Health equity occurs when all people have socially just opportunities for optimal well-being. Disparities in healthcare implementation exist when a healthcare innovation, such as a program or treatment, is delivered with significantly worse access, receipt, use, quality, or outcomes for certain populations compared to others.[1] Structural factors and systems greatly contribute to different as well as unjust or unfair treatment of certain populations. Populations that experience worse health or health care might be defined by race, ethnicity, sexual orientation, gender identity, socioeconomic status, functional limitation, or other characteristics;[2] we refer to these groups as marginalized populations based on social, economic, and/or environmental disadvantage that accompanies health inequities.[3] One example of an implementation disparity in United States (U.S.) pediatric healthcare is screening and diagnosis of autism spectrum disorder. Although there are valid and reliable autism screenings and clear criteria for diagnosis, racial and ethnic minority children who meet criteria are less likely to be diagnosed than non-Hispanic white children.[4] Thus, effective screenings and diagnoses are implemented inequitably for racial and ethnic minority children, resulting in delayed treatment for children of color. This implementation disparity is exacerbated when children are finally diagnosed properly with autism, as children of color are less likely to receive quality treatment.[5] Unfortunately, several implementation disparities may be undetected. As Braveman wrote, “Health disparities are the metric we use to measure progress toward achieving health equity.”[3]
Overall, implementation science has yet to actively and systematically assess, address, and evaluate unique factors contributing to healthcare inequities, including institutional and structural problems, such as racism, that are economic, regulatory, social, historical, and political determinants of implementation for marginalized groups.[6] There are many reasons why implementation researchers have yet to showcase solutions to healthcare inequities including: underrepresentation of marginalized and resource-poor communities in implementation studies,[6,7] lack of true engagement with marginalized communities in developing implementation science and practice,[8] lack of consistent methods and data elements related to equity across implementation studies,[9] and exclusivity and social injustice within the implementation science workforce perpetuated by structures making it harder for institutions to recruit and retain marginalized people (e.g., school-to-prison pipeline). Also, disparities exist for innovations being implemented and, if not adapted for marginalized populations, implementation may perpetuate exclusion of marginalized communities and widen health inequities.[6] Similar to implementation studies, marginalized populations have historically been excluded from clinical trials and efficacy studies.[10] Further, innovations are often not designed nor as efficacious for marginalized populations.[11–13] Thus, the limitations of disparities in innovation development can be inherited by implementation science and likely perpetuated if implementation does not systematically consider disparity determinants, cultural adaptations, and other ways to ensure health equity.
Outside the U.S., health equity and implementation research predominantly focus on a specific marginalized population, which is an important and valid path toward equity.[9,14–16] Examples in low and middle income countries include measurement tools normed with participants from those countries,[17] adapting innovations or delivery methods specifically to those populations,[18] and reviewing or developing frameworks specific to those countries.[14,19,20] Although adaptations to local contexts is important, there remain gaps in applying principles of health equity to implementation research broadly, partly because locally adapted frameworks are not easily generalizable to other countries or contexts. The current charges to implementation researchers to ensure health equity in their efforts[6,21] are not possible without adapting implementation determinant frameworks to first capture and understanding barriers to equitable implementation.
Implementation Determinant Frameworks with an Equity Focus are Needed
Implementation science frameworks have been categorized into three types: determinant (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).[22] Implementation determinant frameworks are key to inform study design and selection of strategies to match contextual needs; yet, we have only recently considered determinants unique to health inequities, starting with the Health Equity Implementation Framework.[23] We first piloted health equity domains within the context of a determinant framework as this type of framework represents the key first step to detecting (and eventually addressing) implementation disparities. If implementation researchers and practitioners could meaningfully and practically assess and understand determinants of implementation disparities, this would allow them to adapt the innovation and implementation strategies for marginalized populations, and detect health equity determinants as potential moderators for implementation success/failure.[21] Unfortunately, most implementation determinant frameworks have yet to be explicitly adapted for or tested within health equity efforts and any that do appear too vague to be used meaningfully.[24]
Our prior work documented and piloted adaptations of one existing implementation determinant framework with three health equity domains to create the Health Equity Implementation Framework.[23] One may also use the Health Equity Implementation Framework in its entirety as an implementation determinant framework, or use the three health equity domains as additions to another implementation determinant framework. Many researchers and practitioners have requested clarification of the Health Equity Implementation Framework domains for practical use. Damschroder argued that implementation frameworks must describe how domains are well-grounded in existing literature, provide clear definitions, and offer suggested validated implementation strategies.[22] Therefore, we review definitions of domain of the Health Equity Implementation Framework in more depth than in prior work, showcase two applications of this determinant framework from the literature, and delineate steps to incorporate health equity domains in an implementation determinant framework, with sample measures and data collection tools for each domain.
