Abstract
Advancing the health of all members of the global community remains core to the mission of the infectious diseases profession. Training, research, healthcare-delivery, and other infectious diseases–related institutions play a central role in meeting this goal. The promotion of inclusion, diversity, access, and equity (IDA&E) is critical to harnessing the full range of human creativity, innovation, and talent necessary to realizing the education, research, patient care, and service missions that constitute the principal objectives of such institutions. Strong and positive institutional cultures and climates are essential to achieving these IDA&E goals. We discuss opportunity gaps that exist in leveraging institutional culture and climate to optimize IDA&E. We further identify effective strategies to address these gaps and achieve excellence in education, research, patient care, and service in infectious diseases and the broader healthcare and biomedical space. We discuss the importance of both local and global context in conceptualizing IDA&E to best achieve these aims.
Fostering inclusive, diverse, accessible, and equitable environments in training, research, and healthcare-delivery institutions is critical to achieving the core mission of the global infectious diseases community: to advance the health of individuals and societies across the world. Inclusion, diversity, access, and equity (IDA&E) goals can, in turn, only be attained when the institutional culture and climate are sufficiently aligned to ensure that IDA&E goals are fully integrated and embedded within an institution’s core mission. Institutional culture is defined as the shared values, beliefs, and customs that shape how individuals behave within an institution [1, 2]. Institutional climate can be defined as the perceptions and meanings attached to processes, policies, and practices that individuals experience in the institution [2]. Institutional culture and institutional climate are complementary constructs that shape the ability of organizations to achieve institutional goals. In this article, we assert the critical importance of developing and sustaining a strong and positive institutional culture and climate to promote IDA&E at all institutional levels. We further put forward strategies that can be put in practice to enhance institutional culture and climate to effectively advance IDA&E for all within the infectious diseases community, especially as these affect training and career pathways, promotion of biomedical research, and patient care and services globally (Figure 1).
Promotion of inclusion, diversity, access, and equity (IDA&E) through enhanced institutional culture and climate. Key drivers for building an exceptional, diverse, and inclusive community to achieve excellence in education, research, patient care, and service within both local and global contexts involve (1) institutional commitment to a mission of inclusive excellence; (2) promotion of a diverse, accessible, and supportive climate; (3) leadership and innovation around principles of IDA&E; (4) community engagement and intrainstitutional and interinstitutional partnerships with relevant stakeholders; and (5) ongoing data evaluation to inform programs, policies, and processes.
ACHIEVING A STRONG AND POSITIVE INSTITUTIONAL CULTURE AND CLIMATE
Research to date suggests multiple factors that can facilitate positive culture and climate within institutions [3–5]. Key among these are an institution’s expression of identity and purpose, how this purpose is communicated to members and informed by institutional stakeholders, the nature and depth of resources allocated to the institution’s purpose and goals, leadership and advocacy processes to drive institutional goals, and data-driven accountability measures to inform progress toward these goals. Data show that institutional culture and climate are strengthened and enhanced when there is a clear expression of an institution’s strategic vision; institutional communication networks are dense and robust; resources are strategically allocated and aligned to institutional mission; members’ retention within the institution is high; and there is strong member identification with the goals and aspirations of the institution, fostering a strong sense of belonging [2]. In sum, an informed vision, strong communication of mission, effective and directed targeting of resources in alignment with that mission, optimal recruitment and retention of talent to convert institutional mission into action, and data-driven processes to inform such action are central to promoting a positive institutional culture and climate that can successfully drive institutional goals.
Implicit in the cultivation of a strong and positive institutional culture and climate is the recognition that a diverse institution by definition does not have a monolithic culture or single perception of climate that is totally embraced and shared by all members of the institution. Subcultures often exist that reflect the vast array of constituent members’ identities [2, 6, 7]. In this regard, both positive and negative perceptions of climate can occur in the same space and across the same domains—embedded in the histories, legacies, and current experiential base of institutional members. Institutional members may have different experiences or ascribe divergent meanings to the same events that differentially shape their perceptions of institutional climate. Thus, the diverse histories and lived experiences of both current and prospective institutional members should be considered for these voices to be included in defining and operationalizing institutional vision and mission.
