A Practical Guide to Incorporating Health Equity Domains in Implementation Frameworks


 Background: Due to limited systematic integration of health equity and implementation science, it is imperative to provide researchers and practitioners tools to guide implementation in settings where there is inequitable implementation of an intervention. Our prior work documented and piloted the first published adaptation of an existing implementation science framework with health equity determinants to create the Health Equity Implementation Framework. We suggested how others’ might adapt their preferred implementation science frameworks with three health equity domains: 1) cultural factors of recipients, 2) clinical encounter, or patient-provider interaction, and 3) societal influences (including but not limited to social determinants of health). This manuscript is a practical guide to utilize three health equity domains in implementation research and practice.Methods: We describe in greater depth than in our previous publication domains typical in implementation determinants frameworks and three adaptations: domains known to affect health equity. For each domain, we compiled definitions with supporting literature, defined relevant subdomains, showcased an illustrative example, and suggested sample measures, both quantitative and qualitative.Results: We describe how to incorporate the three health equity domains in one’s preferred implementation science framework, or how to use the Health Equity Implementation Framework specifically. Practical guidelines follow ten published recommendations on how to use frameworks in implementation research and practice. We describe a new case study in which the framework guided evaluation.Conclusions: Incorporating health equity domains within implementation frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally, addressing, implementation and equity barriers simultaneously. The practical guidance and tools provided can assist implementation scientists and practitioners to concretely address inequity in implementation across populations to capture and analyze information used to assess health outcomes.Contributions to the LiteratureSpecific definitions of implementation and three health equity domains with examples of how they have been applied in published literature and sample measures.Practical tools, including a qualitative interview guide and codebookCase study of how the Health Equity Implementation Framework guided analysis in an implementation study

"employ strategies and build structures that elevate equity concerns"-this can only be done when current implementation determinant frameworks purposefully incorporate health equity domains for assessment informing implementation strategies and as potential moderators for implementation intervention. [14] Outside the U.S., health equity and implementation integration predominantly involve the use of implementation frameworks in low and middle income countries or increasing delivery of services for speci c populations (e.g., Indigenous communities). Regarding use of implementation frameworks in low and middle income countries, examples include a systematic review and intervention to increase the value of money in Burkina Faso and other countries, [15,16] as well as unsuccessful implementation of an intervention to increase quality and coverage of maternal care and reproductive health in India. [7] Other examples in low and middle income countries include measurement tools normed with participants from those countries, [17] adapting interventions or delivery methods, [18] and reviewing or developing frameworks speci c to those countries. [19][20][21] The Need for Practical Tools Speci c to Implementation Equity The need for practical implementation tools speci c to equity is signi cant given the real-world setting of implementation research and practice, and because existing implementation tools focus little or no explicit attention on equity. Frameworks that account for equity and implementation might be too vague to be used meaningfully. [22] Interventions that work well in small-scale or controlled pilots may not perform as expected when disseminated or scaled up in real-world settings due to lack of tools necessary to inform contextual understanding, including presence, drivers, and impact of health inequities. [23] Examples of practical implementation tools include the Consolidated Framework for Implementation Research guide tool, [24] and the website to review and select and implementation framework. [25] Unfortunately, these tools have yet to be explicitly or extensively adapted, integrated with, or tested within health equity efforts. Due to limited systematic integration of health equity and implementation science, [13] we need more implementation tools with an acute awareness for equity.
Our prior work documented and piloted adaptations of one existing implementation science framework with health equity determinants to create the Health Equity Implementation Framework. [11] We also included guidance on how others' might adapt their preferred implementation science frameworks in a similar manner. Since that publication, many scientists and practitioners have requested further clari cation of the Health Equity Implementation Framework domains for practical use. This manuscript provides a practical guide to utilizing the three health equity domains in a framework in settings where there is inequitable implementation.

