Advancing Diversity, Equity, and Inclusion in Scientific Publishing

Abstract

Inequities in multiple dimensions are pervasive across groups and intersections of race, sex, sexual orientation, gender identity, geography, and others stratifications in society.1Ulmer C. McFadden B. Nerenz D.R. Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement. National Academies Press, 2009Google Scholar, 2Smedley B.D. Stith A.Y. Nelson A.R. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, 2003Google Scholar, 32019 National Healthcare Quality and Disparities Report. Agency for Healthcare Research and Quality. Reviewed June 2021.https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.htmlGoogle Scholar, 4Leung K.K. Jawaid N. Bollegala N. Gender differences in gastroenterology and hepatology authorship and editorial boards.Gastrointest Endosc. 2021; 94: 713-723Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 5Peraza J. Agrawal M. Wong S.Y. et al.Disparities in gastroenterology grand rounds speakerships in the USA.Lancet Gastroenterol Hepatol. 2021; 6: 781-782Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 7Institute of Medicine Roundtable on Health DisparitiesChallenges and Successes in Reducing Health Disparities: Workshop Summary. National Academies Press, 2008Google Scholar The disproportionate effect of COVID-19 on racial and ethnic minorities, and increased attention to the deaths of Black persons at the hands of law enforcement reignited national discourse on structural injustices.6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,8Tai D.B.G. Shah A. Doubeni C.A. et al.The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States.Clin Infect Dis. 2021; 72: 703-706Crossref PubMed Scopus (395) Google Scholar For people of color, the embedded, pervasive, and mutually reinforcing systems that underpin structural racism are key drivers of physical, mental, and social health inequities and also hamper advancement in scientific and leadership roles.6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,9Doubeni C.A. Simon M. Krist A.H. Addressing systemic racism through clinical preventive service recommendations from the US Preventive Services Task Force.JAMA. 2021; 325: 627-628Crossref PubMed Scopus (32) Google Scholar, 10Doubeni C.A. Selby K. Levin T.R. Disparities in preventable mortality from colorectal cancer: are they the result of structural racism?.Gastroenterology. 2021; 160: 1022-1025Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 11Doubeni C.A. Breaking down the web of structural racism in medicine: will JEDI reign or is it mission impossible?.Mayo Clin Proc. 2021; 96 (1387–1379)Abstract Full Text Full Text PDF Scopus (2) Google Scholar Research fundings and publications and journal editorial teams manifest inequities, which, for people of color, are traceable to structural racism.12Stevens K.R. Masters K.S. Imoukhuede P.I. et al.Fund Black scientists.Cell. 2021; 184: 561-565Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar,13McFarling U.L. “Health equity tourists”: how white scholars are colonizing research on health disparities. Stat News. Published September 23, 2021.https://www.statnews.com/2021/09/23/health-equity-tourists-white-scholars-colonizing-health-disparities-research/Google Scholar An analysis across all American Gastroenterological Association (AGA) journals in 2020 found that only 2.6% of editors and editorial board members are from groups that are underrepresented in the field.6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Diversity and inclusivity on editorial teams can enhance innovation, expand editorial content, and help to challenge standing assumptions and theories, including use of stigmatizing language in scientific publications, use of race as a biological marker, and biases in clinical algorithms that may perpetuate social injustices. This commentary summarizes efforts in the Journal to advance the AGA roadmap for moving “from intention to action.”6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As a leading journal in digestive diseases, Gastroenterology evaluates, refines, and publishes research and scholarly articles to disseminate knowledge on scientific advancements and best practices on improving digestive disease health and care globally. Articles published in Gastroenterology represent the culmination of years of work, shape careers, and influence leadership roles within and outside academia, including promotion and tenure decisions. To address the effects of structural racism and other “isms” in scientific publications in the field of digestive diseases, the Board of Editors of Gastroenterology is undertaking several important steps to move from intention to action.6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,14Carethers J.M. Quezada S.M. Carr R.M. et al.Diversity within US gastroenterology physician practices: the pipeline, cultural competencies, and gastroenterology societies approaches.Gastroenterology. 