CATALYTIC EFFECT OF CULTURE AND CLIMATE ON IDA&E GOALS
There is strong empirical data indicating that attention to institutional culture and climate is central to the successful promotion of the inclusive, diverse, accessible, and equitable institutional environment necessary to realize excellence in patient care, education, research, and service [8, 9]. Effective and equitable healthcare delivery relies on the presence of diverse members across all sectors who can provide essential services and drive new discoveries to address health issues across the globe. The recruitment and retention of individuals from different backgrounds and experiences who are available to fulfill an institution’s core mission and goals can be amplified through a positive institutional culture and climate that clearly value and concretely promote IDA&E goals [2]. This catalytic effect of culture and climate on IDA&E goals is mediated by both structural diversity (ie, the breadth and depth of representation of members of related communities within the institution) and interactional diversity (ie, the quality and quantity of interactions of diverse members and the depth/breath and exchange of distinct ideas) [10].
Several effective practices have been identified that institutions can implement to transform culture and climate conditions that facilitate IDA&E goals: (1) a clearly written and widely disseminated statement delineating institutional recognition and affirmation of IDA&E as core to the mission, (2) systematic assessment of institutional culture and climate related to IDA&E goals across diverse constituent groups, (3) effective institutional training programs to enhance member self-efficacy in IDA&E domains, (4) clearly communicated accountability expectations regarding IDA&E goals for all members of the institution at all levels of leadership and membership, (5) transparent and regular dissemination of core measures of progress made in IDA&E goals shared with institutional members and external stakeholders/communities, and (6) visible rewards and celebration of achievements in fulfilling IDA&E goals within the institution [1, 11–13].
Additional practices that could significantly positively impact IDA&E-related elements of institutional culture and climate include (1) strongly articulating a positive institutional tone around the critical importance of IDA&E in attracting prospective members to the institution, especially through active outreach and engagement; (2) creating and promoting welcoming activities that facilitate seamless entry of new members into the institutional environment; (3) ensuring that diverse members, particularly those who may identify with groups who are underrepresented within the institution or its related communities, are empowered to have a voice in and meaningfully contribute to the leadership and direction of the institution; and (4) using structured institutional activities, such as mentoring programs, to support diverse individuals across different careers in infectious diseases–related academic and nonacademic environments [14].
For these practices to be effective, an institution must have strong organizational leadership at the very top to drive these efforts forward and ensure that IDA&E goals are being met. The dedication of adequate financial, human capital, and other infrastructure resources, as well as a long-term commitment to these IDA&E goals, are critical to the success of these efforts. There must also be an appreciation of the breadth and multifaceted nature of diversity across different institutional contexts, as well as recognition of the potential multiple identities with which any one institutional member may identify [7, 10]. These are essential investments that institutions need to make to create an inclusive and diverse environment that provides equitable opportunity pathways for current and future prospective institutional members.
ADDRESSING GAPS IN EDUCATIONAL OPPORTUNITY, TRAINING, AND CAREER PATHWAYS
In recent years, significant attention has been paid to the cascade of care that characterizes chronic HIV infection and other chronic diseases and to the critical opportunity gaps that exist for improved prevention and better management of these conditions at each step of the cascade [15].
Along the educational trajectory, a similar cascade of diminished opportunity exists that often falls short of the ultimate desired goal to maximize educational opportunity and human potential of individuals across the full breadth of our diverse existence. There continues to be tremendous leakage along the training pipeline, with loss of opportunity to maximally capture human talent and capital that could be directed to more optimally improve the health of and other key imperatives for our societies [16]. The result has been persistent disparities in educational opportunity across multiple identities and across multiple training pathways.
As studies have shown, the consequence of disparities in this leaky educational pipeline is diminished opportunity for optimal learning, skills development, and maximal intellectual engagement for all learners/trainees [17, 18]. In turn, this can lead to the reduced capacity of healthcare providers to deliver the most culturally competent care to the diverse communities they serve. Such disparities have long been evident in the pathway to academic medicine, with opportunity gaps that extend from preprofessional and professional training institutions and pathways all the way through to the ranks of academic faculty. Maximally optimizing healthcare delivery requires enhanced institutional efforts to ensure that trainees in the health professions educational pipeline reflect in membership the breadth and depth of the diverse communities they serve.