Health Equity Implementation Framework
In the Health Equity Implementation Framework, we proposed determinants or domains believed to predict successful and equitable implementation, seen in Fig. 1. [11] Determinants are factors, levels, or components thought to partially explain why implementation would succeed or fail. [26] In the Health Equity Implementation Framework, we adapted three health equity determinant domains to the Integrated Promoting Action on Research in Implementation in Health Services (i-PARIHS) framework, [27] which also proposes a process-facilitation-by which change in each domain would occur. [26,27] The focus of this manuscript is on three health equity determinants, rather than facilitation, as science is still emerging on how implementation processes should be tailored to promote equity. One does not need to use i-PARIHS to incorporate health equity determinants into another preferred implementation determinants framework.
[insert Fig. 1 here -Health Equity Implementation Framework] Domains Typical in Implementation Determinants Frameworks. Broad domains typical in implementation determinants frameworks focus on factors at multiple levels, including the individual (e.g., personal characteristics, actors of implementation, individuals receiving an innovation), organization (e.g., clinical service, school, department, factory), community (e.g., local government, neighborhood), system (e.g., school district, hospital system) and policy (e.g., state government, broader laws). [28] These domains can be further speci ed, such as inner setting or outer setting within an organization. [29] Domains from i-PARIHS are the basis of the Health Equity Implementation Framework and include those typical in most implementation determinants frameworks. [28] Each domain acts to enable or constrain implementation and is de ned in Table 1 with illustrative examples and sample measures. This is the nature of the interaction between patient and provider. This domain is centered on how the patient and provider choose, adapt, and coordinate the conversation to achieve their shared and personal goals concerning health related matters. [43] The interaction could be in uenced by: • Predisposition features which areindividual differences that in uence communication that may be objective (e.g., age) and subjective (e.g., self-concept) • Cognitive / affective in uences that show how communication is related to strategy (e.g., goals), attributions (e.g., stereotypical) and trust.
• Communication in uences which refers to how the patient and the provider should tailor their responses to create a coherent and effective exchange. [43] In studying recordings of HIV patient-provider encounters, there was less psychosocial talk in patient-provider encounters with Hispanic compared to white patients. [42] In a study on predictors and consequences of negative patientprovider interactions among a sample of African American sexual minority women, authors found racial discrimination was most frequently mentioned, and gender and sexual orientation discrimination were also related to negative patient experiences. [70] Quantitative: Quantitative: • Staff implementation ratings of innovation • Point of contact implementation reports assessing the innovation [75] Qualitative: • Point of contact interview [75] • In a healthcare setting, providers and staff are the people who administer the innovation.
A providers' objectives and beliefs about a patient affects how they behave during the patient-provider interaction. [76] Providers, especially in busy healthcare settings, may be vulnerable to subconscious bias and stereotypes. [77] Physicians who consider themselves "liberal" spent more time giving more information to patients than those who consider themselves "conservative". [43] Providers may engage in more detailed conversations about the health status of educated patients, yet provide basic explanations for less educated patients. [43] During a postangiogram encounter, physicians perceived patients of lower socioeconomic status as having more negative personality characteristics that include lack of selfcontrol and more negative behavioral tendencies. [41] Quantitative: • Implicit Association Test to assess implicit bias [78] • Surveys of relevant practice, knowledge, attitudes, or skills [79,80] • Colorblind Racism Scale [81] Qualitative: • Analysis of taped conversation between provider and patient [42,78] • Participant observation [82] • One-on-one interviews [83] Notes Patients with more formal educations are more expressive and tend to want to play a role in the decisionmaking process than less educated patients. [43] Many patients are unsure about their role in the encounter and the appropriateness of their participation. [88] We have limited ability to predict treatment success based on whether research was conducted with patients of similar clinical phenotype. [89] Quantitative: [37] • Telephone survey of a random sample of residents • Medical Mistrust Index [90] • Measures of underutilization of health services • Health literacy question [91] • Health numeracy question [92] • Appropriated Racial Oppression Scale [93] Qualitative: • Interview about expectations for treatment or the patient-providerinteraction [42,94] • Interviews about experience seeking care [95] Notes Pisando Fuerte is a fall prevention program linguistically and culturally tailored for Latino individuals