Implementation Science to Address Health Disparities During the Coronavirus Pandemic

Abstract

The coronavirus disease 2019 (COVID-19) pandemic is disproportionally affecting racial and ethnic minorities. In the United States, data show African American, Hispanic, and Native American populations are overrepresented among COVID-19 cases and deaths. As we speed through the discovery and translation of approaches to fight COVID-19, these disparities are likely to increase. Implementation science can help address disparities by guiding the equitable development and deployment of preventive interventions, testing, and, eventually, treatment and vaccines. In this study, we discuss three ways in which implementation science can inform these efforts: (1) quantify and understand disparities; (2) design equitable interventions; and (3) test, refine, and retest interventions.

Full text

PERSPECTIVE Open Access
Implementation Science to Address Health Disparities
During the Coronavirus Pandemic
Karla I. Galaviz,
1
Jessica Y. Breland,
2
Mechelle Sanders,
3
Khadijah Breathett,
4
Alison Cerezo,
5
Oscar Gil,
6
John M. Hollier,
7
Cassondra Marshall,
8
J. Deanna Wilson,
9
and Utibe R. Essien
9
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is disproportionally affecting racial and ethnic minorities. In
the United States, data show African American, Hispanic, and Native American populations are overrepresented
among COVID-19 cases and deaths. As we speed through the discovery and translation of approaches to fight
COVID-19, these disparities are likely to increase. Implementation science can help address disparities by guiding
the equitable development and deployment of preventive interventions, testing, and, eventually, treatment and
vaccines. In this study, we discuss three ways in which implementation science can inform these efforts: (1) quan-
tify and understand disparities; (2) design equitable interventions; and (3) test, refine, and retest interventions.
Keywords: health disparities; knowledge translation; equity; health justice
Introduction
The novel coronavirus responsible for coronavirus dis-
ease 2019 (COVID-19), has infected 38 million individ-
uals worldwide and 7.9 million in the United States as
of October 12, 2020 (Ref.
1
). This health crisis has trig-
gered an unprecedented response. From the adoption
of preventive strategies, such as physical distancing,
to conducting clinical trials testing novel drugs and
vaccines, the United States is speeding through the
knowledge translation pipeline
2
faster than ever before.
Indeed the development and human testing of vaccines
against the novel coronavirus took only 65 days,
whereas public health guidelines are revised constantly
based on what we learn every day. In this rapid transla-
tion, the COVID-19 response is leaving some behind—
racial and ethnic minority populations.
National data show African American, Native Amer-
ican, and Hispanic populations are overrepresented
among cases of, and deaths from, COVID-19.
1
More-
over, these disparities are not confined to the treatment
and prevention of COVID-19 but expand to other
facets of health care, such as access to public health
information,
3,4
telemedicine, and care for chronic con-
ditions.
5
As the rate of scientific advancement to fight
COVID-19 moves quickly, COVID-19 disparities are
likely to increase, as we observed during the U.S. H1N1
influenza pandemic.
6
Implementation science, the scientific study of meth-
ods to promote the systematic uptake of evidence-
based interventions into routine practice,
7
can help
understand and address the racial and ethnic dis-
parities exposed during the COVID-19 pandemic.
1
Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, Bloomington, Indiana, USA.
2
Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.
3
Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester, Rochester, New York, USA.
4
General Division of Cardiology, Sarver Heart Center General Internal Medicine, University of Arizona, Tucson, Arizona, USA.
5
Department of Counseling, Clinical and School Psychology, UC Santa Barbara, Santa Barbara, California, USA.
6
Department of Human Development, College of Community and Public Affairs, Binghamton University, Binghamton, New York, USA.
7
Department of Pediatrics, Section of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas, USA.
8
Division of Community Health Sciences, Berkeley School of Public Health, Berkeley, California, USA.
9
Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
*Address correspondence to: Karla I. Galaviz, PhD, MSc, Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, 1025 E 7th Street,
Bloomington, IN 47405, USA, E-mail: kgalaviz@iu.edu
ªKarla I. Galaviz et al. 2020; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Health Equity
Volume 4.1, 2020
DOI: 10.1089/heq.2020.0044
Accepted October 5, 2020
Health Equity
463