2019; 156: 829-833Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The AGA began disparities-related work in the early 1990s and focus on diversity, equity, and inclusion (DEI) in 2016. In 2020, AGA created a roadmap to address racism and other injustices,6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar and supported the creation of a new position, DEI Editor, for the Journal, with a successful recruitment in 2021. Gastroenterology envisions a scientific publishing enterprise that is diverse, equitable, and inclusive through direct actions and by enabling positive change through collaborations and partnerships. Gastroenterology commits to developing and implementing processes, practices, and policies to eliminate structural barriers for groups that are underrepresented in scientific publications. The Journal will both innovate and continuously evaluate and adopt emerging knowledge to optimize policies. This includes a diversity statement. The dedicated DEI role aims to provide consistent informed guidance for advancing initiatives and coordinate DEI efforts across all Journal operations, including manuscript guidelines, editorial evaluations, personnel training, and networking with other organizations. The overall goal is to promote health equity research and promote inclusiveness in the research publication process and on editorial teams (Table 1).Table 1Outline of StrategiesGoalsInitiativeSpecific actionsValue statementEstablish commitmentCommitment to DEIDiversity and inclusivity on editorial teamsEditorial board and personnel trainingImplicit bias trainingCreate pathways to editorial leadershipAssess editorial board and editor selection processes and use of internships and fellowship for people from groups that are underrepresentedSystematically provide coordination and guidance on DEI across all journal operationsSpecial Editor for Diversity, Equity, and InclusionDeveloped, established funding for, and appointed DEI Editor position (see announcement at: https://gastro.org/news/introducing-gastroenterologys-new-dei-editor-chyke-doubeni-md-mph/)Use of inclusive languageIteratively evaluate and use culturally appropriate, nonstigmatizing, and inclusive languageAdopt guidance on inclusive language from the Council of Science Editors and the AMA Manual of Style16JAMA Network EditorsAMA Manual of Style.11th ed. Oxford University Press, 2020Google Scholar (see Supplementary Table 1 for examples)Implement Sex and Gender Equity in Research (SAGER) guidelinesAssess and monitor diversity in scholarly and editorial activitiesAscertain demographics of authors, editors, and other contributorsElectronic key word searches and demographic questions editorial management systemsIdentify health equity–related scholarly articlesExpand content in DEI activitiesSelected summaries of disparities-related researchDevelop relevant scholarly equity article summaries in existing Selected Summaries section—functions as a “journal watch”Online digital collectionsExpanded topic-specific digital collections to include DEI-related research (including commentaries and selected summary links) (see digital collection at: https://www.gastrojournal.org/content/equity-in-gi)Commentary seriesCreate regular commentary series and editorials on DEI topics and health equity–related researchPromote fairness and inclusivity in researchPromote equity researchRequest stratified data on specific racial and ethnic groups and sex in original articles to illuminate important differencesRequire explication of use of race in risk prediction and risk assessment; make health equity research more accessible Open table in a new tab The Journal seeks to address disparities in research scholarship by race and ethnicity, gender, and other stratifications and promote a culture of diversity and inclusion on the Board of Editors through initiatives, for example, inaugural Implicit Bias Summit in 2021 on bias in society, science, and research for the Board of Editors. The Journal is exploring potential fellowships to serve as pathways to editorial leadership for people from groups that are currently underrepresented in relation to the general population. Informed approaches for evaluating and acting on inequities require standardized, sensitive, and inclusive methods, including language used in articles and Journal operations. To that goal, the Journal has adopted the Sex and Gender Equity in Research (SAGER) guidelines,15Heidari S. Babor T.F. De Castro P. et al.Sex and gender equity in research: rationale for the SAGER guidelines and recommended use.Res Integr Peer