at risk for falls. It is adapted from "Stepping On," an evidence-based fall prevention program. Fidelity to Pisando Fuerte was subpar; when comparing delity between two sites, delity was lower in the site that did not give additional time to implement the program (poor leadership support) and had no experience in organizing programs like Pisando Fuerte (no previous experience of innovation). [97] Quantitative: • Perceptions of Supervisory Support Scale [98] • Organizational Commitment [99] • Readiness for Organizational Change measure [100] • Validated CFIR Inner Setting measures [101] Qualitative: [102] • Quantitative: • Measures of organizational readiness for change [106] • Cultural Competency Assessment Tool for Hospitals [104] Qualitative: [107] • There is an increasing amount of research that shows that inequities in obtaining preventative care among minorities compared with whites are due to "organizational characteristics, including location, resources, and complexity of a clinic or practice." [38] Researchers examined predisposing, enabling, and need factors as predictors of changes in health care utilization, and found that patients' experiences differed by group within the healthcare system, and impacted their beliefs and attitudes about receiving healthcare, ultimately affecting the extent to which healthcare services were utilized. [70] Qualitative: • Archival analysis, reading and documenting policies, program manuals, or procedural protocols [109,110] • Interviews with leadership [105] Quantitative: • 15 core measures of health care quality [111] • In a study assessing longitudinal effects of health insurance and poverty, researchers reported low-income, middle-aged adults in the U.S. with no insurance, unstable coverage, or changes in insurance have higher out-of-pocket expenditures and nancial burdens than public insurance holders, as well as increased nancial burden. [113] In a case study, the presence of chronic kidney disease indicators in the payfor-performance system in primary care created an incentive for improvement. [27] Quantitative: • Insurance claims data • Gross Domestic Product [114] • Gross National Product [115] • Minimum Wage [116] • Population & total employment [117] • Annual average wage level of the primary, secondary, and tertiary industries [118] • Tax revenue as percentage of total revenue [119] • Interest rate on saving deposits and in ation rate [120] Qualitative: [121] • Key informant interviews about goods and services exchanged [122] • Analysis of comparative economic structure [121] Notes In a qualitative study of transgender individuals' experiences in residential addiction treatment, researchers observed that residential facilities that split the milieu and housing based on the gender binary may be stigmatizing people who identify as transgender or gender non-conforming. [124] Quantitative: • Indices of Segregation [125] [130] c. Implementation scientists should review existing measurement tools speci c to health disparities in your area of interest or study to further integrate health equity into implementation.
Innovation. Innovation refers to the treatment, intervention, or practice or new "thing" to be implemented, adopted by providers and staff, and delivered to patients. [30] The innovation may be a program, practice, principle, procedure, product, pill, or policy. [31] Recipients. Recipients are the individuals who in uence implementation processes and those who are affected by implementation outcomes, both at the individual and collective team levels. [27] In health care, recipients are often many stakeholders typically grouped into providers and other staff, and patients and caregivers.
Context. Context includes different micro, meso, or macro levels that correspond to inner and outer contexts often speci ed in determinant frameworks. [27] Context can include factors such as resources, culture, leadership, and orientation to evaluation and learning. In this framework, the micro level includes local inner context (e.g., speci c ward or clinic), whereas the meso includes the organization (e.g., hospital or medical center). The macro level of outer context includes the wider healthcare system and effect this has on the other domains (e.g., United Kingdom National Health Service). [28] Facilitation or Process. There are processes by which barriers in implementation domains are solved or overcome, and strengths are harnessed to promote use of an innovation in routine practice. [29] In i-PARIHS, facilitation is the "active ingredient" or process. [32] Facilitation involves implementation strategies that result in implementation coming to fruition. [33,34] Domains Known to Affect Health Equity. Three health equity domains have clear, strong associations with inequities in health status, access to, quality of, or outcomes of health care, [35] or there is enough evidence to suggest these domains should be considered.[e.g., 36] The Health Equity Implementation Framework incorporates these domains known to affect health equity: 1) cultural factors, such as medical mistrust, demographics, or biases of recipients, who include patients, providers, and others; [37][38][39][40] 2) clinical encounter or patient-provider interaction; [41][42][43] and 3) societal in uences including physical structures, economies, and social and political forces. [44][45][46] See Table 1 for illustrative examples and sample measures.