Preprofessional Training
Lack of student exposure to the health professions and limited preparation/skill-building opportunities are some of the challenges identified in the preprofessional training space as factors limiting the entry of students from diverse backgrounds into health professions careers, including infectious diseases [19, 20]. However, there is significant evidence in the literature documenting the success of institutional pipeline programs in countering these challenges, helping to reduce opportunity gaps and enhance IDA&E in health-related careers [11, 21, 22]. These programs provide opportunities for academic skills training; immersion experiences that provide exposure to healthcare environments and enhanced interactions with healthcare communities, in ways that can significantly impact individual motivation to pursue a health professions career; and dedicated health career–directed mentorship, advising, and sponsorship opportunities that promote successful navigation and advancement along the health career pathway. Additional evidence demonstrates that alumni of such pipeline programs are more likely to provide health care to the most vulnerable and underserved communities, thus enhancing service to these key populations [23].
Health Professions Training
Despite some progress over recent decades in enrollment and inclusion of students from diverse backgrounds in health professional training environments, gains have been minimal to none for several groups that have been historically underrepresented in the health professions relative to their overall community representation [24]. Institutional culture and climate continue to play a pivotal role in such trends. A critical mass of individuals from diverse backgrounds is essential to creating an educational environment that fully embraces the principles of IDA&E in society [11, 25]. The seminal 2004 National Academy of Sciences report on diversity in the healthcare workforce identified essential strategies to improve IDA&E in the healthcare professions [18]. These include the use of a comprehensive and holistic approach to health professions schools admissions review processes; diverse representation among admissions reviewers; reducing financial barriers to participation; integration of IDA&E goals as a core measure in institutional accreditation processes; and improving institutional climate related to IDA&E. Institutional climate around IDA&E could be improved through intentional recruitment programs, interinstitutional partnerships to reduce opportunity gaps, and ongoing support for academic enrichment and mentoring throughout the training process [26, 27].
Academic Faculty and IDA&E
An academic faculty that represents the diverse membership of institution-related communities and societies can play a pivotal role in achieving success in IDA&E. A diverse academic faculty can enhance IDA&E success through enhanced intrainstitutional culture and climate and broader development and maintenance of culturally informed institutional relationships and contributions to the larger community and society in which the institution resides within the larger healthcare and related space. Significant empirical data indicate that enhanced institutional culture and climate is key to efforts to improve IDA&E among faculty in academic medicine [13, 28–31]. Despite this recognition, promoting IDA&E among academic faculty has been a persistent challenge [32–36]. This reflects in part the significant leakage across the educational training continuum in disparate ways, which some data suggest is steeper at the point of transition into academic faculty ranks, the pinnacle of this pathway [37]. Several studies have shown that changes that promote a more positive institutional culture and climate are necessary to make significant progress in IDA&E goals related to faculty [29, 38–40]. These changes include ongoing focus on diversity of the health professions pipeline, intentional institutional recruitment efforts, and promoting a positive institutional culture and climate informed through evidence-based strategies.
There has been a notable body of research on evidence-based initiatives to enhance institutional culture and climate to promote IDA&E among academic faculty [28, 31, 41–45]. Successful evidence-based strategies have included programs and policies that increase trust in institutional leadership around IDA&E components through the systematic establishment of the following: (1) enhancing formal and informal networking opportunities for faculty, including those with identities underrepresented in the community; (2) increasing institutional structural and program support for faculty from communities underrepresented in the institution/higher academic ranks; (3) strategically deploying institutional resources (eg, funds to departments with clear and data-informed diversity recruitment plans); (4) providing institutional mentoring resources for faculty, including targeted programs for underrepresented faculty; (5) providing structured professional and career development training opportunities for all faculty; (6) promoting a positive work-life balance (eg, access to childcare resources, a flexible work schedule, and health and wellness programs); (7) providing access to and support from senior faculty mentors; (8) securing a network of mentors with diverse academic expertise, rank, and background; (9) promoting equity in the promotion process; (10) ensuring transparency and equity in compensation; (11) promoting diversity among members of academic search committees; and (12) providing support for rigorous scholarship on mechanisms to advance IDA&E. Such institutional programs and policies have been shown to improve perceptions of and satisfaction with institutional culture and climate, to improve structural diversity, and to enhance success in promotion and career satisfaction.
