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Implementation Science to Address Health Disparities During the Coronavirus Pandemic

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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.
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
http://online.liebertpub.com/doi/10.1089/heq.2020.0044
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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... Low trust in the health system, reported as a lack of trust in government and medical professionals in general, was cited as a barrier to seeking COVID-19 testing by six sources [16, [26][27][28][29][30]. Due to the nature of the sources, there is limited validated evidence that trust in the health system impacts the likelihood that an individual will or will not seek COVID-19 testing. ...
... Distrust in the health system combined with minority status results in decreased access to testing and overall disparities in access to COVID-19 care. Histories of systemic abuse and exploitation of minorities by the medical and research communities, such as the Tuskegee syphilis experiment, were cited by two sources [26,29] as a cause of distrust in the healthcare system. ...
... Another proposed making testing sites more convenient by providing drive-through testing, which could help to address the fear of infection [59]. Galaviz et al. (2020) proposed ongoing monitoring and evaluation of testing interventions and their impact on access, where factors such as culture, history, values and needs of minority communities are considered [29]. ...
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Background Testing is a foundational component of any COVID-19 management strategy; however, emerging evidence suggests that barriers and hesitancy to COVID-19 testing may affect uptake or participation and often these are multiple and intersecting factors that may vary across population groups. To this end, Health Canada’s COVID-19 Testing and Screening Expert Advisory Panel commissioned this rapid review in January 2021 to explore the available evidence in this area. The aim of this rapid review was to identify barriers to COVID-19 testing and strategies used to mitigate these barriers. Methods Searches (completed January 8, 2021) were conducted in MEDLINE, Scopus, medRxiv/bioRxiv, Cochrane and online grey literature sources to identify publications that described barriers and strategies related to COVID-19 testing. Results From 1294 academic and 97 grey literature search results, 31 academic and 31 grey literature sources were included. Data were extracted from the relevant papers. The most cited barriers were cost of testing; low health literacy; low trust in the healthcare system; availability and accessibility of testing sites; and stigma and consequences of testing positive. Strategies to mitigate barriers to COVID-19 testing included: free testing; promoting awareness of importance to testing; presenting various testing options and types of testing centres (i.e., drive-thru, walk-up, home testing); providing transportation to testing centres; and offering support for self-isolation (e.g., salary support or housing). Conclusion Various barriers to COVID-19 testing and strategies for mitigating these barriers were identified. Further research to test the efficacy of these strategies is needed to better support testing for COVID-19 by addressing testing hesitancy as part of the broader COVID-19 public health response.
... Implementation research can enhance the reach and sustainability of behavioral interventions and consequently, increase behavioral medicine's impact on reducing health disparities. A growing body of literature emphasizes the critical need for closer integration of health equity and implementation research [12][13][14][15][16]. Similarly, more health equity-focused implementation research in behavioral medicine is vital to eliminating disparities in health. ...
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Disparities in health persist despite the development of innovative and effective behavioral interventions. Both behavioral medicine and implementation science are vital to improving health care and health outcomes, and both can play a critical role in advancing health equity. However, to eliminate health disparities, more research in these areas is needed to ensure disparity-reducing behavioral interventions are continually developed and implemented. This special issue on interventions to promote health equity presents a diverse set of articles focused on implementing behavioral interventions to reduce health disparities. The current article summarizes the special issue and identifies key themes and future considerations. Articles in this special issue report on behavioral medicine intervention studies (including those examining aspects of implementation) as well as implementation science studies with implications for behavioral medicine. Articles discuss community-, provider-, and system-level interventions; implementation processes; and barriers and facilitators to implementation. Also included are commentaries calling for greater prioritization of behavioral medicine and implementation research. As evidenced in this special issue, behavioral medicine is primed to lead the implementation of behavioral interventions in historically marginalized and minoritized populations to advance health equity and improve overall population health.
... Indeed, achieving equity would have also required early concomitant prioritization and efforts to target structural barriers to vaccine uptake and reasons for later adoption [45]. Several programs demonstrated success using early, low barrier, and widely available access to vaccines at community-based sites (as opposed to mass vaccination sites and large health systems, often requiring online registration) in areas with high social vulnerability, coupled with abundant opportunities to connect with and discuss concerns with trusted sources of information [30,34,41,[46][47][48][49][50]. A program in San Francisco leveraged a community-based vaccination site near a transportation hub to target both access and trust-related barriers, and leveraged both high-touch (e.g., going door-to-door to provide information and register individuals) and low-touch methods (e.g., flyers and advertisements) [50]. ...