Cultural factors of recipients. Recipients in the implementation process are individuals who will consume a particular innovation (e.g., patients, providers). [27] Recipients have unique characteristics, as single individuals and as a group, that in uence whether an innovation will be adapted and adopted successfully. Implementers should tailor implementation strategies so they are culturally aligned with beliefs, behaviors, preferences, and needs of all recipients-providers, staff, and patients. Some examples of recipient cultural factors are implicit bias, socioeconomic status, race and/or ethnicity, immigrant acculturation, language, health literacy, health beliefs, or trust in the clinical staff or patient group. [39,40] Although cultural factors will vary by group and local context, it is crucial recipient cultural factors are considered, particularly when patients belong to a group experiencing a healthcare inequity.
Clinical encounter (patient-provider interaction). This domain recognizes the transaction that occurs between patients and provider in health care, where decisions concerning diagnoses and treatment are made, and providers administer care. [47] It is important the recipients tailor and adapt the conversation accordingly to achieve their individual and shared goals. [43,48] Factors from both the patient and provider include individual differences in, for example, age and self-concept, pre-existing stereotypes, or lack of trust that could hinder the interaction. [43] There could be subconscious, implicit, or explicit bias from either recipient due to the others' characteristics, such as race, weight, or perceived sexual orientation. Due to the myriad factors intersecting during the clinical encounter, it is crucial to assess and address it, especially with regards to health inequities.
Societal in uence. Societal in uence includes three subdomains: 1) economies, 2) physical structures, and 3) sociopolitical forces. This domain is similar to social determinants of health, yet incorporates more upstream determinants (e.g., governance) that have been investigated less relative to mid-or downstream determinants (e.g., neighborhoods). [35] Societal in uences also include historical or current discrimination against marginalized groups, such as racism, classism, or transphobia, that may be formally or informally institutionalized within any implementation subdomain. These factors usually occur in broadest levels of the environment (e.g., province, nation), thus affecting downstream the healthcare system, clinics, and recipients. Many societal in uences are interrelated, such as a policy affecting a physical structure. It is not as important at this point to distinguish whether a factor is exclusively an economy, physical structure, social norm, or all three; rather, it is important these societal in uences are considered and addressed to ensure strategies address these key drivers of societal inequities. For example, Latinx patients in community mental health care (recipients, some immigrants, some Spanish speaking) interface with a service system (purveyor of mental health services, potentially an economic factor). There may be limited purveyors of services in certain geographic regions (physical structure), with higher levels of perceived racism among some providers (social discrimination interacting with recipient factor), and limited purveyors that offer culturally or linguistically aligned care to match needs of monolingual patients who have immigrated to the U.S. (physical structure). Societal in uences may not all be assessed in one study or initiative using established measures, due to feasibility constraints, but they should be documented in formative evaluations / initial diagnostic assessments of the implementation problem.