Overarching and more-comprehensive programs and policies instituted by grant funding agencies, professional societies, and accreditation programs can also significantly influence institutional culture and climate to enhance IDA&E at the academic faculty level [37, 46]. Ultimately, careful attention to both institutional culture and climate at baseline and through ongoing periodic assessments can significantly enhance IDA&E among the academic faculty ranks.
ACHIEVING EXCELLENCE IN BIOMEDICAL RESEARCH
Biomedical research continues to lie at the core of advances in clinical care, certainly in infectious diseases. Notable evidence has shown that a biomedical research workforce that is fully inclusive and representative of the diverse members of its related community and society enhances creativity and innovation and is ultimately key to promoting the best science [37, 47–49]. Historically, the pathway to an inclusive and diverse biomedical research workforce also has been adversely influenced by disparate cascades of diminished educational opportunities from preschool through to the graduate training level, particularly as it relates to training in science, technology, engineering, and mathematics (STEM) fields [37, 50, 51]. The limited participation in STEM training institutions by individuals from diverse backgrounds represents significant missed opportunities to harness the full intellectual capital necessary to advance the biomedical research enterprise.
Training institutions have a key role to play in addressing these marked opportunity gaps along this educational continuum. The culture and climate of such institutions can significantly affect opportunities for core knowledge acquisition, skill building, experiential biomedical research exposure, motivation for and self-identification with the biomedical research field, and awareness of the requirements and opportunities to successfully navigate the pathway to a biomedical research career. These elements have been viewed as critically important for successful persistence in the biomedical research training pathway [52]. Data show that targeted institutional investments, both programmatic and infrastructural investments that address these key elements, can significantly enhance IDA&E in biomedical research. These investments include rich and intensive hands-on research exposure; opportunities for peer-to-peer social support; strong role-modeling, mentorship, and sponsorship structures; opportunities for networking and professional development; and facilitation of successful training transition points [14, 53, 54]. Interinstitutional partnerships have been particularly important facilitators of such efforts [11]. The success of such investments has been evident in the increased representation of historically underrepresented groups in the biomedical research training ranks through the graduate training level in US institutions [37]. However, additional work is needed, both in the biomedical research training ranks and in the posttraining biomedical research workforce itself [55–57].
It is important to recognize that biomedical research and healthcare delivery occur in both academic and nonacademic settings. Many of the practices articulated above can be applied to nonacademic institutions, which are equally important stakeholders in promoting IDA&E in healthcare and science environments. Further, given that healthcare and biomedical research professionals in nonacademic institutions pass through academic training environments at some stage (and that the experiences, opportunities, and skills they attained in the training environment can fundamentally influence operations in future professional life), the culture and climate for IDA&E in training environments can have enduring effects on nonacademic institutions, as well.
ACHIEVING EXCELLENCE IN PATIENT CARE AND SERVICE
Health equity has been defined as the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance [58]. Health equity remains a fundamental goal of patient care and healthcare service delivery institutions [59]. While achieving health equity requires larger societal interventions, institutions can still play a significant role in efforts to achieve equitable patient care and healthcare service delivery. Data show that an inclusive and diverse health professional workforce can significantly advance efforts to achieve health equity through mechanisms that include (1) increased access to care for the most vulnerable and underserved populations and (2) better quality of care through delivery of more culturally informed and more culturally competent care to patients in the communities served across multiple identities [4, 18, 60–63]. In the context of research, an inclusive and diverse biomedical research workforce can expand the healthcare research agenda in ways that could lead to enhanced evidence-based strategies to alleviate the effects of or intervene upon the determinants of health inequity [57, 64].