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Background Equity in vaccination coverage is a cornerstone for a successful public health response to COVID-19. To deepen understanding of the extent to which vaccination coverage compares with initial strategies for equitable vaccination, we explore primary vaccine series and booster rollout over time and by race/ethnicity, social vulnerability, and geography. Methods and findings We analyzed data from the Missouri Department of Health and Senior Services on all COVID-19 vaccinations administered across 7 counties in the St. Louis region and 4 counties in the Kansas City region. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip-code-level Social Vulnerability Index (SVI), vaccine location type, and COVID-19 disease burden. We adapted a well-established tool for measuring inequity—the Lorenz curve—to quantify inequities in COVID-19 vaccination relative to these key metrics. Between 15 December 2020 and 15 February 2022, 1,763,036 individuals completed the primary series and 872,324 received a booster. During early phases of the primary series rollout, Black and Hispanic individuals from high SVI zip codes were vaccinated at less than half the rate of White individuals from low SVI zip codes, but rates increased over time until they were higher than rates in White individuals after June 2021; Asian individuals maintained high levels of vaccination throughout. Increasing vaccination rates in Black and Hispanic communities corresponded with periods when more vaccinations were offered at small community-based sites such as pharmacies rather than larger health systems and mass vaccination sites. Using Lorenz curves, zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations while representing 25% of the total population, cases, deaths, or population-level SVI, respectively. When tracking Gini coefficients, these disparities were greatest earlier during rollout, but improvements were slow and modest and vaccine disparities remained across all metrics even after 1 year. Patterns of disparities for boosters were similar but often of much greater magnitude during rollout in fall 2021. Study limitations include inherent limitations in the vaccine registry dataset such as missing and misclassified race/ethnicity and zip code variables and potential changes in zip code population sizes since census enumeration. Conclusions Inequities in the initial COVID-19 vaccination and booster rollout in 2 large US metropolitan areas were apparent across racial/ethnic communities, across levels of social vulnerability, over time, and across types of vaccination administration sites. Disparities in receipt of the primary vaccine series attenuated over time during a period in which sites of vaccination administration diversified, but were recapitulated during booster rollout. These findings highlight how public health strategies from the outset must directly target these deeply embedded structural and systemic determinants of disparities and track equity metrics over time to avoid perpetuating inequities in healthcare access.
... Essentially, IS serves to close the gap between research and practice [2]. In the context of dual pandemics, the COVID-19 pandemic and the pandemic of structural racism and anti-Black violence, a new call to action has been made for IS to focus on health inequities at the intersections of race, gender, and social injustice [3][4][5][6]. ...
Article
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Background Recent calls to action have been made for Implementation Science to attend to health inequities at the intersections of race, gender, and social injustice in the United States. Transgender people, particularly Black and Latina transgender women, experience a range of health inequities and social injustices. In this study, we compared two processes of transgender community engagement in Los Angeles and in Chicago as an implementation strategy to address inequitable access to care; we adapted and extended the Exploration Planning Implementation and Sustainment (EPIS) framework for transgender health equity. Methods A comparative case method and the EPIS framework were used to examine parallel implementation strategies of transgender community engagement to expand access to care. To foster conceptual development and adaptation of EPIS for trans health equity, the comparative case method required detailed description, exploration, and analyses of the community-engagement processes that led to different interventions to expand access. In both cities, the unit of analysis was a steering committee made up of local transgender and cisgender stakeholders. Results Both steering committees initiated their exploration processes with World Café-style, transgender community-engaged events in order to assess community needs and structural barriers to healthcare. The steering committees curated activities that amplified the voices of transgender community members among stakeholders, encouraging more effective and collaborative ways to advance transgender health equity. Based on analysis and findings from the Los Angeles town hall, the steering committee worked with a local medical school, extending the transgender medicine curriculum, and incorporating elements of transgender community-engagement. The Chicago steering committee determined from their findings that the most impactful intervention on structural racism and barriers to healthcare access would be to design and pilot an employment program for Black and Latina transgender women. Conclusion In Los Angeles and Chicago, transgender community engagement guided implementation processes and led to critical insights regarding specific, local barriers to healthcare. The steering committee itself represented an important vehicle for individual-, organizational-, and community-level relationship and capacity building. This comparative case study highlights key adaptations of EPIS toward the formation of an implementation science framework for transgender health equity.
