concerns Black newborns: Black newborns are more than twice as likely as white newborns to die before their first birthday. Given that all newborns are presumably born at the same level of nonverbal communication, the researchers assert that any differences in health outcomes between racially concordant and racially discordant patient-doctor pairs must involve factors other than the ability of the infant patient to self-advocate or provide additional information. The authors hypothesize that the effect of racial concordance on health outcomes may occur because Black doctors are more aware of the racial and socioeconomic barriers that Black mothers and newborns face, and thus may be better equipped to treat, and more attentive to, their patients’ social determinants of health.

Dr. Brad N. Greenwood is an Associate Professor of Information Systems and Operations Management at George Mason University who researches the intended and unintended effects of innovation on welfare. Dr. Rachel R. Hardeman is a tenured Associate Professor of Health Policy & Management at the University of Minnesota School of Public Health and a reproductive health equity researcher. Dr. Laura Huang is an Associate Professor of Organizational Behavior at Harvard Business School who researches interpersonal relationships and implicit bias in the workplace. Dr. Aaron Sojourner is a labor economist and Associate Professor at the University of Minnesota Carlson School of Management who studies labor-market institutions, early childhood and K-12 education, and behavioral economics.

Methods and Findings

The authors examined data from Florida’s Agency for Healthcare Administration from 1992 to 2015, including information about: mother and child’s race, comorbidities, and outcomes; hospital where birth occurred; and attending doctor’s name, specialty certifications, and date of licensure. The authors then tracked the attending doctor’s race through a public photo search. The authors used statistical analysis to estimate the interaction effect of infant race and doctor race, controlling for insurance providers, comorbidities, and factors related to the quarter and year, specific hospital, and specific doctor. This methodology allowed them to investigate whether a newborn’s mortality risk changed based on their doctor’s race.

The authors note four key findings related to Black infancy and medical care:

Finding 1: Overall, Black infants have three times worse health outcomes than white infants regardless of the doctor’s racial identity. However, compared to Black infants treated by white doctors, Black infants treated by Black doctors have half the mortality risk. When accounting for all controls, racial concordance lowers mortality risk for Black infants by 39%. The gap in mortality risk for Black infants is smaller among board certified pediatricians, regardless of race, compared to non-pediatricians, but the mortality gap persists among Black infants treated by white pediatricians compared to Black pediatricians.

Finding 2: As note, as the number of newborn comorbidities rises (representing more medically complicated cases), Black doctors produce increasingly better health outcomes for their Black newborn patients compared to white doctors.

Finding 3: Hospitals that deliver more Black newborns see an even greater benefit of racially concordant patient-doctor pairs. The mortality risk for Black newborns treated by Black patients is fairly stable across hospitals that deliver more Black newborns and those that deliver few Black newborns. However, the gap in infant mortality risk between Black newborns treated by racially concordant and racially discordant patient-doctor pairs is larger at hospitals that deliver more Black newborns than those that deliver few Black newborns, suggesting this disparity in health outcomes is primarily due to the underperformance of white doctors rather than significantly better performance by Black doctors at hospitals that deliver more Black newborns. The authors also demonstrated in supplementary analysis that white doctors’  underperformance does not differ based on the overall experience that hospitals have in treating newborns, or in treating white newborns, but only in their level of experience in treating Black newborns.

Finding 4: There is no statistically significant effect of patient-doctor racial concordance on the mother’s mortality, but the authors note that Black mothers treated by white doctors experience triple the mortality risk of white mothers treated by white doctors. 

Conclusions

This article highlights the critical inequity in health outcomes for Black mothers and their children, in addition to the significance of Black professionals in healthcare. The authors effectively demonstrate that the Black-white newborn mortality gap is smaller for Black newborns treated by Black doctors than white doctors, and that the benefit of racially concordant newborn care is even greater for Black infants with complex medical conditions.

