A Rubric to Center Health Equity in Research

What is so important about a rubric? We are familiar with competencies, milestones, benchmarks, and metrics as these terms are ubiquitous to health care clinical and learning environments. Simply put, a rubric is a tool or guide used to assess performance. A thoughtful rubric should start with a clear, meaningful goal at the forefront. It should be used to align expectations, measure skills, foster reflection, and improve opportunity for correction and less-biased feedback. Further, the best rubrics are intermittently updated based on how well they serve their intended purpose. With Accreditation Council for Graduate Medical Education (ACGME) changes to program requirements for family medicine residency programs enacted in July 2023 many are creating or revamping curricula that will include a rubric for evaluators and learners to understand when objectives are met. ¹

Often in spaces of diversity, equity, inclusion (DEI), antiracism, and social justice work, meaningful goals are made, and issues of disparity and inequity are importantly described. Yet, a goal without a plan is just a wish. Tangible interventions may be slow or lacking altogether, as those most impacted and their allies, struggle to access resources of support and to have a shared framework for assessing initiatives and move goals forward strategically. Without a clear plan and rubric, DEI efforts may be overly critiqued or dismissed due to limited understanding or bias, or conversely, can be implemented prior to genuine evaluation, resulting in harm or being perceived as performative without true impact.

In the article “Evaluation of Family Medicine Residency Programs for Diversity, Equity, and Inclusion Milestones,” Dr Wheat and colleagues importantly start with a goal of measuring DEI initiatives in curriculum development; resident evaluation; faculty and resident recruitment, mentorship, and retention; and in overarching institutional DEI efforts across family medicine residency programs. ² The article provides a rubric developed by the Association of Family Medicine Residency Directors’ Diversity and Health Equity Task Force for programs to conceptualize, design, and assess strengths and opportunities across DEI domains.

Like ACGME initiatives to address DEI needs, medical journals have noted inequities in editorial processes and have stated goals to advance efforts toward inclusion and antiracism. ^{3, 4} In October 2023, The Green Journal of Obstetrics and Gynecology published a special issue, “Racism in Reproductive Health: Lighting a Path to Health Equity.” This issue was spearheaded by the efforts of Dr Ebony Carter, associate editor, equity, and a steering committee that included disciplinary thought leaders in reproductive health and health equity. The goal of the special issue? “Publication of an entire issue devoted to addressing issues of racism in reproductive health.” ⁵ To this goal, the steering committee collaborated to create a rubric to center equity in obstetrics and gynecology research. This rubric provides “a tool to help researchers systematically center health equity as they conceptualize, design, analyze, interpret, and evaluate research in obstetrics and gynecology.” Authors highlight the utility for scholars, peer reviewers, and editorial teams to use this rubric as a tool and resource, but not a scorecard, to center racial health equity across academic journals. ⁶

Some features of this rubric include:

• A positionality statement allowing scholars to reflect how research questions are formulated and consider personal and team biases. This statement does not simply cite race, ethnicity, or gender but may include layers of intersectionality. It may also provide transparency for readers to understand authors’ perspective and closeness to their work. Sample positionality statements are included in the commentary appendix.

• An introduction centering on equity and considering the domains of influence at play that impact health. Authors reference the National Institute on Minority Health and Health Disparities Research Framework that provides a graphic of the complex nature of these domains and the varied levels of influence in society. ⁷

• The methods should include any engagement of community partners or patient representatives, and how that helped inform or guide research. Further, how and why race, ethnicity, and gender are reported, and the strategy for recruitment should be included and not assumed inherent to every study.

• The results should avoid framing findings in a way that may perpetuate racism and bias.

• As with the introduction, the discussion section should promote health equity and avoid genetic explanations unless such genetic work was clearly imbedded in the study. As race is a social construct, it should not be used as a risk factor but instead exposure to racism if disparities are found.

• Terminology should be inclusive and person-first, following AMA Manual of Style recommendations of capitalizing race and ethnicity, used in adjectival form. An exception is often made in context where capitalization may be perceived as inflammatory (eg, “white supremacy”). ⁸

• “Centering the Margins” is a caution to avoid centering White perspectives and experiences as the standard by which everything else is compared. Authors reaffirm the importance of creating diverse scholar teams including interdisciplinarity, as this may decrease bias and add valuable perspectives.

• Lastly the bibliography and resources should display intentional inclusivity, seeking to include work from marginalized voices and communities when available.

These concepts and more are regularly included in the editorial team conversations at Family Medicine. As we continually work toward our goal of centering health equity and inclusion in our editorial processes, such a rubric is another useful tool for authors, reviewers, and readers to reflect on as we consider opportunities for improvement in our clinical and academic roles and certainly in our scholarly endeavors.