... Addressing these will require a sharp focus on understanding the varied mechanisms by which underlying fundamental injustices (e.g., racism, discrimination) and social determinants of health influence, and in some case hinder, the implementation of policies and programs for populations. The complex, multilevel array of factors that contribute to health inequities also have important implications for the implementation of EBIs across diverse settings/populations [128], though they have not always been explicitly identified as such [129,130]. While we recognize the complexity in addressing these structural, upstream challenges, the ongoing public-health crises present important opportunities for changing systems on a broad scale by taking a proactive approach to incorporate a focus on health equity in ongoing and future implementation studies [25,131]. ...
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Background The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute’s Consortium for Cancer Implementation Science convened an action group focused on ‘health equity and context’ to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions. Discussion In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. Summary To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.
... Furthermore, the calls for integration of these two fields are largely theoretical and often focus on changes in applying frameworks [7] and methods [11], consideration for research questions [12], and how implementation processes are carried out and initiated [13,14]. These foci require extensive information, skills, and collaborations across both fields (i.e., health disparities and D&I research) to develop and conduct impactful research. ...
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Background A recent paradigm shift has led to an explicit focus on enhancing health equity through equity-oriented dissemination and implementation (D&I) research. However, the integration and bidirectional learning across these two fields is still in its infancy and siloed. This exploratory study aimed to examine participants’ perceived capabilities, opportunities, and motivations to conduct equity-oriented D&I research. Methods We conducted an exploratory cross-sectional survey distributed online from December 2020 to April 2021. Participants were recruited at either D&I or health disparities-oriented conferences, meetings, through social media, or personal outreach via emails. Informed by the Capability, Opportunity, and Motivation Model (COM-B), the survey queried respondents about different aspects of engaging in and conducting equity-oriented D&I research. All analyses were conducted in SPSS Version 27.0. Results A total of 180 participants responded to the survey. Most participants were women (81.7%), white (66.1%), academics (78.9%), and faculty members (53.9%). Many reported they were advanced (36.7%) or advanced beginners (27.8%) in the D&I field, and a substantial proportion (37.8%) reported being novice in D&I research that focused on health equity. Participants reported high motivation (e.g., 62.8% were motivated to apply theories, models, frameworks for promoting health equity in D&I research), but low capability to conduct equity-oriented D&I research (e.g., 5% had the information needed for promoting health equity in D&I research). Most participants (62.2%) reported not having used measures to examine equity in their D&I projects, and for those who did use measures, they mainly used individual-level measures (vs. organizational- or structural-level measures). When asked about factors that could influence their ability to conduct equity-oriented D&I research, 44.4% reported not having the skills necessary, and 32.2% stated difficulties in receiving funding for equity-oriented D&I research. Conclusions Study findings provide empirical insight into the perspectives of researchers from different backgrounds on what is needed to conduct equity-oriented D&I research. These data suggest the need for a multi-pronged approach to enhance the capability and opportunities for conducting equity-oriented D&I work, such as: training specifically in equity-oriented D&I, collaboration between D&I researchers with individuals with expertise and lived experience with health equity research, funding for equity-oriented D&I research, and recognition of the value of community engaged research in promotion packages.
... For example, it is vital to engage stakeholders from project inception and consider context during implementation, as factors such as available resources, policy support, health system and population characteristics can impact the uptake of an intervention (9). Additionally, implementation science theories and methods can help inform the equitable development, implementation, and evaluation of interventions to address health disparities and promote health equity (11)(12)(13)(14). However, there has been a limited research focus to date regarding implementation outcomes that may be unique to COVID-19 vaccinations and how to utilize implementation strategies to address vaccine program-related implementation challenges. ...
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Recent articles have highlighted the importance of incorporating implementation science concepts into pandemic-related research. However, limited research has been documented to date regarding implementation outcomes that may be unique to COVID-19 vaccinations and how to utilize implementation strategies to address vaccine program-related implementation challenges. To address these gaps, we formed a global COVID-19 implementation workgroup of implementation scientists who met weekly for over a year to review the available literature and learn about ongoing research during the pandemic. We developed a hierarchy to prioritize the applicability of “lessons learned” from the vaccination-related implementation literature. We identified applications of existing implementation outcomes as well as identified additional implementation outcomes. We also mapped implementation strategies to those outcomes. Our efforts provide rationale for the utility of using implementation outcomes in pandemic-related research. Furthermore, we identified three additional implementation outcomes: availability, health equity, and scale-up. Results include a list of COVID-19 relevant implementation strategies mapped to the implementation outcomes.
