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Scholarly Perspectives

Advancing Social Mission Research: A Call to Action

Erikson, Clese MPAff1; Ziemann, Margaret MPH2

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doi: 10.1097/ACM.0000000000004427
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Abstract

Health professions schools are increasingly interested in adopting policies, programming, pedagogy—and in some cases founding philosophies—that reflect a social mission to advance health equity and address the health disparities of the society in which they exist. 1 Schools may demonstrate their social mission in a variety of ways, ranging from their mission statements to curricular design to diversity efforts. 2 Forces external to educational institutions, including federal initiatives, community-sponsored efforts, and accreditation standards, also play a role in shaping the social mission of health professions education by funding workforce training programs, 3,4 providing a pathway for prospective health professions students and training opportunities to work with the medically underserved, 5 and establishing standards that contribute to the production of health professionals primed to meet the needs of society. 6

These efforts have been gaining traction for years, but one could argue that they have reached an inflection point as COVID-19 lays bare the stark health disparities endemic in the United States, 7 calls from students grow for health professions schools to take a more active role in acknowledging and dismantling systemic racism, 8 and emerging research shows backward movement in racial and ethnic diversity in some health professions. 9 Additionally, health professional shortage areas persist, and an insufficient health workforce in rural areas has led to hospitals being overwhelmed during COVID-19, yet the number of medical students from rural backgrounds is declining. 10 Understanding what works in health professions education to address these challenges and to advance health equity is therefore a critical area of reflection and reforms for academic, funding, regulatory, and policy initiatives.

Social mission research focuses on the contribution of health professions training programs to advancing health equity and addressing the health disparities in our society. 11 Given the exigencies of our current times and the incredible potential for social mission to directly affect health equity, now is the time for all key stakeholders to engage in a joint and coordinated, full-force effort to advance social mission research. Health systems, providers, governments, foundations, professional associations, and accrediting bodies as well as health professions schools, students, and communities directly affected by health disparities all have something to gain and something to contribute in this pursuit. With leadership from an organizing body to convene and harness the collective power of this fully engaged community of stakeholders, we can eliminate critical gaps in social mission research and leap forward in our ability to identify the policies and programs that are most effective at producing a health workforce that is prepared and motivated to advance health equity. In this article, we explore ways to accelerate social mission research and propose a road map to activate stakeholders and to ensure we have the resources, data, and methods to fully assess the role of health professions education in advancing health equity.

Existing Social Mission Research Landscape

The social mission research landscape comprises a broad scope of inquiry on activities and inputs spanning the health professions training pipeline and its impact on the production of health care professionals primed to meet societal needs. Much of the existing social mission research and evaluation literature examines activities to cultivate student interest in the health professions before training, like postbaccalaureate or pipeline programs, 12,13 and those implemented in health professions schools, such as recruitment 14,15 and admissions, 16,17 practices, and curricular 18–20 and clinical training 21–23 elements. Researchers have also examined student characteristics 24 and institutional factors 25–27 associated with social mission–oriented practice and workforce outcomes as well as the contribution of community-sponsored partnerships to increase interest in and enhance provision of care for the underserved. 28 Social mission activities originating or operating outside of health professions schools, such as funding for federal workforce training, 29 accreditation standards, 6,30 and school rankings conducted by the research community, 31 comprise a smaller component of the social mission literature, yet demonstrate the ecosystem of influencing factors that contribute to it.

Collectively, this broad body of research provides some evidence that social mission–related activities and inputs are associated with intended outcomes like primary care practice, 14,32 provision of care for the medically underserved, 12,22,23 student diversity, 6,33,34 and students graduating with skills and knowledge that ostensibly prepare them to address societal needs. 19–21,35 However, critical gaps remain that limit our ability to generalize findings and to be strategic in using social mission to advance health equity.

Rigorous Research Needed to Assess the Role of Social Mission in Advancing Health Equity

While theoretically it makes sense that social mission efforts will contribute to health equity, we lack direct evidence of whether any of the social mission inputs outlined above reduce health disparities or improve population health. Much of the research at the time of writing has focused on short-term outcomes, such as the diversity of applicants to or matriculants at health professions schools, 6,36 practice intent before entering the workforce, 22,28,37 or student knowledge, competencies, and attitudes. 19,35,38 Research examining distal social mission outcomes that may shed light on the contributions of health professions education programs to postgraduate practice patterns 12,13 or on population health 39 is comparatively scarce and a recognized area of need. 23,34,40,41 At the same time, there is no strong evidence to infer that the short-term social mission outcomes that are often reported translate to longer-term practice patterns, workforce composition, or population health outcomes. 34,35,37 Notably, we are not aware of any published studies that have established causation between individual health professions education programs and reduced health disparities. Rather, the research base largely presents evidence for intermediate outcomes to health equity without establishing linearity.

