ArticlePDF Available

Implementation Science to Address Health Disparities During the Coronavirus Pandemic



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.
Implementation Science to Address Health Disparities
During the Coronavirus Pandemic
Karla I. Galaviz,
Jessica Y. Breland,
Mechelle Sanders,
Khadijah Breathett,
Alison Cerezo,
Oscar Gil,
John M. Hollier,
Cassondra Marshall,
J. Deanna Wilson,
and Utibe R. Essien
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
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.
). 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
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.
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
telemedicine, and care for chronic con-
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.
Implementation science, the scientific study of meth-
ods to promote the systematic uptake of evidence-
based interventions into routine practice,
can help
understand and address the racial and ethnic dis-
parities exposed during the COVID-19 pandemic.
Department of Applied Health Science, School of Public Health, Indiana University-Bloomington, Bloomington, Indiana, USA.
Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.
Center for Communication and Disparities Research, Department of Family Medicine, University of Rochester, Rochester, New York, USA.
General Division of Cardiology, Sarver Heart Center General Internal Medicine, University of Arizona, Tucson, Arizona, USA.
Department of Counseling, Clinical and School Psychology, UC Santa Barbara, Santa Barbara, California, USA.
Department of Human Development, College of Community and Public Affairs, Binghamton University, Binghamton, New York, USA.
Department of Pediatrics, Section of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas, USA.
Division of Community Health Sciences, Berkeley School of Public Health, Berkeley, California, USA.
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:
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 (, 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
Complementing previous perspectives,
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/
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
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
ity, employment status, poverty, and length of commute
to the nearest hospital.
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.
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.
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.
Wide spatial
inequities in COVID-19 positivity and incidence in
three large metropolitan areas of the United States
have also been documented.
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.
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.
Metrics to as-
sess gaps in the reach and adoption of interventions in
minority communities and settings are also available.
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
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)
to enhance their
relevance and potential impact. Approaches to enhance
participation and representativeness of minority popu-
lations are also available,
as are strategies to enhance
adoption, implementation, and sustainability of inter-
ventions in settings that serve minority populations.
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
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.
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).
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.
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
: 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.
Pragmatic trials allow for the testing of interventions in
real-world settings or routine practice conditions
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
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.
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.
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.
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.
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
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).
1. Centers for Disease Control and Prevention. Cases of coronavirus disease
(COVID-19) in the U.S. Available at
cases-updates/cases-in-us.html Accessed May 6, 2020.
2. Brown CH, Curran G, Palinkas LA, et al. An overview of research and
evaluation designs for dissemination and implementation. Annu Rev
Public Health. 2017;38:1–22.
3. Paakkari L, Okan O. COVID-19: health literacy is an underestimated
problem. Lancet Public Health. 2020;5:e249–e250.
4. Ross J, Diaz CM, Starrels JL. The Disproportionate Burden of COVID-19
for Immigrants in the Bronx, New York. JAMA Intern Med. 2020;180:1043–
5. Nouri S, Khoong Elaine C, Lyles Courtney R, et al. Addressing equity in
telemedicine for chronic disease management during the COVID-19
pandemic. NEJM Catalyst, 2020, DOI: 10.1056/CAT.20.0123.
6. Quinn SC, Kumar S, Freimuth VS, et al. Racial disparities in exposure,
susceptibility, and access to health care in the US H1N1 influenza
pandemic. Am J Public Health. 2011;101:285–293.
7. Eccles MP, Mittman BS. Welcome to implementation science. Implement
Sci. 2006;1:1.
8. Taylor SP, Kowalkowski MA, Beidas RS. Where is the implementation
science? An opportunity to apply principles during the COVID19
pandemic. Clin Infect Dis. 2020, DOI: 10.1093/cid/ciaa622.
9. Chambers DA. Considering the intersection between implementation
science and COVID-19. Implement Res Pract. 2020;1:0020764020
10. Johns Hopkins University. Racial Data Transparency. States that have
released breakdowns of Covid-19 data by race. Available at https:// Accessed May 6, 2020.
11. Emory University. COVID-19 Health Equity Dashboard. Available at Accessed June 1, 2020.
12. Chowkwanyun M, Reed AL. Racial health disparities and COVID-19—
Caution and context. N Engl J Med. 2020;383:201–203.
13. Millett G, Jones AT, Benkeser D, et al. Assessing differential impacts
of COVID-19 on black communities. medRxiv. 2020:2020.2005
14. NPR. In Large Texas Cities, Access To Coronavirus Testing May Depend On
Where You Live. Available at
have-fewer-coronavirus-testing-sit Accessed June 1, 2020.