Rev. 2016; 1: 2Crossref PubMed Google Scholar and will adopt other culturally sensitive, nonstigmatizing, and inclusive language and update as needed. Although there are no universally agreed on terminologies for race and ethnicity, some preferences are emerging. The Journal has adopted updated recommendations from the 11th edition of the AMA Manual of Style,16JAMA Network EditorsAMA Manual of Style.11th ed. Oxford University Press, 2020Google Scholar including capitalizing Black and White, use of only adjectival forms and person-first language, and use of specific racial and ethnic groups (see Supplementary Table 1).17Health equity guiding principles for inclusive communicationCenters for Disease Control and Prevention.https://www.cdc.gov/healthcommunication/Health_Equity.htmlGoogle Scholar Language on ethnicity is currently fluid and may include Latino, Latina, Latiné, Latinx, or Hispanic. Authors are encouraged to avoid the use of broad summary descriptors, such as “non-White” or “Black, Indigenous, and people of color” as descriptors because the terms lack specificity or consensus on definition.18Flanagin A. Frey T. Christiansen S.L. et al.The reporting of race and ethnicity in medical and science journals: comments invited.JAMA. 2021; 325: 1049-1052Crossref PubMed Scopus (90) Google Scholar,19Christiansen S.L. Inclusive language: race and ethnicity.Sci Ed. 2020; 43: 95-96Google Scholar The Journal will adhere to parallel construction as recommended by the US Preventive Services Task Force (Black persons vs White persons or African American people vs European American people, and not African American people vs White people) as preferred styles.20US Preventive Services Task Force, Davidson KW, Mangione CM, et al. Actions to transform US Preventive Services Task Force methods to mitigate systemic racism in clinical preventive services [published online ahead of print November 8, 2021]. JAMA doi:10.1001/jama.2021.17594.Google Scholar During the past 5 years, Gastroenterology has published numerous articles that considered race, ethnicity, sex, and gender.10Doubeni C.A. Selby K. Levin T.R. Disparities in preventable mortality from colorectal cancer: are they the result of structural racism?.Gastroenterology. 2021; 160: 1022-1025Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,21Sedano R. Hogan M. McDonald C. et al.Underrepresentation of minorities and underreporting of race and ethnicity in Crohn's disease clinical trials.Gastroenterology. 2022; 162: 338-340Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 22Balzora S. May F.P. Ogedegbe G. COVID-19 and social determinants of health in gastroenterology and hepatology.Gastroenterology. 2021; 161: 1373-1376Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 23Chua S.G. Wasan S.K. Long M.T. How to promote career advancement and gender equity for women in gastroenterology: a multifaceted approach.Gastroenterology. 2021; 161: 792-797Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 24Ashktorab Y. Brim A. Pizuorno A. et al.COVID-19 pediatric patients: gastrointestinal symptoms, presentations, and disparities by race/ethnicity in a large, multicenter US study.Gastroenterology. 2021; 160: 1842-1844Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 25Adeniji N. Carr R.M. Aby E.S. et al.Socioeconomic factors contribute to the higher risk of COVID-19 in racial and ethnic minorities with chronic liver diseases.Gastroenterology. 2021; 160: 1406-1409.e3Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 26Goldberg D. Ross-Driscoll K. Lynch R. County differences in liver mortality in the United States: impact of sociodemographics, disease risk factors, and access to care.Gastroenterology. 2021; 160: 1140-1150.e1Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 27Ashktorab H. Pizuorno A. Oskroch G. et al.COVID-19 in Latin America: symptoms, morbidities, and gastrointestinal manifestations.Gastroenterology. 2021; 160: 938-940Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 28Barnes E.L. Loftus Jr., E.V. Kappelman M.D. Effects of race and ethnicity on diagnosis and management of inflammatory bowel diseases.Gastroenterology. 2021; 160: 677-689Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 29Brim H. Mirabello L. Bass S. et al.Association of human papillomavirus genotype 16 lineages with anal cancer histologies among African Americans.Gastroenterology. 2021; 160: 922-924Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 30Bui A. Yang L. Myint A. et al.Race, ethnicity, and socioeconomic status are associated with prolonged time to treatment after a diagnosis of colorectal cancer: a large population-based study.Gastroenterology. 