Complementing previous perspectives,
8,9
we discuss
three ways implementation science can help build a
more equitable COVID-19 response.
Quantify and Understand Disparities
COVID-19 disparities are exacerbated by the limited
data and understanding of their underlying causes.
As we write, 47 out of 50 states report COVID-19 in-
fection and death rates by race/ethnicity, whereas
only 6 states report COVID-19 testing rates by race/
ethnicity.
10
Furthermore, health centers and insurance
plans have limited the publication of these data for
the patients under their care. This hinders our under-
standing of the COVID-19 burden in these communi-
ties and our ability to increase the reach of available
interventions.
Promising efforts are beginning to emerge. A team
from Emory University has built a COVID-19 Health
Equity Dashboard, a tool that shows the number of
casesanddeathsforeachU.S.countybyage,race,ethnic-
ity, employment status, poverty, and length of commute
to the nearest hospital.
11
The goal of this dashboard is to
identify counties with the greatest COVID-19 burden
and direct resources toward these communities.
More importantly, efforts should be directed toward
unmasking the drivers of these disparities and miti-
gating the myths of racial biology, behavioral racial ste-
reotypes, and territorial stigmatization.
12
For this, we
need to identify the underlying factors that constrain
access to, and benefit from, preventive and curative
COVID-19 interventions. For instance, African Amer-
ican, Hispanic, and other minority populations face
barriers to accessing and understanding COVID-19
health information, such as language and health liter-
acy limitations.
3,13
There are also systemic barriers
such as the availability of COVID-19 testing, with
data from Texas showing testing sites are dispropor-
tionately located in whiter communities.
14
Wide spatial
inequities in COVID-19 positivity and incidence in
three large metropolitan areas of the United States
have also been documented.
15
Implementation science offers approaches that can
help understand factors driving these disparities. For
instance, implementation frameworks can be used to un-
derstand historical context, values, culture, and needs
of minority populations, as demonstrated in a study
exploring inequities in hepatitis C care among African
American veterans.
16
Furthermore, behavioral appro-
aches can be used to identify drivers of health behavior
and inform the design of interventions; this approach
can be used to design interventions for improving shel-
tering in place, mask wearing, and physical distancing
behaviors among minority populations.
17
Metrics to as-
sess gaps in the reach and adoption of interventions in
minority communities and settings are also available.
18
If we make use of these approaches to improve our un-
derstanding of the factors driving health disparities,
our chances of reducing inequities will be better.
Design Equitable Interventions
Efforts to ensure equitable design, implementation,
and effectiveness of interventions against COVID-19
are urgently needed. These efforts should include the
design of interventions that respond to the culture, his-
tory, values, and needs of minority communities. This
is crucial since testing, sheltering in place, and physical
distancing are not options for many. Furthermore, pre-
ventive interventions and testing should be deployed
where minority populations live and work, along with
strategies to facilitate adoption and implementation in
settings that serve these populations. Another critical ac-
tion is to purposefully sample and include minority pop-
ulations in studies testing vaccines and treatments to
understand their applicability and effectiveness in
these populations. Finally, while vaccines and treat-
ments are still in development, now is the time to de-
velop a plan to ensure manufacturing capacity,
financing, and timely distribution across minority
groups. Indeed, the National Academy of Medicine
has issued recommendations to ensure the equitable
distribution of the COVID-19 vaccine.
Although not an early focus in implementation
science, there are now several frameworks focused on
equity,
16,19,20
which can be used to ensure equitable
design, participation, and implementation of interven-
tions. There are also tools to guide the design of inter-
ventions based on individual—(e.g., health literacy
and cultural beliefs), community—(e.g., clinic physical
location), and health system-level characteristics (e.g.,
access and resource distribution)
21
to enhance their
relevance and potential impact. Approaches to enhance
participation and representativeness of minority popu-
lations are also available,
18
as are strategies to enhance
adoption, implementation, and sustainability of inter-
ventions in settings that serve minority populations.
22
Implementation strategies can also be used to promote
the uptake of clinical guidelines and public health rec-
ommendations among health care professionals and
decision makers, something crucial as recommenda-
tions keep emerging. Overall, implementation science
Galaviz, et al.; Health Equity 2020, 4.1
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464

FIG. 1. Examples of how implementation science can be used to address COVID-19 disparities. This figure highlights three ways in which
implementation science can help address COVID-19 disparities: (1) quantify and understand the gap; (2) design equitable interventions; and (3) test,
refine, and retest interventions to optimize for minority populations. The bidirecional arrows indicate information obtained in each step influences
activities and decisions in previous or subsequent steps. This also depicts an iterative process in which understanding and addressing disparities
may require going back and forth between these steps. COVID-19, coronavirus disease 2019.
465