Health Equity Implementation Framework
In the Health Equity Implementation Framework, we proposed determinants believed to predict successful and equitable implementation, seen in Figure 1.[23] These determinants are grouped under domains. We define domains as broad constructs relevant to implementation and health equity success. Within each domain are several determinants or specific factors that are measurable and, together in constellation with other determinants, clarify barriers, facilitators, moderators, or mediators to implementation and health equity success. This framework was developed for health care and clinical practice settings.[25] In the Health Equity Implementation Framework, we added three health equity domains to the Integrated Promoting Action on Research in Implementation in Health Services (i-PARIHS) framework,[26] which also proposes a process—facilitation—by which change in each domain would occur.[25,26] The focus of this manuscript is on the three health equity domains, rather than facilitation, as science is still emerging on how implementation processes should be tailored or adapted to promote equity.
[insert Figure 1 here – Health Equity Implementation Framework]
Domains Typical in Implementation Determinant Frameworks.
Broad domains typical in implementation determinant frameworks focus on factors spanning 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).[27] These domains can be further specified, such as inner setting or outer setting within an organization.[28] Domains from i-PARIHS are the basis of the Health Equity Implementation Framework and include those typical in most implementation determinant frameworks.[27] Determinants within each domain act to enable or constrain implementation and each domain is briefly defined below.
Innovation. Innovation refers to the treatment, intervention, practice, or new “thing” to be implemented, adopted by providers and staff, and delivered to patients.[29] The innovation may be a program, practice, principle, procedure, product, pill, or policy.[30]
Recipients. Recipients are individuals who influence implementation and those who are affected by its outcomes, both at the individual and collective team levels.[26] In health care, recipients are 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.[26] 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., specific 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.[28] In i-PARIHS, facilitation is the “active ingredient” or process.[31] Facilitation involves implementation strategies that result in implementation coming to fruition.[32,33]
Domains Known to Affect Health Equity. The Health Equity Implementation Framework incorporates these domains known to affect health disparities and thus, equity: 1) cultural factors, such as medical mistrust, demographics, or biases of recipients;[34–37] 2) clinical encounter or patient-provider interaction;[38–40] and 3) societal context including physical structures, economies, and social and political forces.[41–43] We added these three health equity domains, described below, from existing research that have clear, strong associations with disparities in health status, access to, quality of, or outcomes of health care,[44] or there is enough evidence to suggest determinants within these domains should be considered.[e.g., 45]
- Cultural factors of recipients. Recipients in the implementation process are individuals who will consume a particular innovation (e.g., patients, providers).[26] Cultural factors of recipients are the unique characteristics to a particular group in the implementation effort (e.g., patients, staff, providers) based on their lived experience. 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.[36,37] Factors from both the patient and provider might include individual differences in, for example, age, pre-existing stereotypes, or lack of trust that could hinder the interaction.[40] Cultural factors will vary by group, local context, and individuals. It is crucial that cultural factors of recipients are considered as determinants or potential moderators in implementation success/failure when patients belong to a group experiencing a health or healthcare disparity.
- Clinical encounter (patient-provider interaction). This domain describes the transaction that occurs between patients and provider in health care appointments, where decisions concerning diagnoses and treatment are made, and providers administer care.[46] The clinical encounter is important to assess because there are a myriad of behaviors and perceptions during the clinical encounter that affect whether an innovation is offered by a provider and whether it is accepted by a patient. Behaviors will vary by innovation, context, and recipients and may be especially important for patients who experience health or healthcare disparities due to unequal power between them and providers. Factors to measure might be how recipients maneuver the conversation accordingly to achieve their individual and shared goals.[40,47] It would also be important to capture unconscious or implicit bias from either recipient about the other recipient’s characteristics, such as race, weight, or perceived sexual orientation.[48–50] These unconscious biases may manifest in unhelpful behaviors during the encounter, such as dismissing someone’s concerns, interrupting the other person, or not smiling, touching, or making eye contact. Clinical encounters predict patient satisfaction, trust, and health outcomes; thus, it is crucial to assess and address what occurs during the clinical encounter, especially with regards to implementation disparities.[47,50–52]
- Societal context: Economies, physical structures, and sociopolitical forces. This domain is similar to social determinants of health, yet also incorporates more upstream determinants (e.g., governance) that have been investigated less relative to mid- or downstream determinants (e.g., neighborhoods).[44] Societal context includes three specific determinants: 1) economics, 2) physical structures, and 3) sociopolitical forces. In piloting the Health Equity Implementation Framework, societal context affected receipt of antiviral Hepatitis C Virus medicine for Black patients in the U.S. Veterans Health Administration.[23]
Economies. There are four typical structures of economies including a traditional economy (i.e., mostly agricultural), market economy (i.e., firms and private interests control capital), command economy (i.e., government controls capital), and a mixed economy (combination of command and market).[53] 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.[41]
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.[41] Physical structures include any factors in where people have to physically go to get healthcare and what environmental elements people may be exposed to (e.g., privacy or lack thereof, what they see, what is emitted in the air and into their bodies). One example in healthcare settings is type and quality of language translations of information displayed (e.g., flyers, waiting rooms)—whether it matches the language of patients served.[54] The location of the healthcare setting in a town or city is important in relation to where patients reside [54,55] e.g., is it difficult for patients to get to the point of care? Another example is the implementation of one U.S. state’s naloxone standing order in which pharmacies could distribute naloxone without a prescription: 61.7% of retail pharmacies had naloxone available without a prescription.[56] However, naloxone availability was lower in neighborhoods with higher percentages of residents with public health insurance—a physical structure problem (lower availability of naloxone in some neighborhoods) interacting with an economic factor (public health insurance). This finding was particularly problematic due to an increased cost of naloxone for people on public health insurance as a result of the statewide mandate.