2021; 160: 1394-1396.e3Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 31Shah S.C. McKinley M. Gupta S. et al.Population-based analysis of differences in gastric cancer incidence among races and ethnicities in individuals age 50 years and older.Gastroenterology. 2020; 159: 1705-1714.e2Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 32Levin T.R. Jensen C.D. Chawla N.M. et al.Early screening of African Americans (45-50 years old) in a fecal immunochemical test-based colorectal cancer screening program.Gastroenterology. 2020; 159: 1695-1704.e1Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The Journal is assessing approaches to the evaluation of original articles that promote fairness and inclusivity of people of color and both sexes in clinical and basic science research. A necessary first step in enhancing DEI is to establish a rigorous baseline to which future interventions can be compared. This involves a current effort to ascertain demographic data of authors, editors, reviewers, and other contributors. The Journal is creating and assessing electronic key words and self-designated demographic questions across all of the editorial databases and portals. The Journal is identifying relevant scholarly activities to enrich the number of submissions and acceptances of original research in this field. As a central tenet, Gastroenterology affirms race as a social construct and acknowledges its cross-cutting effect among social determinants of health.9Doubeni C.A. Simon M. Krist A.H. Addressing systemic racism through clinical preventive service recommendations from the US Preventive Services Task Force.JAMA. 2021; 325: 627-628Crossref PubMed Scopus (32) Google Scholar The Journal is committed to promoting research on understanding deleterious social and biologic effects of racism and other forms of discrimination. To that end, the Journal encourages analyses that are stratified (rather than adjustments only) to both inform health equity–related knowledge and extend the actionable value of the research. Disaggregated data on specific racial and ethnic groups and by sex or gender illuminate important differences in the burden of disease, variations in quality and outcomes of care, effectiveness of interventions, and policies needed to advance health equity. Therefore, authors of original reports are encouraged to collect and provide disaggregated data that specifically evaluate individual racial, ethnic, and other groups as appropriate. The methods and the specific groups included in data collection should be described in the analyses even if the numbers are sparse, to enable transparent assessment of the inclusiveness of research studies. This includes reporting of sex and age of mice or other in vivo experimental models used in studies.33Omary M.B. Cohen D.E. El-Omar E.M. et al.Not all mice are the same: standardization of animal research data presentation.Hepatology. 2016; 63: 1752-1754Crossref PubMed Scopus (10) Google Scholar Uninformed use of, or adjustment for, race or proxies of racism in scientific research, and attribution of biological meaning to race and ethnicity can systematically bias health care delivery.34Vyas D.A. Eisenstein L.G. Jones D.S. Hidden in plain sight—reconsidering the use of race correction in clinical algorithms.N Engl J Med. 2020; 383: 874-882Crossref PubMed Scopus (345) Google Scholar An additional factor in algorithm bias is research that is not inclusive of racial and ethnic groups in proportion to the prevalence of the conditions under study, which may stem from recruitment practices, access and quality of care, and structural barriers to participation and retention in research. For this goal, the Journal will require explication of use of race in risk assessment tools. Gastroenterology has created a dedicated DEI digital collection on the Journal website that is identified and curated monthly by the editors. This collection will include original research, commentaries, editorials, and selected summaries to increase ease of access and dissemination, given such publications can be difficult to identify consistently with search engines. The Journal will expand the outreach of disparities-related content using AGA communication outlets to educate members about health disparities and unconscious or implicit bias in gastroenterology. Gastroenterology will leverage existing journal components in tandem with new mechanisms to enrich content on health equity. The current Selected Summaries special section, which brings to our readership summaries of high-profile research published in other journals, for example, will now include a specific focus on relevant scholarly articles on health equity–related research. Also, the Journal has created and is soliciting relevant new content, led by the recently appointed DEI Editor. This new section will integrate a portfolio of content across