Economies. There are four typical structures of economies including a traditional economy (i.e., mostly agricultural), market economy (i.e., rms and private interests control capital), command economy (i.e., government controls capital), and a mixed economy (combination of command and market). [49] It is helpful to consider how economic structure affects access to resources for implementation. Market forces can be used to change demand for products deemed healthy or unhealthy, therefore driving policy implementation. Examples of market forces include taxes on tobacco, unhealthy food, and soft drinks, or food subsidy programs for women with low incomes. [44] As another example, one study found poverty was concentrated in the U.S. central Appalachia region where mountain top mining was the main income source. [50] These residents had increased exposure to environmental hazards combined with limited resources to address negative health outcomes as a result of those hazards. Implementation in this region would need to account for resources available to residents, their unique health concerns, and healthcare in their local context. Physical structures. Equity can be affected by how physical spaces, or "built environments," are arranged and how transition between those spaces occurs for health care. [44] One example in healthcare settings is type and quality of language translations of information displayed (e.g., yers, waiting rooms)whether it matches the language of patients served. [51] The location of the healthcare setting in a town or city is important in relation to location of patients [51,52] e.g., is it di cult for patients to get to the point of care? An example even broader includes an air pollution intervention implemented in the U.S. in which low emission zones improved air quality and had positive effects on mortality rates for all residents, but a greater bene t for the wealthiest, widening mortality inequities. [53] Another example is the implementation of one U.S. state's naloxone standing order in which pharmacies could distribute naloxone without a prescription. [54] Results demonstrated 61.7% of retail pharmacies had naloxone available without a prescription. However, naloxone availability was lower in neighborhoods with higher percentages of residents with public health insurance-partially a physical structure problem. This nding was particularly problematic due to an increased cost of naloxone for people on Medicaid (public health insurance) as a result of the statewide mandate. These examples suggest health inequity can be maintained or widened through implementation efforts, such that the most a uent experience a better outcome than others.
Sociopolitical forces. Other societal in uences are social norms or political forces, which can include but are not limited to political support, laws, and social structures such as racism, misogyny, classism, or heterosexism. [46,55] Public health policies (e.g., scal, regulation, education, preventative treatment, and screening) demonstrate positive and negative effects on health inequalities that occur across health domains (e.g., tobacco, food and nutrition, reproductive health services). [44] As another example, a study examined U.S. state legislators' behavioral health research-seeking practices and dissemination preferences and found signi cant variation between Democrats and Republicans, suggesting dissemination materials be tailored to different social norms for different groups. [56] Another example is how ableism (discrimination and stigma against people with mental or physical disabilities) acts as a barrier to implementation. [46] Results How to Use the Three Health Equity Domains as Determinants of Equitable Implementation Three health equity domains can be applied to one's preferred implementation determinants framework.
Implementation determinant frameworks need well-grounded constructs that are clearly de ned, labeled, and described, with suggested validated measures[57]-we provide this in Table 1 for the Health Equity Implementation Framework. We will describe how to use the three health equity domains according to ten recommendations on using implementation frameworks in research and practice. [58] Practical tools are presented in additional les. Refer to Table 2 for an overview of all ten recommendations and de nitions.
We expand in text only on steps relevant for using the three health equity domains. Table 2 Ten Recommendations on Using Implementation Frameworks Step De nition 1. Select a suitable framework. Choose a framework relevant and for your implementation question and population.
2. Establish and maintain community stakeholder engagement and partnerships.
Engage community members to develop/select, adapt, evaluate, and implement an intervention. [11] 3. De ne issue and develop research or evaluation questions and hypotheses.
Specify the problem for the speci c population and intervention you plan to implement.

4.
Develop an implementation mechanistic process model or logic model.
Use your framework to identify and map out the process and different domains through which you believe the intervention will become implemented.

Select research and evaluation methods.
Identify methods and evaluation tools that are speci c to the intervention and population you plan to engage for implementation. There exist for populations experiencing healthcare inequities all the usual research challenges for measuring improvement in health or healthcare, and low prevalence of some issues (e.g., suicide) or low numbers of a population (e.g., gender nonconforming people) make measurement harder. It can be helpful to select an evaluation framework to assess outcomes, as well as selection of outcomes relevant to the implementation.
9. Use a framework(s) at micro level to conduct and tailor implementation.
As implementation progresses, the implementation plan needs to be altered as determinants change.
10. Write the proposal and report. Write a scienti c and/or program report using the Implementation Framework Utilization Checklist as a nal documentation of an implementation effort.