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Purpose of Review Stroke is a prime example of a medical disorder whose incidence, prevalence, and outcomes are strongly characterized by health disparities across the globe. This scoping literature review seeks to depict how implementation science could be utilized to advance health equity in the prevention, acute treatment, and post-acute management of stroke in the underserved regions of high-income countries as well as in all low-income countries. Recent Findings A major reason for the persisting and widening cerebrovascular disease disparities is that evidence-based stroke prevention and treatment interventions have been differentially translated (if at all) to various populations and settings. The field of implementation science is endowed with frameworks, theories, methodological approaches, and outcome measures, including equity indices, which could be harnessed to facilitate the translation of evidence-based interventions into clinical practice for underserved and vulnerable communities. Summary Encouragingly, there are several novel frameworks, which eminently merge implementation science constructs with health equity determinants, thereby opening up key opportunities to bridge burgeoning worldwide gaps in cerebrovascular health equity.
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Background Recent calls to action have been made for Implementation Science to attend to health inequities at the intersections of race, gender, and social injustice in the United States. Transgender people, particularly Black and Latina transgender women, experience a range of health inequities and social injustices. In this study, we compared two processes of transgender community-engagement in Los Angeles and in Chicago. The study addressed inequitable access to care and adapted and extended the Exploration Planning Implementation and Sustainment (EPIS) framework for transgender health equity. Methods A comparative case method and the EPIS framework were used to examine parallel implementations of transgender community engagement to expand access to care. In order to foster the conceptual development and adaptation of EPIS for trans health equity, the comparative case method required detailed description, exploration, and analyses of the community-engagement processes to expand access to healthcare. In both cities, the unit of analysis was a steering committee made up of local transgender and cisgender stakeholders. Results Both steering committees initiated their exploration processes with World Café-style, transgender community-engaged events in order to assess community needs and structural barriers to healthcare. The steering committees curated activities that amplified the voices of transgender community members among stakeholders, encouraging more effective and collaborative ways to advance transgender health equity. Based on analysis and findings from the Los Angeles town hall, the steering committee worked with a local medical school, extending the transgender medicine curriculum and incorporating elements of transgender community-engagement. The Chicago steering committee determined from their findings that the most impactful intervention on structural racism and barriers to healthcare access would be to design and pilot a transgender employment program. Conclusion In Los Angeles and Chicago, transgender community-engagement guided exploration, planning, and implementation processes and led to critical insights regarding specific, local structural barriers to healthcare. The steering committee itself represented an important vehicle for individual- and community-level relationship and capacity building. This comparative case study highlights key adaptations of EPIS toward the formation of an implementation science framework for transgender health equity.
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There is increasing attention being given to opportunities and approaches to advance health equity using implementation science. To reduce disparities in health, it is crucial that an equity lens is integrated from the earliest stages of the implementation process. In this paper, we outline four key pre-implementation steps and associated questions for implementation researchers to consider that may help guide selection and design of interventions and associated implementation strategies that are most likely to reach and be effective in reducing health disparities among vulnerable persons and communities.
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Purpose Given incomplete data reporting by race, we used data on COVID-19 cases and deaths in US counties to describe racial disparities in COVID-19 disease and death and associated determinants. Methods Using publicly available data (accessed April 13, 2020), predictors of COVID-19 cases and deaths were compared between disproportionately (>13%) black and all other (<13% black) counties. Rate ratios were calculated and population attributable fractions (PAF) were estimated using COVID-19 cases and deaths via zero-inflated negative binomial regression model. National maps with county-level data and an interactive scatterplot of COVID-19 cases were generated. Results Nearly ninety-seven percent of disproportionately black counties (656/677) reported a case and 49% (330/677) reported a death versus 81% (1987/2,465) and 28% (684/ 2465), respectively, for all other counties. Counties with higher proportions of black people have higher prevalence of comorbidities and greater air pollution. Counties with higher proportions of black residents had more COVID-19 diagnoses (RR 1.24, 95% CI 1.17-1.33) and deaths (RR 1.18, 95% CI 1.00-1.40), after adjusting for county-level characteristics such as age, poverty, comorbidities, and epidemic duration. COVID-19 deaths were higher in disproportionally black rural and small metro counties. The PAF of COVID-19 diagnosis due to lack of health insurance was 3.3% for counties with <13% black residents and 4.2% for counties with >13% black residents. Conclusions Nearly twenty-two percent of US counties are disproportionately black and they accounted for 52% of COVID-19 diagnoses and 58% of COVID-19 deaths nationally. County-level comparisons can both inform COVID-19 responses and identify epidemic hot spots. Social conditions, structural racism, and other factors elevate risk for COVID-19 diagnoses and deaths in black communities.
