A More Practical Guide to Incorporating Health Equity Domains in Implementation Determinant Frameworks Eva N

Woodward et al. Implementation Science Communications (2021) 2:61 Implementation Science https://doi.org/10.1186/s43058-021-00146-5 Communications METHODOLOGY Open Access A more practical guide to incorporating health equity domains in implementation determinant frameworks Eva N. Woodward1,2* , Rajinder Sonia Singh2,3, Phiwinhlanhla Ndebele-Ngwenya4, Andrea Melgar Castillo5, Kelsey S. Dickson6 and JoAnn E. Kirchner2,7 Abstract Background: Due to striking disparities in the implementation of healthcare innovations, it is imperative that researchers and practitioners can meaningfully use implementation determinant frameworks to understand why disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted the first published adaptation of an existing implementation determinant framework with health equity domains to create the Health Equity Implementation Framework. We recommended integrating these three health equity domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance. Methods: We completed a consensus process with our authorship team to clarify steps to incorporate a health equity lens into an implementation determinant framework. Results: We describe steps to integrate health equity domains into implementation determinant frameworks for implementation research and practice. For each step, we compiled examples or practical tools to assist implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative measures. Conclusion: Incorporating health equity domains within implementation determinant frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers and practitioners to concretely capture and understand barriers and facilitators to implementation disparities. Keywords: Health equity, Implementation, Health disparities, Framework, Theory, Implementation science, Determinant * Correspondence: [email protected] 1Center for Mental Healthcare and Outcomes Research, U.S. Department of Veterans Affairs, North Little Rock, AR, USA 2Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Woodward et al. Implementation Science Communications (2021) 2:61 Page 2 of 16 communities in developing implementation science and Contributions to the literature practice [8], lack of consistent methods and data ele- Applications of how the Health Equity Implementation ments related to equity across implementation studies Framework guided other implementation efforts [9], and exclusivity and social injustice within the implementation science workforce perpetuated by structures Practical tools, including a table of sample measures for making it harder for institutions to recruit and retain health equity determinants, a qualitative interview guide, marginalized people (e.g., school-to-prison pipeline). and a qualitative codebook Also, disparities exist for innovations being implemented Clarified broad steps for integrating a health equity lens into and, if not adapted for marginalized populations, imple- an implementation determinant framework mentation may perpetuate the exclusion of marginalized communities and widen health inequities [6]. Similar to Background implementation studies, marginalized populations have Health equity occurs when all people have socially just historically been excluded from clinical trials and effi- opportunities for optimal well-being. Disparities in cacy studies [10]. Further, innovations are often not de- healthcare implementation exist when a healthcare signed nor as efficacious for marginalized populations innovation, such as a program or treatment, is delivered [11–13]. Thus, the limitations of disparities in with significantly worse access, receipt, use, quality, or innovation development can be inherited by implemen- outcomes for certain populations compared to others tation science and likely perpetuated if the implementa- [1]. Structural factors and systems greatly contribute to tion does not systematically consider disparity different as well as unjust or unfair treatment of certain determinants, cultural adaptations, and other ways to populations. Populations that experience worse health or ensure health equity. healthcare might be defined by race, ethnicity, sexual Outside the U.S., health equity and implementation re- orientation, gender identity, socioeconomic status, func- search predominantly focus on a specific marginalized tional limitation, or other characteristics [2]; we refer to population, which is an important and valid path toward these groups as marginalized populations based on so- equity [9, 14–16]. Examples in low- and middle-income cial, economic, and/or environmental disadvantage that countries include measurement tools normed with par- accompanies health inequities [3]. One example of an ticipants from those countries [17], adapting innovations implementation disparity in United States (U.S.) or delivery methods specifically to those populations pediatric healthcare is screening and diagnosis of autism [18] and reviewing or developing frameworks specific to spectrum disorder. Although there are valid and reliable those countries [14, 19, 20]. Although adaptations to autism screenings and clear criteria for diagnosis, racial local contexts are important, there remain gaps in apply- and ethnic minority children who meet the criteria are ing principles of health equity to implementation re- less likely to be diagnosed than non-Hispanic white chil- search broadly, partly because locally adapted dren [4]. Thus, effective screenings and diagnoses are frameworks are not easily generalizable to other coun- implemented inequitably for racial and ethnic minority tries or contexts. The current charges to implementation children, resulting in delayed treatment for children of researchers to ensure health equity in their efforts [6, color. This implementation disparity is exacerbated 21] are not possible without adapting implementation when children are finally diagnosed properly with aut- determinant frameworks to first capture and under- ism, as children of color are less likely to receive quality standing barriers to equitable implementation. treatment [5]. Unfortunately, several implementation disparities may be undetected. As Braveman wrote, Implementation determinant frameworks with an equity “Health disparities are the metric we use to measure focus are needed progress toward achieving health equity” [3]. Implementation science frameworks have been catego- Overall, implementation science has yet to actively and rized into three types: determinant (establishing what systematically assess, address, and evaluate unique fac- factors determine or predict implementation success), tors contributing to healthcare inequities, including in- process (clarifying how to address determinants to stitutional and structural problems, such as racism, that achieve implementation success), and evaluation (deter- are economic, regulatory, social, historical, and political mining metrics and assessment to know when imple- determinants of implementation for marginalized groups mentation success is achieved) [22]. Implementation [6]. There are many reasons why implementation re- determinant frameworks are key to inform study design searchers have yet to showcase solutions to healthcare and selection of strategies to match contextual needs; inequities including underrepresentation of marginalized yet, we have only recently considered determinants and resource-poor communities in implementation stud- unique to health inequities, starting with the Health ies [6, 7], lack of true engagement with marginalized Equity Implementation Framework [23].

Load more