Research-based institutions that promote institutional cultures and climates that intentionally enhance IDA&E goals can also play an important role in advancing health equity by providing an environment in which such work can flourish, attracting and supporting diverse talent with the distinct skill sets and experiences necessary to synergistically advance this research agenda, and cultivating long-term relationships with surrounding communities that build trust and that can be leveraged to optimally inform the research itself.
In striving to promote health equity, institutional partnerships with their communities should extend beyond direct patient care or engagement in biomedical research. Institutions should also promote inclusive practices that facilitate a community’s capacity to shape their own health outcomes [65–67].
PROMOTING A GLOBAL PERSPECTIVE OF IDA&E ACROSS INSTITUTIONS
The infectious diseases community, the constituency it serves, and the conditions it treats are all global in nature. Consequently, applying the principles of IDA&E to achieve excellence in education, research, patient care, and service needs to be considered in a global context [68, 69]. Optimal approaches to promoting IDA&E may vary across different cultures, climates, and settings, with particular attention to (1) definitions of individual identity—that is, both how an individual self-identifies and how they may be perceived within a specific community—may shift across settings; (2) institutional cultures and climates themselves may be influenced by the culture and climate of the communities and societies within which these institutions reside; and (3) an institution’s understanding of the specific identities that constitute both the institution and its related community, as well as its appreciation for the specific societal framework in which its members operate, is essential to best inform effective, tailored, institutionally defined approaches to IDA&E.
While the challenges and opportunities related to IDA&E may diverge across the globe, many of the aforementioned principles relative to institutions and IDA&E cut across geographical boundaries, including (1) institutional focus on maximizing access to educational and career development opportunities across the life course in a manner that promotes an inclusive and diverse healthcare and biomedical workforce that reflects the communities being served, (2) a research agenda that is informed by and reflective of the diverse array of healthcare needs of community members and that seeks to maximally capture the intellectual talent across the multiple identities that constitute the community, and (3) pursuing patient care and service that is sensitive to the histories, legacies, identities, and diverse life experiences within the community.
In reflecting further on IDA&E goals of the infectious diseases community as being global in scope, additional consideration should be given to (1) developing enhanced opportunities for training the global infectious diseases workforce, particularly for persons from communities/regions with fewer resources and disproportionate impact by the infectious disease conditions we treat, who remain underrepresented in the training and professional ranks; (2) ensuring that the infectious diseases biomedical research community includes and reflects the global constituency it serves, not only as research participants but also as equivalent partners in research investigation—this is a moral imperative and is essential to promoting more contextually informed and thus better research; and (3) helping further advance access to care and healthcare equity across the global space.
Ensuring that diverse and representative voices are at the table in these discussions at a global level will be critical to advancing these efforts, with a clear focus on the communities the infectious diseases community seeks to serve.
CONCLUSION
For the infectious diseases community to fully maximize its contribution to advance the health of the diverse communities it serves, it is essential to effectively capture the breadth and depth of human talent that exist across the global space. Training, research, and healthcare-delivery institutions can all play a key role in realizing this goal. The arc of the educational training trajectory may be long, but there are multiple opportunities along this path to harness successfully the diverse experiences, perspectives, and skills necessary to optimally tackle the most intransigent clinical and research challenges in infectious diseases and the larger healthcare community. Creating opportunities and enhancing the capacity for persons of all identities and aspirations to maximally contribute and achieve will be key to current and future success in reducing the human and societal toll from infectious diseases. However, we must create the environments and conditions that allow such diverse talent to thrive. Institutions enabled by cultures and climates that reflect commitment to IDA&E could significantly advance this cause. Ultimately, as institutions strive toward a future with IDA&E as core guiding principles, it is critical to understand who has access and who does not, who has opportunity and who does not, and the significant imperative to close these access and opportunity gaps to achieve excellence in education, research, patient care, and service across the globe. Training, research, and healthcare-delivery institutions will continue to have a critical role to play in advancing these efforts.
Notes
Supplement sponsorship. This supplement is sponsored by the Infectious Diseases Society of America.
Potential conflicts of interest. Both authors: No reported conflicts.
Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
