Background
What is implementation science and implementation research?
Why is IR research different in general?
Methods
Results
First phase
Models | Aspects of equity | Relevant issues for the development of the EquIR conceptual framework |
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National framework for health sector monitoring, evaluation, and analysis [27] | General | • Monitoring and evaluation if implementation: access and availability of services, coverage of interventions and impact (health condition, ability to respond) |
Impact evaluation framework [28] | General | • Program Planning: Effectiveness analysis, equity analysis, health systems analysis, scale-up analysis, and policy analysis |
Framework for strengthening health systems [29] | General | • Program Planning: Benefits for strengthening health systems |
Promoting Action on Research Implementation in Health Services (PARISH) [20] | Race/Ethnic | • Program Planning: A diagnostic and evaluative measure of evidence and context elements. • Design: Determination of the most appropriate facilitation method. |
Child Health and Nutrition Research Initiative (CHNRI) [30] | Children’s health | • Program Planning: o Research question: description, delivery, development and discovery research. o Identification of disadvantaged group: prioritization of research ideas in terms of answerability, effectiveness, deliverability, maximum potential for disease burden reduction, and effect on equity • Design: facilitated consensus development through measuring collective optimism. |
Conceptual Model for Racial and Ethnic Disparities in Healthcare [31] | Race/Ethnic | • Program Planning: make recommendations for future interventions to reduce disparities |
Implementing health promotion tools in Australian Indigenous primary healthcare [32] | Race/Ethnic | • Program Planning: Participation agreements, orientations, and training. • Design: Quality assessments, feedback and action planning. • Implementation tools |
Large-scale fortification of condiments and seasonings as a public health strategy: equity considerations for implementation [33] | General | • Implementation of equity strategies: Enhancing the capabilities of the public sector, improving the performance of implementing agencies, strengthening the capabilities and performance of frontline workers, empowering communities and individuals, and supporting multiple stakeholders engaged in improving health. |
Equity-focused knowledge translation toolkit [34] | General | • Getting ready, starting in the right place and developing a comprehensive strategy. • Building a coalition of partners, determining the current challenge (planning your equity-focused knowledge translation strategy), and clarifying your intended audience |
Second phase
Country | IR theme | Equity consideration | Disadvantaged Population | |
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Argentina | Before | “Health policies implementation unit for the imprisoned population in Buenos Aires.” | To evaluate the possibility to implement focused strategies for disadvantaged populations inside the prisons. | Authors identified transgender individuals as more disadvantaged population inside prisons and developed a focused strategy for them. However, it was not explicit in the initial proposal |
After | “Barriers and facilitators of a tuberculosis prevention and control implementation program in imprisoned population, in Buenos Aires” | |||
Bolivia | Before | To identify barriers to “Nutritional Chispitas” in children 6 to 23 months old attending a primary healthcare center in the Andean Health Network | Children that do not attend these programs present greater social disadvantages | Children 6 to 23 months old of the Andean Health Network including those who go and who do not go to the primary healthcare centers and receive care under “Mi Salud” Program |
After | To identify barriers and facilitators to “Nutritional Chispitas” in children 6 to 23 months old attending primary healthcare centers, and by Mi Salud Program | |||
Brazil | Before | Psychosocial Attention Network Qualification Program (RAPS) | There is no mention of a socio-economic disadvantaged population with higher risks of mental illness | It was not included in the final version of the proposal. It was suggested to consider a population with mental illness, specifically those with a higher grade of social disadvantage. It was suggested to include them in the analysis. |
After | Implementation research of strategies to strengthen leadership to guarantee the rights in the CAPS of São Bernardo do Campo / SP. | |||
Chile | Before | Policy on interchangeability of medications in Chile | It was suggested to the authors to evaluate the impact on out-of-pocket payments related to medicines | The authors focused the project on the private market. However, it won’t be possible to know the impact on different income quintiles of the population, because this information is not available in the database. |
After | Medication interchangeability policy implementation of medicaments in Chile | |||
Colombia | Before | “Por ti Mujer” Program for early detection and treatment of women with cervical anomalies. | The program could implement strategies of vertical equity to improve the adherence of the more disadvantaged population. | A disadvantaged population is not identified in the final version. However, it was suggested to the authors to analyze the population from the perspective of ethnicity and a socio-economic variable. |
After | “Por ti Mujer” Program | |||
Perú | Before | Inter-programmatic articulation of tuberculosis and mental health for the National Tuberculosis Prevention and Control health strategy | Adherence to TB treatments of patients with mental disorders is a problem. However, it was suggested to consider also TB patients with mental disorders that are not near healthcare centers, and can be further disadvantaged. | The initial proposal and researchers were changed. Callao is a Peruvian region with a high social disadvantage in many aspects -economic, access to healthcare, standard of living, population density, sanitation, etc. A multi-sectoral approach was suggested considering these social determinants of health. |
After | Implementation factors and treatment adherence of the Tuberculosis Prevention and Control National health strategy at Callao - Perú | |||
Dominican Republic | Before | Family planning program | The perspective of gender equity is included from the beginning. It was suggested to consider male adolescents that do not have access to the family planning program, given that they are usually in a more disadvantaged condition than those who really do. | The socio-economic perspective is not identified in this new version. However, it was suggested to include it in the analysis. |
After | Gender and contraception in the Dominican Republic: a look at men |
Third phase
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1st Step: To identify the health status of the population as the starting point in each cycle and as the focus of the health program or intervention. This step must include the health status of the general population as well as of the disadvantaged population. It is a crucial step because it could affect the results of the program, and specifically, the results for the disadvantaged population. In the case of Bolivia, the program was going to be implemented in a disadvantaged community of children. However, at the beginning it focused on children with the possibility of access to a primary healthcare center. Within this community, children unable to attend a healthcare center are more disadvantaged than others and would not benefit from the program. Consequently, the authors changed the way of implementing the program with a view of having a positive effect on children living far away from health centers.