offers approaches to guide the disparity-sensitive
design, distribution, and implementation of interven-
tions to fight COVID-19.
Equitable design and implementation are also rele-
vant for the care of chronic conditions that dispropor-
tionally affect minority populations. Consider the rapid
rollout of telemedicine: early data show that current
wide-scale implementation may increase disparities in
health care access for vulnerable populations with lim-
ited digital literacy or access (e.g., older adults and peo-
ple with limited English proficiency).
5
Implementation
science can be used to enhance participation and repre-
sentativeness of minority groups in telemedicine, to
explore which telemedicine strategies are preferred
(e.g., phone calls and video calls), and to facilitate the
adoption of telemedicine in diverse settings. Finally,
implementation science can help ensure telemedicine
is delivered with fidelity in minority groups, and to
promote its sustainability and continued implementa-
tion in settings that serve these populations.
18
Test, Refine, and Retest
As we deploy COVID-19 preventive and curative inter-
ventions, it is critical to assess whether they are work-
ing in minority populations. Our current COVID-19
response is failing at this because it models what has
been done for other health conditions
23
: interventions
have not been designed for, or tested in, racial and eth-
nic minorities. Also important is the continuous assess-
ment of interventions, as adaptations and refinement
may be needed to keep up with the changing nature
of COVID-19. Testing and refining of interventions
should be guided by comprehensive sociodemographic
data to ensure feasibility of implementation, enhance
relevance, and improve effectiveness of interventions
across racial and ethnic minorities.
Implementation science offers study designs that can
be used in this endeavor. For instance, quasi-experimental
designs are particularly relevant for testing preventive and
treatment approaches in cases when randomization to
control conditions is neither be feasible nor ethical.
24
Pragmatic trials allow for the testing of interventions in
real-world settings or routine practice conditions
25
:
these can be used to assess whether infection rates change
after implementation of testing sites in minority commu-
nities, or to examine how infection rates compare with
those of communities with no access to testing. Adaptive
study designs
26
allow for testing of interventions that
change based on how participants receiving it respond:
these can be used to adapt interventions based on the
changing needs of minority populations. Step-wedge de-
signs allow the staggered rollout of promising treatments
in entire hospitals, settings, or communities that serve
minority populations.
2
The staggered rollout can fa-
cilitate implementation of interventions for which
resources are scarce, and can help stop rollout of in-
terventions that are not working in minority popula-
tions, avoiding waste of resources.
Finally, hybrid effectiveness–implementation study
designs can be used to identify and address underlying
factors driving disparities in both effectiveness and im-
plementation of interventions.
27
Specifically, there are
three types of hybrid study designs that allow the
simultaneous testing/assessment of intervention effec-
tiveness and the testing/assessment of intervention
implementation. These hybrid study designs can be
used to accelerate the implementation of effective inter-
ventions in settings serving minority communities. The
examples outlined here are summarized in Figure 1.
Conclusion
The national COVID-19 response should address, not ex-
acerbate, health disparities. As we speed through the
knowledge translation pipeline, we have a unique oppor-
tunity to use implementation science and address the ra-
cial and ethnic health disparities COVID-19 has exposed.
Successfully addressing disparities amid a global pan-
demic will ensure that not only the most vulnerable but
also all individuals have access to, and benefit from, qual-
ity health care and public health interventions. Although
we focus on COVID-19, the approach we outline here
could also help tackle health disparities across several con-
ditions. The lessons are clear and opportunities to tackle
ingrained health injustices in this country are paramount.
Acknowledgments
The authors want to thank Drs. Kirsten Bibbins-
Domingo, Adithya Cattamanchi, Margaret Handley,
and Alicia Fernandez of the University of San Fran-
cisco California for their mentorship and support.
Author Disclosure Statement
No competing financial interests exist. Views represent
those of the authors and do not necessarily represent
those of the Department of Veterans Affairs or the
U.S. government.
Funding Information
This work was supported by the Research in Imple-
mentation Science for Equity (RISE) program funded
Galaviz, et al.; Health Equity 2020, 4.1
http://online.liebertpub.com/doi/10.1089/heq.2020.0044
466

by the National Health Lung and Blood Institute
(5R25HL126146-05) through the Programs to Increase
Diversity Among Individuals Engaged in Health-
Related Research (PRIDE). Dr. Galaviz is supported
by NHLBI (1K01HL149479-01). Dr. Breland is sup-
ported by a VA Health Services Research and Develop-
ment Career Development Award at the VA Palo Alto
(CDA 15-257). Dr. Breathett is supported by NHLBI
K01HL142848, R25HL126146 subaward 11692sc, and
L30HL148881; University of Arizona Health Sciences,
Strategic Priorities Faculty Initiative Grant; and Univer-
sity of Arizona, Sarver Heart Center, Novel Research
Project Award in the Area of Cardiovascular Disease
and Medicine, Anthony and Mary Zoia Research
Award. Dr. Hollier is supported by the National Insti-
tute of Diabetes and Digestive and Kidney Diseases
(K23 DK120928).
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Cite this article as: Galaviz KI, Breland JY, Sanders M, Breathett K,
Cerezo A, Gil O, Hollier JM, Marshall C, Wilson JD, Essien UR (2020)
Implementation science to address health disparities during the
coronavirus pandemic, Health Equity 4:1, 463–467, DOI: 10.1089/
heq.2020.0044.
Abbreviation Used
COVID-19 ¼coronavirus disease 2019
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