Contributions to the literature
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There is an urgent call to address issues of equity, health, and social justice in the USA—driven in part by greater awareness of striking increases in economic inequality and the visibility and impacts of structural racism and associated societal problems.
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Implementation science is an area of research with high potential to accelerate progress toward achieving health equity goals in both public health and healthcare.
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We provide 10 recommendations to advance health equity as a priority of implementation science to address challenges in building the evidence base, developing new measures and methods, and addressing context.
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Actions to address ours and other recent recommendations are likely to further health equity and implementation science.
Background
Key challenges
Limitations of the evidence base
Underdeveloped measures and methods
Inadequate attention to context
First author Focus of study | Year of publication | Type of review | Selected findings |
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Pinto [55] PrEP implementation in the USA | 2018 | Narrative review | Implementation is not often addressing key barriers: • Within healthcare systems, the lack of communication about, funding for, and access to PrEP • The lack of attention to the intersection between PrEP-stigma, HIV-stigma, transphobia, homophobia, and disparities across gender, racial, and ethnic groups |
Yapa [56] Implementation in resource-poor countries and communities | 2018 | Narrative review | Among existing implementation science in resource-poor countries and communities, three key opportunities were identified: • Intervention and methods innovations may thrive under constraints due to higher creativity when choices are restricted • Reverse innovation transferring novel approaches from resource-poor to research-rich settings will gain in importance • Policy makers in resource-poor countries tend to be open for close collaboration with scientists to inform national and local policy |
Alonge [57] Implementation in low- and middle-income countries | 2019 | Systematic review | • Most of the studies were not conducted under routine conditions for management and financing • Most studies do not describe implementation characteristics completely; more complete descriptions are needed on implementation strategies, implementation variables, and the context under which implementation occurs • More rigorous and adaptive research designs are needed to address how to scale-up and sustain interventions |
Harding [58] Implementation in Indigenous communities | 2019 | Systematic review | Among studies of indigenous communities in Australia, Canada, New Zealand, or the USA, four implementation themes were common: • Studies showed high levels of community engagement • From the culture-centered approach, most studies reflected moderate to high levels of community voice/agency • Most studies addressed systems thinking • Approximately 40% of studies included high levels of end user (e.g., policy makers, tribal leaders) engagement reflective of integrated knowledge translation |
Wali [59] Community engagement in Indigenous populations | 2021 | Scoping review | • Key themes included adapting for the local cultural context and the inclusion of community outreach • Despite the claimed use of participatory research methods, only 6 studies involved community members to identify the area of priority and only 5 used Indigenous interviewing to provide feedback |
Recommendations
Domain | Recommendation | Core elements | Actorsa |
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Evidence base | |||
1. Link social determinants with health outcomes | • Build literature linking social determinants with health outcomes of importance to key stakeholders (e.g., funders) • Build the literature on implementation processes in low-resource settings • Identify opportunities to address social risk in primary care • Describe the role of social determinants as moderators of behavior change • Apply equity-relevant guidelines and evidence frameworks | • Funders • Researchers | |
2. Build equity into all policies | • Incorporate health and equity consideration in policy decisions across sectors (Equity in All Policies) • Analyze barriers to change with an equity focus • Frame and communicate policy information in new ways (e.g., framing for audience segments, use of narratives) | • Advocates • State and local practitioners • Policy makers | |
Methods and measures | |||
3. Use equity-relevant metrics | • Expand macro-level metrics to focus on upstream indicators to measure progress toward equity in communities • Identify new metrics in studies to address context and historical disadvantage • Apply existing taxonomies (e.g., outcomes developed by Proctor et al.) in an equity context | • Funders • Researchers • State and local practitioners | |
4. Study what is already happening | • Describe how end users experience implementation • Work with practitioners and policy makers to conduct natural experiments • Enhance the role of equity in tailored implementation | • Funders • Researchers • Program evaluators | |
5. Integrate equity into models | • Identify the focus of existing models regarding equity and related gaps, social determinants, and stakeholder engagement • Identify methods for fully integrating equity into existing models • Use interactive webtools to increase the focus on equity | • Researchers • Program evaluators | |
6. Design and tailor implementation strategies | • Apply lessons from previous studies of implementation and scale-up • Enhance the explicit focus on equity among implementation strategies • Test novel strategies at multiple levels • Enhance the role of adaptive designs in development of equity-relevant implementation strategies | • Researchers • Program evaluators | |
Context | |||
7. Connect systems and sectors outside of health | • Establish the premise that justice across societal sectors is essential • Conduct more disease-agnostic interventions • Apply models and methods from systems science | • Advocates • Funders • Researchers • State and local practitioners • Health system leaders | |