Sociopolitical forces. The third societal context describes social norms or political forces, which can include but are not limited to political support, laws, and social structures in which linkages between institutions perpetuate oppression, such as racism, misogyny, classism, or heterosexism.[43,57] For instance, public health policies (e.g., fiscal, regulation, education, preventative treatment, and screening) demonstrate positive and negative effects on health disparities occur across health domains (e.g., tobacco, food and nutrition, reproductive health services).[41] As another example, a study examined U.S. state legislators’ behavioral health research-seeking practices and dissemination preferences and found significant variation between Democrats and Republicans, suggesting dissemination materials be tailored to different social norms for different groups.[58]
Next, we showcase two examples of how implementation teams have used cultural factors of recipients, patient-provider clinical encounter, and societal context as health equity domains in formative and process evaluations. Each example comes from different health service sectors and describes efforts focused on implementation disparities.
Conducting a formative needs assessment prior to implementation
The Health Equity Implementation Framework has been applied to guide a needs assessment for an implementation project aiming to reduce inequities in the provision and receipt of publicly funded services for individuals with developmental disabilities in the U.S.[59] In 2016, the State of California Department of Developmental Services made funds available to address significant inequities in service expenditures for Latinx clients. In response, the San Diego Regional Center, the local agency coordinating and funding publicly-funded developmental disability services, initiated a partnership with local services and implementation researchers 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 implementation activities. Quantitative data included administrative data from the previous year. Qualitative data were gathered from focus groups with Regional Center case managers to identify key determinants of inequities from their perspectives.
The Health Equity Implementation Framework guided identification of implementation determinants and selection of data coding and analyses. Specifically, the framework informed the development of the qualitative codebook, including coding domains and definitions that were iteratively refined for this project. The framework guided subsequent integration of qualitative and quantitative data, including use of qualitative themes to complement and expand quantitative findings. Preliminary findings indicate a significant impact of outer and inner context on inequities, including fit between patient recipient characteristics, cultural factors, and characteristics of available innovations. Additional outer context factors, including sociopolitical factors and physical structures such as location (urban versus rural) also impact service utilization, including interactions with provider factors and innovation characteristics.[59]
Conducting a process evaluation to categorize ongoing barriers/facilitators
In Toronto, Canada, legally sanctioned supervised consumption services (the innovation) are integrated within health centers; implementation has occurred and is ongoing. Supervised consumption services are for people who inject drugs to receive sterile injection equipment and inject under staff supervision. Staff educate on safer injecting, provide referrals to services, and can respond to overdoses, reducing transmission of infectious diseases (e.g., HIV) and overdose deaths. Researchers used ethnographic observation and individual semi-structured interviews with 24 patients who injected drugs in supervised consumption services at two community health centers, half of who were people of color or Indigenous to Canada.[60]. After coding, researchers interpreted findings within domains of the Health Equity Implementation Framework.
Integrating legally sanctioned supervised consumption services within health centers (sociopolitical force) provided clients access to other health services, including dentistry and medical assistance that eliminated the need for a provider visit (characteristics of the innovation, organizational context). Patients appreciated having everything in one physical place (physical structure). One participant said the services allowed them to avoid meeting providers who were prejudice against drug use (sociopolitical force, provider cultural factor).
Yet, there were barriers to implementation. Patients were uncomfortable being seen by peers using the center due to stigma about drug use (sociopolitical force). Spatial limitations at the center made it difficult to have privacy while injecting (physical structure). Patients preferred the center to be open all the time (organizational context), but there were not enough staff for that flexibility (healthcare system context). Ethnographic observation suggested standalone supervised consumption services were consistently busier than integrated services, potentially because some people felt uncomfortable in a healthcare setting (patient factor).