all journal categories, including commentaries, editorials, expert reviews from thought leaders, and original articles in the discipline. The goal is to promote discussion and catalyze new research and funding that advance the science of health equity and promote innovation from groups that are underrepresented and understudied in research. New content for this effort will also seek to draw from the multisociety Digestive Disease Week, as part of the shared commitment to high-quality research offerings, including a Healthcare, Delivery, Disparities, and Quality Track. Gastroenterology endorses the recommendations of the AGA Equity Project and seeks to continually improve the ability to favorably impact scientific discourse on health equity.6Carr R.M. Quezada S.M. Gangarosa L.M. et al.From intention to action: operationalizing AGA diversity policy to combat racism and health disparities in gastroenterology.Gastroenterology. 2020; 159: 1637-1647Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The steps outlined represent a beginning. The Journal is committed to ongoing development of these concepts and encourages original research that is inclusive of, and conducted by, people from groups that are underrepresented in the discovery-to-publication continuum.13McFarling U.L. “Health equity tourists”: how white scholars are colonizing research on health disparities. Stat News. Published September 23, 2021.https://www.statnews.com/2021/09/23/health-equity-tourists-white-scholars-colonizing-health-disparities-research/Google Scholar The Journal welcomes submissions on how race and ethnicity, and other stratifications of inequities, should be addressed in research in digestive diseases across the translational science continuum, health equity, effects of systemic racism and other forms of discrimination, interventions that reduce disparities, and research that elucidates and mitigates biases in existing risk assessment tools in digestive disease care, and advance workforce diverse and inclusivity. The Journal invites comments and feedback on the steps outlined. The authors would like to acknowledge the members of The Association of Black Gastroenterologists and Hepatologists and the American Gastroenterological Association Equity Project for their valuable contributions to this commentary. Supplementary Table 1Examples of Inclusive Language From Centers for Disease Control and Prevention’s Health Equity Guiding Principles for Inclusive Communication17Health equity guiding principles for inclusive communicationCenters for Disease Control and Prevention.https://www.cdc.gov/healthcommunication/Health_Equity.htmlGoogle ScholarTerms or language to avoidNonstigmatizing and inclusiveAvoid terms such as vulnerable, marginalized, and high-risk as adjectives for demographic groups (can be stigmatizing)Disproportionately affectedGroups that have been economically/socially marginalized Vulnerable groupsGroups that have been marginalized Marginalized groupsGroups placed at higher risk/put at higher risk of [outcome] High-risk groupsGroups at higher risk of [outcome] At-risk groupsGroups experiencing disadvantage High-burden groupsGroups experiencing disproportionate impact Hard to reach groupsPopulation of focus Targeted populationUnderresourced communitiesPotentially dehumanizing languageUse person-first language Diabetics People with [disease or condition] Diabetes patients People experiencing [health outcome or life circumstance] The diabetes population Survivors COVID-19 cases The homeless Inmates VictimsNoun forms on race and ethnicityCapitalize Black and White and use adjectival forms Blacks, Hispanics, Latinos, WhitesPreferred terms for specific racial and ethnic groups: Indian; Eskimo; Oriental; Afro-American; Caucasian American Indian or Alaska Native persons The [racial/ethnic] community (eg, the Black community) Asian American persons (Asian and Asian American are not synonymous unless defined) Non-White Black or African American personsHispanic or Latino personsNative Hawaiian or other Pacific Islander personsWhite personsPeople who identify with more than one race or ethnicity; people of more than one race or ethnicityNonspecific terms in original research and potentially stigmatizingRacial and ethnic minority groups MinoritiesSexual/gender/linguistic/religious minority groups MinorityPolitical minority group Ethnic groupsRacial groupsPeople of colorAmerican Indian and Alaska Natives are the only federally recognized political minority in the United States. Tribes hold government to government relationship with the United StatesAdapted from: CDC's Health Equity Guiding Principles for Inclusive Communication. Open table in a new tab Adapted from: CDC's Health Equity Guiding Principles for Inclusive Communication.