8. Engage organizations, internally and externally | • Internally, assess climate and culture with an equity focus • Evaluate existing programs and policies regarding their equity impacts • Externally, bring on new equity partners, share power and decision-making, and break down funding silos | • Researchers • State and local practitioners • Program evaluators | |
Cross-cutting issues | |||
9. Build capacity for equity | • For the “who” of capacity building, increase engagement of persons in trainings from under-represented minority backgrounds • Re-shape the “how” of trainings with an equity lens on the audience, competencies, engagement, and evaluation • Add new settings to expand the “where” of capacity building | • Funders • Researchers | |
10. Focus on equity in dissemination efforts | • Provide incentives for researchers to engage with end users in ways to improve dissemination • Engage with equity-focused partners early and often in the research process • Develop new dissemination products that resonate with key stakeholders | • Advocates • Funders • State and local practitioners • Researchers |
Improving the evidence base
Link social determinants with health outcomes
First author Focus of study | Year of publication | Type of review | Selected findings |
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Paradies [62] Racism as a determinant of health | 2015 | Systematic review (meta-analysis) | • Racism was associated with poorer mental health (r = − .23; 95% confidence interval (CI) = − .24, − .21) • Racism was also associated with poorer general health (r = − .13; 95% CI = − .18, − .09) and poorer physical health (r = − .09; 95% CI = − .12, − .06) • Among physical health outcomes, racism was associated with diabetes (r = − .02; 95% CI = − .09, .04) |
Purnell [63] Gaps and innovative interventions for health equity | 2016 | Narrative review | • Identified persistent disparities for cardiovascular disease and cancer risk by race and urban-rural residence • Culturally tailored, promotora-based interventions improved mammography screening among Latinas • Use of referrals to community resources to address sociocultural barriers was associated with smoking cessation • A stakeholder-engaged, culturally tailored intervention was effective in controlling blood pressure |
Taylor [64] Impacts of investments in social determinants interventions | 2016 | Narrative review | • Housing support interventions showed reduced healthcare costs and improvements in health outcomes (obesity, diabetes, asthma, HIV) • Nutrition support interventions improved health outcomes (protective for low birthweight and preterm delivery, body weight) • Income support interventions consistently demonstrated a positive impact on health outcomes (infant mortality, disability rates, mental health) • Care coordination and community outreach interventions showed decreased healthcare costs |
Asare [65] Social determinants and cancer disparities | 2017 | Narrative review | • Social and economic factors may negatively affect minority patients’ ability to participate in cancer research • Lack of accessible transportation can restrict access to health and cancer care • Exposure to discrimination may lead to mistrust of elements of this society and suspicion of healthcare systems • The social determinants of health framework posits that all social and economic constructs are interrelated |
Bailey [4] Structural racism and health inequities | 2017 | Narrative review | • Most studies on racism and health have focused on interpersonal racial/ethnic discrimination, with comparatively less emphasis on investigating the health effects of structural racism • Structural racism involves interconnected institutions, whose linkages are historically rooted and culturally reinforced Promising approaches include: • Use of a focused external force that acts on multiple sectors at once (e.g., place-based multisector initiatives such as Promise Neighborhoods) • Disruption of leverage points within a sector that might have ripple effects in the system (e.g., reforming drug policy and reducing excessive incarceration) |
Dendup [66] Environmental risk for type 2 diabetes | 2018 | Systematic review | • Walkability, air pollution, food and physical activity environment, and roadways proximity were the most common environmental characteristics studied • Higher levels of walkability and green space were associated with lower risk of type 2 diabetes • Increased levels of noise and air pollution were associated with greater risk |
Suleman [67] Xenophobia and health | 2018 | Scoping review | • Among individuals living with HIV, xenophobia is a barrier to medical service access • Xenophobia is associated with higher rates of mental health outcomes (e.g., depression, chronic anxiety, psychoses) |
Thomson [39] Health policies and inequalities | 2018 | Umbrella review of systematic reviews | • Results were mixed across the public health domains • Some policy interventions were shown to reduce health inequalities (e.g., food subsidy programs, immunizations) • Some policy interventions had no effect • Some interventions appear to increase inequalities (e.g., 20 mph and low emission zones) |
Naik [38] Macroeconomic determinants of health inequalities | 2019 | Review of systematic reviews | • Policies to promote employment and improve working conditions can improve health and reduce gender-based health inequities • Market regulation of tobacco, alcohol, and food was effective at improving health and reducing inequities (rates of smoking, alcohol use, healthy food consumption) • Privatization of utilities and alcohol sectors, income inequality, and economic crises increase health inequities |
Martinez-Cardoso [68] Social determinants of diabetes management | 2020 | Narrative review | • Diabetes management and care is deterred by housing precarity, food insecurity, poverty, uninsurance and underinsurance, and limited support for immigrants in healthcare systems • Interventions to address diabetes require a more upstream approach to mitigate the drivers of diabetes disparities among immigrants |