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Health systems have adopted telemedicine with remarkable speed not only for Covid-19–related care, but also for chronic disease management. But without proactive efforts to ensure equity, the current wide-scale implementation of telemedicine may increase disparities in health care access for vulnerable populations with limited digital literacy or access, such as rural residents, racial/ethnic minorities, older adults, and those with low income, limited health literacy, or limited English proficiency. To ensure that the current telemedicine implementation does not exacerbate health disparities, the authors propose four key actions for clinicians and health system leaders: (1) proactively explore potential disparities in telemedicine access, (2) develop solutions to mitigate barriers to digital literacy and the resources needed for engagement in video visits, (3) remove health system–created barriers to accessing video visits, and (4) advocate for policies and infrastructure that facilitate equitable telemedicine access. Without taking these actions now, health care systems risk creating telemedicine programs that exclude vulnerable populations.
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Background: Implementation research is increasingly used to identify common implementation problems and key barriers and facilitators influencing efficient access to health interventions. Objective: To develop and propose an equity-based framework for Implementation Research (EquIR) of health programs, policies and systems. Methods: A systematic search of models and conceptual frameworks involving equity in the implementation of health programs, policies and systems was conducted in Medline (PubMed), Embase, LILACS, Scopus and grey literature. Key characteristics of models and conceptual frameworks were summarized. We identified key aspects of equity in the context of seven Latin American countries-focused health programs We gathered information related to the awareness of inequalities in health policy, systems and programs, the potential negative impact of increasing inequalities in disadvantaged populations, and the strategies used to reduce them. Results: A conceptual framework of EquIR was developed. It includes elements of equity-focused implementation research, but it also links the population health status before and after the implementation, including relevant aspects of health equity before, during and after the implementation. Additionally, health sectors were included, linked with social determinants of health through the "health in all policies" proposal affecting universal health and the potential impact of the public health and public policies. Conclusion: EquIR is a conceptual framework that is proposed for use by decision makers and researchers during the implementation of programs, policies or health interventions, with a focus on equity, which aims to reduce or prevent the increase of existing inequalities during implementation.
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Background Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies. Methods We integrated and modified two conceptual frameworks—one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge—hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA. Results The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality. Conclusion The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities. Electronic supplementary material The online version of this article (10.1186/s13012-019-0861-y) contains supplementary material, which is available to authorized users.
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The coronavirus disease 2019 pandemic represents a global crisis that has received extraordinary response from healthcare workers and scientists. One critical but potentially overlooked field in a pandemic is implementation science—the study of methods to reduce the research-to-practice gap. In this Viewpoint, we discuss the important role of implementation science during this and future pandemics and highlight considerations to maximize the utility of implementation research.
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Human behaviour is central to transmission of SARS-Cov-2, the virus that causes COVID-19, and changing behaviour is crucial to preventing transmission in the absence of pharmaceutical interventions. Isolation and social distancing measures, including edicts to stay at home, have been brought into place across the globe to reduce transmission of the virus, but at a huge cost to individuals and society. In addition to these measures, we urgently need effective interventions to increase adherence to behaviours that individuals in communities can enact to protect themselves and others: use of tissues to catch expelled droplets from coughs or sneezes, use of face masks as appropriate, hand-washing on all occasions when required, disinfecting objects and surfaces, physical distancing, and not touching one’s eyes, nose or mouth. There is an urgent need for direct evidence to inform development of such interventions, but it is possible to make a start by applying behavioural science methods and models. Behaviour change is crucial to preventing SARS-CoV-2 transmission in the absence of pharmaceutical interventions. West et al. argue that we urgently need effective interventions to increase adherence to personal protective behaviours.