Step 1. Select a suitable framework. The Health Equity Implementation Framework (or three health equity domains adapted to another implementation framework) is population and country agnostic; domains can be adapted to any setting where inequitable implementation occurs. The framework proposes determinants of inequitable implementation and a process (facilitation) by which to address determinants, but it is not an evaluation framework and not suitable for selecting evaluation outcomes.
Steps 3-5. De ne issue and develop research or evaluation questions and hypotheses; Develop an implementation mechanistic process model or logic model; Select research and evaluation methods. For quantitative research questions, between-site or between-group comparisons may answer questions about equitable delivery of care. [59] Potential questions of interest to equitable implementation are: Do speci c people have more access to the innovation who did not before (i.e., reach)? Are systemic changes (e.g., policy changes, increased training for providers) occurring (i.e., adoption)? Are inequities between low-and well-resourced sites or patients decreasing or non-signi cant (effectiveness or implementation delity)? [60] For step 4 (mechanisms), using the three health equity domains (added to another implementation framework, as done in the Health Equity Implementation Framework), one may develop theoretically driven hypotheses about which domains or mechanisms must change to lead to improved equity and implementation success. [61] When working on an inequitable implementation problem, this will ensure some mechanisms related to equity and implementation are investigated. For example, there may be inequity in the research-practice gap related to outer context (e.g., this intervention is only implemented in well-funded institutions that serve mostly a uent people). Clearly identify patient recipients intended to receive the innovation and if there is a subset within this population who experience inequitable access to, quality of, or outcomes of healthcare.
Research and evaluation methods should match existing evidence of the intervention and implementation, but also the evidence related to the inequity or marginalized population. To select an implementation research design, consider the decision tree from Chinman and colleagues. [62] Consult Table 1 for sample measures as possible measures or methods.
Step 6. Determine implementation factors/determinants. This recommendation is most closely aligned with use of Health Equity Implementation Framework to date. [11] If one is using a different implementation framework for a problem in which inequity occurs, adapt the framework to include the three health equity domains described above. Through formative evaluation to assess barriers and facilitators in each domain, [63,64] align qualitative interview guides, quantitative measures, and other assessment methods (e.g., participant observation, policy review) to the framework's determinants-see Table 1. One might also include patient recipient perspectives in formative evaluation, speci cally sampling for those who are experiencing the health or healthcare inequity. We provided an example of an interview guide aligned to domains of the Health Equity Implementation Framework (see additional le 1). Box 1. Application of the Health Equity Implementation Framework to Guide an Equity-Focused Implementation Project: A Case Study The Health Equity Implementation Framework has been applied to guide evaluation of an ongoing implementation project aiming to reduce inequities in the provision and receipt of publicly funded services for individuals with developmental disabilities. In 2016, the State of California Department of Developmental Services made funds available to address signi cant inequities in service expenditures for Latinx clients. In response, local researchers initiated a partnership with the San Diego Regional Center, the primary local purveyor of publicly-funded developmental disability services, to identify inequity reduction targets and develop and implement an inequity reduction model. A mixed-methods needs assessment was conducted to inform model development and activities. Quantitative data was gathered from secondary data extraction and analyses of the purveyor's service utilization data for the previous year. Focus groups with purveyor case managers were held to identify key determinants and sources of inequities from their perspectives. The Health Equity Implementation Framework was applied to guide identi cation of implementation determinants and selection of data coding and analyses for this needs assessment (Steps 5 and 6 described above). Speci cally, the framework informed the development of the qualitative codebook, including identi cation of coding domains and de nitions that were then iteratively re ned and tailored for this project. The framework also guided subsequent mixed-methods data merging and integration, including use of qualitative themes to complement and expand quantitative ndings.