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2nd Step: In the equity focused planning phase of the program (EquIR Planning Phase), it is important to identify the relevant research questions, taking into consideration the disadvantaged populations potentially impacted by the program (positive or negatively); and to quantify the inequalities to be solved and the possible equity-focused or equity-sensitive recommendations (preferably based on evidence) to be implemented with the program. During this phase, the aim should be to diminish current inequalities, or at least, not to increase them. The researcher of the Bolivian proposal planned the program and following consideration of the most disadvantaged among the disadvantaged, proceeded to involve new players that could facilitate the implementation of the program, including children living in remote rural areas.
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3rd Step: During the EquIR design phase, the following is suggested: to identify key players for implementing equity-focused recommendations (e.g., health professionals, patients, community, stakeholders and others); and to identify barriers and facilitators for the implementation of equity-focused recommendations. During this phase, it is relevant to consider equity-focused implementation outcomes in order to identify the best research design to evaluate the impact of implementing the program based on those outcomes (Fig. 1). In the Bolivian case, researchers will use a qualitative design to evaluate the variables that affect adherence to the Program, including families that attend the primary healthcare centers and families living in remote rural areas, visited by providers of the “Mi Salud” program. This was included in the project during the design. Researchers also included anemia and child nutrition as variables routinely monitored under the program. Identification of barriers and facilitators during this phase is the essential previous step to build on.
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4th Step: The following is suggested for the EquIR implementation: to design strategies aimed at overcoming the barriers identified; to define resources and incentives; to define the monitoring and evaluation strategies; and to design the equity-focused communication strategies to be used in the next phase. In the Bolivian case, the researchers talked with policy-makers and government agencies in order to facilitate the participation of visitors from the “Mi Salud” program within the implementation phase of this program.
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5th Step. In the EquIR implementation outcomes phase, it is expected that the impact of the Program will be monitored using classical implementation outcomes defined in Implementation Research [22], but these should have an equity focus, as suggested in Table 3. During this phase, it is essential to evaluate and monitor the outcomes established. In our examples, in Brazil, Colombia, Peru and the Dominican Republic, which did not explicitly include a disadvantaged population, to the use of these equity focused implementation outcomes was suggested. In the Bolivian case, they were included from the EquIR planning phase.
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6th Step and 1st Step: The equity-focused health population status is included as the final step and the new starting point of this or any other program designed to improve inequalities. The new heath population status is the best possible outcome to monitor the implementation of health interventions or programs. However, these are long-term outcomes that are not preferred by politicians or policy-makers, or by researchers that need to know if it is convenient to continue with the program when health outcomes have not changed. In this case, the EquIR implementation outcomes are the best way to know if the program is improving health inequalities across the implementation outcomes in the short-term. If a program is not able to improve EquIR implementation outcomes in the short-term, inequalities in the health population status will not be improved in the long-term. From this perspective, the equity-sensitive IR outcomes approach would lead equity-sensitive improvements in program and policy processes that finally drive to positive population health outcomes. The iterative process proposed here with this model allows the evaluation of the impact of the program with a before-after design, emphasizing the impact on a disadvantaged population. Each of the implementation outcomes, or a set of them, could require a different kind of research design, depending on the research questions and the disadvantaged population defined from the start, during the planning phase of the program (Fig. 1).
Implementation outcomes | Equity-focused Definition |
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Acceptability | The perception among the key players in implementation: health professionals, stakeholders, patients, community, disadvantaged population and others. |
Adoption | The intention, utilization or action to try to employ the sensitive equity recommendation in the new program or intervention. |
Appropriateness | The relevance or perceived fit, or usefulness or practicability of the program or intervention in the disadvantaged population. |
Feasibility | The extent to which the program or intervention allows to reduce the barriers, and can be carried out in any setting, especially among disadvantaged populations. |
Fidelity | The adherence of disadvantaged population to the equity-focused implementation program or intervention. |
Implementation cost | Total cost of the program implementation in disadvantaged and non-disadvantaged populations, and the final adjusted cost-effectiveness economic evaluation. |
Coverage | The degree of reach, access, service spread or effective coverage (combining coverage and fidelity) on the disadvantaged population eligible to benefit from the program or the intervention. |
Sustainability | The maintenance, continuation or durability of the program or intervention implemented through short, medium and long-term strategies, including disadvantaged populations. |
Discussion
Innov8 is proposed for use with current programs in order to design or re-design them in an attempt at addressing health inequalities. Although monitoring and evaluation strategies are included to propose new changes, there are no explicit components related to implementation research or equity-focused implementation research.“1. Complete the diagnostic checklist; 2. Understand the program theory; 3. Identify who is being left out by the program; 4. Identify the barriers and facilitating factors experienced by subpopulations. 5: Identify the mechanisms that give rise to health inequities; 6. Consider inter-sectorial action and social participation as central elements; 7. Produce a redesign proposal to act on the review findings; and 8. Strengthen monitoring and evaluation” [50].