The researchers’ data indicates why Black families giving birth may prefer to seek care from Black doctors. However, the authors note that because the physician-level workforce in the US is disproportionately white, it is not always possible for a Black newborn to receive care from a Black doctor. 

Additionally, doctor performance varies widely regardless of the doctor’s race. The findings presented highlight the need for additional research to understand the drivers of performance among doctors (and their teams) and why Black doctors outperform their white colleagues when caring for Black newborns. Such findings could be used to improve the care that white doctors offer for Black newborns.

Greenwood, Hardeman, et al.’s  work underscores the need to diversify the physician workforce and for further investment in reducing the effects of institutional racism on health outcomes. The authors also point out the need for education for health professionals about the prevalence and effect of racial and ethnic disparities in health outcomes and the need to include other actors, such as nurses, hospital administrators, and policymakers, in examining organizational policies and processes to reduce racial bias.

Pushing Beyond “Cultural Competency” to “Structural Competency” in Medical Education

Introduction

Medical professionals recognize that physicians must learn both the science of medicine and the art of patient communication. Currently, much of the medical field is focused on the concept of “cultural competency” and “cultural humility.” These concepts have pushed medical education to move beyond “colorblindness” and recognize that social factors, such as race, ethnicity, sexual orientation, and class, impact how patients’ symptoms can present. These factors also play a role in patients’ understanding of illness, health, well-being, cultural stigma, and compliance with treatment. Training on cultural competency and humility are essential to understanding the patient as a whole person. Culturally sensitive, non-judgmental communication, diagnosis, and treatment strategies improve health outcomes and reduce health-related stigma.

Medical professionals also recognize the limitations of “cultural competency.” Health is all-encompassing, with the social determinants of health (social, economic, education, political, and physical systems) impacting a patient’s well being long before they arrive for treatment and after they leave. An individualized approach towards healthcare that focuses only on addressing disease’s biological components is limited in its effectiveness because it does not see or treat the whole patient. Metzl and Hansen argue that doctors need to incorporate learnings from public health, social sciences, and critical race studies in a new approach to training medical students that equips them with an understanding of structural analysis. In their view, structural analysis refers to the language to engage with and communicate about structural impacts on health and propose interventions that address structural factors of care.

Jonathan M. Metzl, MD, Ph.D. is the Frederick B. Rentschler II Professor of Sociology and Medicine, Health, and Society; Director of the Center for Medicine, Health, and Society; and Professor of Psychiatry at Vanderbilt University as well as the Research Director of the Safe Tennessee Project. Helena B. Hansen, MD, Ph.D., is an Associate Professor of Psychiatry of Anthropology at New York University. 

Methods and Findings

This paper advances the idea of  “structural competency” and theorizes that structural competency should be incorporated into medical curricula. The authors draw from social science to guide their thinking. 

Metzl and Hansen propose five core competencies that a structural competency curriculum should prepare medical students to achieve. These are:

1. Recognizing the structures that shape clinical interactions: introducing an understanding of the broader socio-political, economic, and physical contexts that influence the healthcare system from the macro-level (e.g., decisions about insurance or drug pricing) to the micro-level (e.g., interpersonal interactions with patients)
2. Developing an extra-clinical language of structure: creating a more interdisciplinary, social science-based curriculum that trains students to understand the impact of social structures on biology and to engage with the complex broader contexts of individual patients and cases.
3. Rearticulating ‘cultural’ formulations in structural terms: connecting the useful pieces of “cultural competency” that inform patient interaction practices to reduce stigma with a structural understanding of the contexts that create and sustain that stigma.
4. Observing and imagining structural interventions: connecting training to the real world and empowering students to learn how they could change the structures influencing health.
5. Developing “structural humility”: training students to embrace humility and recognize that their role is to be continually learning and listening in addition to speaking and leading.