The need to establish a stronger evidence base for the relationships between social mission inputs and longer-term practice, population health, and disparities outcomes has prompted a call for more rigorous research and data collection. 14,32 Review articles and meta-analyses related to social mission present some of the strongest evidence available, but authors note a lack of methodological rigor among the individual studies assessed. 14,23,32,33,41 Further, some of the strongest predictive factors of social mission outcomes identified in the literature are related to student characteristics, 23,24,32 which could introduce a confounding factor into studies assessing institutional activities if students are self-selecting into training programs. Instances of study designs that could mitigate selection bias in social mission research, like randomized controlled trials and the use of matched control groups, are infrequently encountered. Likewise, comparative effectiveness research is exceptionally rare; a need for research and evaluation methodologies that provide clarity on the most effective strategies for achieving specified social mission outcomes is expressed in the literature. 14,15,23

Measuring social mission presents a challenge to strengthening the evidence base. While pioneering social mission research provides de facto outcomes of interest (percentage of graduates who practice primary care, work in health professional shortage areas, or are underrepresented minorities), 31 a standard set of social mission outcomes across the health professions training and workforce pipeline and corresponding indicators and metrics have not yet been collectively defined and recognized. This gap is reflected in the analytic heterogeneity observed in the literature across the training and workforce pipeline. For example, diversity has been categorically assessed based on applicant, 36 matriculant, 6 and graduate 42 diversity metrics, while studies of high-need workforce–related outcomes have used indicators ranging from student intentions 22 to residency placement 43 and practice placement. 13 We acknowledge that there is value in assessing a range of outcomes across the education and practice pipeline that may represent intermediate steps to advancing health equity. However, the lack of standardization and clarity in this area stymies researchers’ ability to apply consistent analytic methods to social mission research that could increase the generalizability of findings and allow for comparison across programs. We also observe that research instruments and concomitant measures that extend beyond the self-report, are standardized to allow for direct comparisons across cohorts and programs, and have been validated as good predictors of outcomes of interest are lacking in the existing social mission literature.

Advancing Social Mission Research

In an effort to strengthen the evidence base for social mission as it relates to causal impact rather than simply short-term or intermediate results, we propose a road map with several milestones to measure progress. Milestones include (1) creating a social mission research community by consolidating stakeholders, (2) building a solid foundation for the research through development of a consensus-driven logic framework and research agenda, and (3) laying out both the data and methodological needs imperative to strengthening the social mission evidence base and the opportunities to address them. Critical to achieving these milestones will be leadership from an organizing body that can serve as a hub for social mission research and activate relevant stakeholder groups to contribute to building the evidence base on social mission strategies to advance health equity.

Consolidate stakeholders

Multiple stakeholder groups have opportunities not only to contribute to the advancement of social mission research but also to benefit from it (see Table 1 for a summary of these contributions and benefits). A first step in this endeavor is to consolidate these stakeholders as a social mission research community working toward shared goals. Key stakeholders go beyond health educators and health professions students to include community members who can help inform priorities and participate in research; health professionals who can participate in social education activities; health systems, payers, and professional associations that maintain key data or can enhance data collection efforts; academic researchers and journals that can advance methods and help disseminate findings; and accrediting bodies, state and federal governments, and foundations that can provide accountability and other incentives and resources to drive change. To propel social mission research forward so we can do comparative effectiveness research, track providers into practice, and ultimately directly examine how social mission initiatives translate into improving health equity, we must harness the collective power of the broad set of stakeholders who are key players in this pursuit.