Step 8. Specify implementation outcomes and evaluate implementation. Evaluation frameworks can be helpful in selecting implementation outcomes, [26] and it is essential to also select outcomes to evaluate equity in access to, quality of, or outcomes of implementation. [38,59] The three health equity domains (in addition to typical implementation domains) can be helpful in designing qualitative codebooks or templates for analysis or re-evaluating quantitative measures rst collected during formative evaluation or an earlier data collection period. See Additional File 2 for a codebook for analysis of three health equity domains. Consider innovative analytic techniques to best assess multilevel contributors to implementation success and equity. [65] Step 9. Use a framework(s) at micro level to conduct and tailor implementation. As implementation progresses, an implementation plan will need to be tailored as determinants change. The Health Equity Implementation Framework can be useful for determining areas to assess repeatedly and thus, intervene on, throughout implementation. Doing so ensures an equity lens is applied throughout implementation and that implementation processes, such as planning, strategy use, and goal setting, are thoughtfully executed according to dynamic needs. Repeated assessments can be done through multimodal methods, including ones used previously in formative evaluation. [64] Step 10. Write the report. For documenting results of an implementation effort, clarify how the Health Equity Implementation Framework or its three health equity domains were incorporated. For example, barriers and facilitators from formative evaluation may be presented within framework domains. The multimethod assessment and evaluation approaches used in prior steps will provide key information to be reported, making clear why implementation was successful or not, and how certain strategies affected equitable implementation. [13] Discussion The three health equity domains are key adaptations for implementation scientists and suggested to adapt one's preferred implementation framework (e.g., CFIR) to incorporate an equity lens. This manuscript, tables, and additional les provide some practical guidance and tools for incorporating three health equity domains into an implementation determinants framework. To focus on health equity explicitly at multiple ecological levels in implementation science and practice will elucidate drivers of health inequities such as structural racism, heterosexism, and patriarchy. Thus, discovery of causes of health inequities should necessitate implementation strategies to overcome or resolve such complex and oppressive structures. Future research should focus on implementation strategies (or other processes) used to address the three health equity determinants of unjust health inequities in our healthcare systems and societies.
Implementation science frameworks have been categorized into three types: determinants (establishing what factors determine or predict implementation success), process (clarifying how to address determinants to achieve implementation success), and evaluation (determining metrics and assessment to know when implementation success is achieved). [57] One may also use the Health Equity Implementation Framework in its entirety as an implementation determinants framework, or use the three health equity domains as additions to another implementation determinants framework. For an implementation process framework that incorporates an equity lens, see frameworks proposed by Nápoles and Stewart [12] and Eslava-Schmalbach and colleagues. [60] For an implementation evaluation framework that incorporates an equity lens, see preliminary equity-focused implementation outcomes [60] and the proposed extension of RE-AIM framework. [66] There are limitations to our practical guidance presented here. We have piloted test many, but not all, the feasibility and acceptability of steps using three health equity domains described in the results section.
We have not piloted feasibility and acceptability of all measures suggested in Table 1. However, we suggest these as starting places, and with con dence, as they all have entire bodies of science showcasing their relevance to health equity. Implementation scientists and practitioners must adopt a health equity lens as foundational to any research-practice gap where inequity exists and collect data on the feasibility, acceptability, and predictive utility of three health equity domains.

Conclusion
The Health Equity Implementation Framework provided groundwork for the use of implementation science frameworks to address health inequities by incorporating factors that drive health inequities. [11] This manuscript providers practical tools and explanations for systematic integration of health equity and implementation science in frameworks. These tools can assist implementation scientists and practitioners to concretely address inequity in implementation across populations to capture and analyze information used to assess health outcomes. [23] Abbreviations RSS was a major contributor in writing the manuscript and preparing Tables 1 and 2. PN contributed writing to some implementation and health equity domains, to literature searching and writing in Table 1, and to writing the conclusion.
AMC contributed writing to some implementation and health equity domains and to literature searching and writing in Table 1.
KSD helped conceptualize the purpose of the manuscript, prepared and wrote the case study example, and edited writing of the manuscript.
JEK re ned conceptualizations of the manuscript and edited writing of the manuscript. Health Equity Implementation Framework

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. CodebookThreeHealthEquityDomainsforImplementation.xlsx AdditionalFile1HealthEquityInterviewGuide.docx