Conclusions

A medical curriculum that incorporates each of these components would prepare future physicians to understand and recognize the structural forces that impact their patients’ health. Further, it would train medical students with the skills they need to use language from across disciplines to communicate and think about the impact of structural forces. At the same time, it would prepare medical students to apply this structural knowledge to design health interventions and to recognize the limits of this approach. In essence, this would allow physicians to engage with the full complexity of health and illness and recognize when they need to bring in additional experts to advise on care. This curriculum also prepares physicians to step into the expanded and increasingly important non-clinical public health role. Finally, by shifting the focus of clinical treatment from individuals to addressing structures, infrastructure, and contexts, structural competency allows medicine to adopt a framework that would enable the field to engage in antiracist practices, both within medicine and in addressing the social determinants of health.

Structural racism is a barrier to leadership advancement in nonprofit organizations

Although the nonprofit sector is recognizing its own need for greater diversity, equity, and inclusion (DEI), the implementation of DEI strategies generally stops at the interpersonal level and few nonprofits have addressed the structures and systems that keep these racialized barriers in place.

Introduction

Four years ago, the Building Movement Project (BMP) studied the racial make-up of nonprofit leaders across the country to understand why so few people of color hold leadership roles in nonprofits. In that initial Race to Lead report, BMP found people of color were similarly qualified as their white counterparts and were even more likely than their white counterparts to aspire to leadership. They concluded that the lack of diversity among nonprofit leaders is the racialized barriers to these opportunities, including executive officers and executive recruiters’ biases. 

BMP has found that these challenges persist. Although organizations have embraced Diversity, Equity, and Inclusion (DEI) efforts to some degree in their external practices, this has not translated to an evaluation of their internal procedures. While there is a greater understanding of racism and recognition of persistent racial barriers within the sector, DEI efforts have generally been limited to training. There is little change in power, workplace experiences, or career advancement among staff members of color. The authors also compare organizations led by people of color with those led by white people. In this comparison, they find that staff of color reports more equitable treatment, and all staff reports better workplace experiences in organizations led by people of color. This comparison also showed that organizations led by white people are more likely to have large organizational budgets, which also translates into a greater likelihood of staff receiving bonuses and raises. Thus, within organizations and across the sector, organizational structures continue to systematically reinforce whiteness’s benefits in what the authors termed “white advantage.” These findings are especially significant in the context of the economic recession due to the COVID-19 pandemic, where layoffs and budget contractions provide an opportunity to either continue to devalue staff of color as expendable or shift the structural dynamics of power within their organizations.

The Building Movement Project (BMP) is dedicated to researching, training, and pushing the nonprofit sector on ways to promote social change. BMP is composed of staff with deep ties to the nonprofit community. They leverage their understanding of and connections within the sector to support organizations in developing the vision, leadership, and capacity to advance diversity, equity, and inclusion. Frances Kunreuther is a Co-Director of the BMP and works, teaches, and writes on leadership issues within the nonprofit sector. Sean Thomas-Breitfeld is a Co-Director of the BMP and previously worked at Community Change to support their training, coordination, and advocacy efforts. 

Methods and Findings

The BMP conducted a nationwide online survey in the summer of 2019. They distributed the survey among the BMP’s online newsletter list of almost 10,000 people through partner organizations’ outreach, and social media, including Facebook, Instagram, Linkedin, and Twitter, resulting in a convenience sample. The survey was open for eight weeks, and more than 8,000 individuals started the study, of which 5,261 completed responses were included in the final evaluation. The BMP then supplemented survey data through focus groups in Albuquerque, Austin, Boston, Detroit, Memphis, and Milwaukee during the fall of 2019 and early 2020. They asked about respondents’ personal and financial backgrounds, career plans and career supports, their perceptions and experiences of race and ethnicity in the nonprofit sector, and their experiences with DEI activities. 