T1
Table 1:
Summary of Contributions Stakeholders Could Make to Advance Social Mission Research and the Benefits They Could Accrue

Create a framework

The field of social mission lacks a recognized logic framework to ground and guide the research and help communicate its importance to stakeholders. A social mission framework could aid in the design of outcomes-based research by clearly illustrating consensus-based social mission inputs, outcomes, and the pathways by which health professions education may contribute to health equity. Acknowledging that long-term outcomes take time to evaluate, a framework could also be used to garner buy-in from funders and stakeholders by demonstrating potential returns on investment in the short, intermediate, and long terms. Similar models and evaluation frameworks in the related area of social accountability, 44 such as the social accountability theory of change, 45 developed by The Training for Health Equity Network (THEnet), serve as relevant examples. However, these models omit several factors central to shaping social mission in a systems context, notably market and policy influences, accreditation standards, and accountability levers. For this systems perspective to be reflected, the development of a social mission framework should be a collaborative process, representing multidisciplinary stakeholders from academia, health systems, communities (including those that disproportionately experience health disparities), government and regulatory bodies, and beyond.

Develop a research agenda

The development of a social mission research agenda would help prioritize and sequence research questions, creating opportunities for researchers to contribute and for funders and policymakers to support the effort. A successful, consensus-based research agenda was developed by the Social Interventions Research and Evaluation Network to advance research on the integration of the social determinants of health (SDOH) in health care. 46 Similarly, an agenda in the field of social mission research could serve as a platform for connecting researchers, data, and policy leaders around priority topics and later ensure that findings are widely disseminated.

Bolster the data

Data challenges must be addressed to advance social mission research. It is essential that researchers be able to link data on individual providers throughout the health workforce pipeline, starting from pre–health professions training engagement; to initial application; to health professions schools; through matriculation, graduation, and practice. While some professions can link applicants to matriculants, 47,48 few health professions beyond medicine have the capability of linking data across the full educational continuum into practice, making it challenging to validate linear relationships between social mission inputs and outcomes. The federal government has a well-established national provider identifier (NPI) system, the National Plan and Provider Enumeration System (NPPES), 49 which, as of early 2021, includes over 4 million health care professionals across all professions, though some professions, such as nursing, are less well represented than others, and important details are missing in some cases, such as specialty for physician assistants. Additionally, billing data only capture a relatively small subset of clinicians, limiting the ability to track all providers into practice using NPPES. Nonetheless, if health professions training programs systematically collected NPI numbers for graduating students (and retroactively collected NPIs for past graduates), and if more entities, such as state licensure boards and health professions associations, collected NPI numbers, this identifier could be the needed linchpin for significantly advancing social mission research—particularly if known NPPES weaknesses were addressed in the future.

Beyond the NPPES, health systems, health profession associations, and the federal government all hold substantial amounts of data that could inform social mission research. The federal government has begun to release provider-level data through public use files. 50 Additionally, data from the Transformed Medicaid Statistical Information System, 51 available at the time of writing for the years 2016 through 2018, open new avenues for exploring how specific health professions schools and training program graduates contribute to caring for underserved populations and whether they have the skills and training to address SDOH. Foundations and health systems are also increasingly making new health data available to researchers at no or low cost, though provider identifiers are often not included. 52,53

A significant data challenge to social mission research that needs to be addressed is the lack of centralized data on pipeline program participants. Similarly, we need a way to systematically track whether students were exposed to particular social mission programs as part of training, such as attendance at a regional medical campus during medical school. Manual efforts to track a subset of graduates have shown positive long-term impacts of such programs, 12,54 but the lack of readily available data in this area has likely prevented more widespread evaluation efforts. Adding new data fields to existing student record systems could provide a systematic way to collect important missing data and advance social mission research, though this practice could be burdensome for schools.

When data are available, data proprietors should be encouraged to share them as part of a collaborative effort to promote evidence-based practices to improve health equity through health professions education and training. The Health Care Cost Institute, along with other data partners, has made a wide range of proprietary data available at no charge to expedite COVID-19 research, 55 providing a strong proof of concept that health professions organizations and health systems could emulate to create longitudinal datasets that are linked across the education and practice continuum and securely accessible to the broader research community. Mission-driven data sharing such as this (that includes provider-level data with NPI numbers) could greatly expand the capacity of academics, researchers, policymakers, and funders to critically examine and invest in health professions programs likely to have the greatest impact on communities.