Upon completing the survey, the researchers found three key findings, each of which is summarized below: 

Key Finding 1: There are few people of color at top leadership positions in nonprofit organizations, but greater interest among the non-CEO staff of color in taking a top leadership position than their white counterparts. People of color are similarly qualified as their white counterparts and experience racial barriers to career advancement, including less workplace career supports. Career-related gaps among people of color and whites remained the same or increased compared to 2016, including access to career support, frustrations about their jobs, and perceptions of reasons for the leadership gap. An analysis considering both race and gender showed that women of color and gender non-conforming people of color were the least likely to have internal workplace mentors.

Key Finding 2: White-led organizations systematically create environments that only enable white staff to thrive, from the culture to compensation to hiring. Its leadership’s racial composition impacts even the size of an organization’s budget. Despite the structural racism that keeps the policies, processes, and protocols that privilege white workers in place, more than half (64%) of nonprofit organizations serve constituents with at least 50% people of color. Among organizations led by more than 50% of people of color on the board of directors and top staff leaders, all staff reports better workplace experiences. In these organizations, the gap in experiences between white staff and people of color staff is also smaller. 

Key Finding 3: More organizations are embracing Diversity, Equity, and Inclusion (DEI) efforts. However, these efforts only show up in the form of staff training, and many staff members don’t believe that these efforts are effective or that their organizations are truly committed to DEI. This is particularly true at white-led organizations and notably reported by the staff of color at these white-led organizations. Although the vast majority of respondents agree that it is a problem that leadership within the nonprofit sector does not represent the racial/ethnic diversity of the US, much fewer white staff recognize that decision-makers in the nonprofit sector don’t have the will to make changes to improve DEI. Staff members of color and their white counterparts also have different opinions about the effectiveness and feasibility of efforts to increase and support the leadership of people of color in the nonprofit sector. The authors connect this data with the observation from outside sources that the philanthropy that supports nonprofits systematically under-invest in people of color-led organizations at such blatant rates that some advocates describe this phenomenon as “philanthropic redlining.”

Conclusions

This report’s data reaffirms the need to address racism at the individual, organizational, and sectoral levels, involving internal and external changes. It recognizes that the sector has made some progress in understanding DEI’s importance, affirming that racism impacts their work, and is beginning to change culture and behavior. However, most of the racial gaps surveyed, particularly around intangible experiences and career support, remained the same or widened from 2016 to 2019. The report also finds this work stalls and delays by only training white people to think about DEI without continuing to the concrete work of dismantling the explicit policies and informal processes that keep power in white people’s hands. The authors point to expanding the voices and experiences that determine how the nonprofit sector operates as a way forward.

They recommend the following:

• Create a cohort of like-minded organizations to learn and collaborate; share learnings and challenges; provide feedback and accountability, and support each other and celebrate accomplishments.
• Aim to tackle both the structures and culture of race and racism. Connect a structural, historical analysis of race and racism with validating the individual and collective experiences of people of color.
• Enforcement and implementation of policies are just as important as the design of the policy. Revised policies and processes will only be effective at creating change if they are consistently and universally applied. This also means that organizations should develop explicit policies that provide accountability for unwanted behavior and reinforce models of wanted behavior.
• Fund organizations led by people of color.
• Diversifying staff and leadership is essential, but diversification needs to be explicitly supported with resources, from recruitment to retention to incorporating their recommendations for continued change. Diversification must be an active process with explicit targets that aim to ensure that leadership reflects constituents’ racial demographics. The voices of new hires should be heard and valued. 
• DEI requires continuous investment in measurement, assessment, and accountability to ensure concrete change. The change plan needs to be widely and transparently communicated throughout the organization. It should explicitly detail who is responsible, what should change, and how the organization will know that it has changed. This plan should be updated at predetermined intervals (e.g., every year).

This report emphasizes the importance of taking on structural changes to counter the significant challenges of the global COVID-19 pandemic and the accompanying recession. Implementing structural change would also respond to the growing attention to the movement for justice for Black people, to ensure that structural racism does not become further entrenched. The report also notes that although organizational and sectoral change is challenging, it could be expedited if organizations directly address the underlying societal structures that entrench racism across the United States.