Improve access to research instruments

An inventory and database of the relevant research instruments and assessment tools that could be leveraged to demonstrate the outcomes of health professions education programs would greatly contribute to social mission research. While some model initiatives to consolidate topic-specific research instruments in SDOH 56 and interprofessional education 57 are already underway, individual instruments are often siloed, difficult to locate, and firewalled. Further, we should establish a culture of making instruments relevant to social mission research publicly available, as has been done by Mapping Inequality. This group has enabled easy downloads of geocoded maps from the 1930s that show redlined neighborhoods, making it possible for a growing cadre of researchers to document the impact of systemic racism on health disparities. 58 Making additional social mission tools and resources publicly available could encourage more researchers to focus on social mission and simultaneously bring a standardized approach to measuring outcomes, thus enhancing the breadth and quality of research in the field.

Invest in the research

Investments in social mission research are necessary for the field’s advancement. Indeed, the federal government and foundations, such as The Robert Wood Johnson Foundation and the Josiah Macy Jr. Foundation, have already provided significant support to many of the social mission studies cited in this paper. For example, the Health Resources and Services Administration (HRSA) funds 2 health workforce research centers 59,60 focused on health equity in health professions education and training, as well as initiatives to improve training in primary care, 61 SDOH, 62 and interprofessional education. 63 However, there is little workforce funding available through other federal agencies primed to support this work, for example, the Agency for Healthcare Research and Quality and the National Institutes of Health. Expanded investments in social mission research could help build the longitudinal datasets and research platforms that will enable and empower the research community to fill in the important research gaps on how health professions education programs contribute to health equity.

Funders’ support of social mission research need not be limited to the financial. By stipulating that funding recipients make their data, research findings, and instruments available to the broader research community at no or low cost, funders can help bring rigor and reliability to the field. Further, an argument could be made that data collection that is funded in part or in whole through federal or state agencies should be considered a public good. Funders can also help raise the bar for social mission research through the provision of technical assistance and program evaluation guidance, such as that offered by HRSA to its primary care training enhancement grantees. 64

Designate an organizing body

Achieving the milestones we lay out in this article could be enabled by an organizing body that will serve as the hub for social mission research. A social mission research organizing body could help create research cohesion and disseminate findings, advocate for additional funding, and bring diverse stakeholders to the table and provide them with a platform for communication and cultivating partnerships. With respect to the latter, such an organizing body could play a lead role in garnering buy-in and engagement from stakeholders identified in Table 1 by reaching out to each group and helping them see the benefits of engaging in social mission research as well as the potential ways each might contribute. The organizing body may, for example, engage community stakeholders by positioning them not only as the intended recipients of social mission outputs but also as the group most able to identify and voice the community needs that should drive social mission innovation and evaluation.

It may be possible to engage stakeholders who have access to data that could be used to build the social mission evidence base by (1) emphasizing the cost of not sharing resources for social mission research (e.g., missing out on new insights that could increase their market advantage or ability to meet constituent needs and significantly advance health equity) and (2) establishing data use agreements that facilitate data sharing while protecting proprietary information and confidentiality. An organizing body, therefore, would play a central role in not only bringing stakeholders to the table but also in activating and supporting them as key social mission research partners.

Model organizing bodies spearheading related efforts provide precedents for this role. For example, the Social Interventions Research and Evaluation Network, at the University of California, San Francisco, 46 and the National Collaborative for Education to Address the Social Determinants of Health, at Northwestern University, 62 are both organizing bodies for the advancement of SDOH research. Potential organizing bodies primed to undertake the initiative to advance social mission research likely already exist; the Beyond Flexner Alliance, for example, is a national forum that collaborates to bring attention to social mission in health professions education. 1 Though the organization has historically lacked an emphasis on research, their inclusive approach to promoting and encouraging social mission across the health professions may attract key players from outside of medicine (social mission research is heavily concentrated in medical education) and facilitate multidisciplinary research initiatives and alliances.

Conclusion

As the world confronts new challenges, like COVID-19, and the preexisting disparities they exacerbate, there has never been a more relevant time to advance knowledge on the role of health professions education in promoting health equity. While a broad body of social mission research exists, the evidence base to support its direct contribution to reducing health disparities and increasing equity is “still marked more by aspiration than measurable accomplishment,” an observation made in 2006. 65 More rigorous investigation is needed to develop, support, and scale evidence-based strategies that will promote social mission, address health workforce challenges, and advance health equity. A collaborative, coordinated, and strategic approach to social mission research has the potential to propel us forward in this area of inquiry.

Acknowledgments:

The authors would like to acknowledge and extend their gratitude to Noah Westfall for his significant contributions to the literature review that informed this perspective.

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