15. Bilal U, Barber S, Diez-Roux AV. Spatial Inequities in COVID-19 outcomes
in Three US Cities. medRxiv. 2020:2020.2005.2001.20087833.
16. Woodward EN, Matthieu MM, Uchendu US, et al. The health equity
implementation framework: proposal and preliminary study of hepatitis C
virus treatment. Implement Sci. 2019;14:26.
17. West R, Michie S, Rubin GJ, et al. Applying principles of behaviour change
to reduce SARS-CoV-2 transmission. Nat Hum Behav. 2020;4:451–459.
18. Glasgow RE, Askew S, Purcell P, et al. Use of RE-AIM to Address Health
Inequities: application in a low-income community health center based
weight loss and hypertension self-management program. Transl Behav
Med. 2013;3:200–210.
19. Eslava-Schmalbach J, Garzon-Orjuela N, Elias V, et al. Conceptual frame-
work of equity-focused implementation research for health programs
(EquIR). Int J Equity Health. 2019;18:80.
20. Na
´poles AM, Stewart AL. Transcreation: an implementation science
framework for community-engaged behavioral interventions to reduce
health disparities. BMC Health Serv Res. 2018;18:710.
21. Michie S, van Stralen MM, West R. The behaviour change wheel: a new
method for characterising and designing behaviour change interven-
tions. Implement Sci. 2011;6:42.
22. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of
implementation strategies: results from the Expert Recommenda-
tions for Implementing Change (ERIC) project. Implement Sci. 2015;
23. Purnell TS, Calhoun EA, Golden SH, et al. Achieving health equity: closing
the gaps in health care disparities, interventions, and research. Health
Affairs. 2016;35:1410–1415.
24. Handley MA, Lyles CR, McCulloch C, et al. Selecting and improving quasi-
experimental designs in effectiveness and implementation research.
Annu Rev Public Health. 2018;39:5–25.
25. Patsopoulos NA. A pragmatic view on pragmatic trials. Dialogues Clin
Neurosci. 2011;13:217–224.
26. Collins LM, Murphy SA, Strecher V. The multiphase optimization strategy
(MOST) and the sequential multiple assignment randomized trial
(SMART): new methods for more potent eHealth interventions. Am J Prev
Med. 2007;32(5 Suppl.):S112–S118.
27. Chinman M, Woodward EN, Curran GM, et al. Harnessing implementation
science to increase the impact of health equity research. Med Care. 2017;
55(Suppl. 9, Suppl. 2):S16–S23.
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/
Abbreviation Used
COVID-19 ¼coronavirus disease 2019
Publish in Health Equity
-Immediate, unrestricted online access
-Rigorous peer review
-Compliance with open access mandates
-Authors retain copyright
-Highly indexed
-Targeted email marketing
Galaviz, et al.; Health Equity 2020, 4.1
... Researchers can partner with local organizations to develop and test the effectiveness of socio-economic and health initiatives. This includes using an implementation science approach to connect SMW to critical socio-economic and health resources (Galaviz et al., 2020;Perry & Elwy, 2021). The pandemic demonstrated the need to move beyond routine surveys of pandemic stress and toward connecting SMW to critical resources. ...
... The pandemic demonstrated the need to move beyond routine surveys of pandemic stress and toward connecting SMW to critical resources. Psychologists and other service providers are well positioned to pursue efforts in policy advocacy and through implementation science approaches that have a proven track record of improving access to health services (Galaviz et al., 2020;Perry & Elwy, 2021;Wiltsey Stirman & Beidas, 2020). ...
Full-text available
In partnership with community stakeholders, the aim of the present study was to gather descriptive data on pandemic-related stress and its association with mental health outcomes among a community sample of self-identified sexual minority women (SMW) in Los Angeles County (N = 84; Mage = 35.61). The sample was comprised solely of women (i.e. self-identified gender identity as woman, including cisgender and transgender women). Data were collected in April 2021, the “third wave” of the COVID-19 global pandemic. Los Angeles experienced some of the highest COVID-19 incidence rates in the United States. Yet, there was a significant lack of COVID-19 data on SMW, thus making it difficult to address the specific needs of this community. Background data were collected on pre-existing health conditions and COVID-19 infection history. Data were specific to COVID-19 stressors in the areas of mental health, financial strain, social isolation and health and discrimination concerns. Findings revealed that mental health concern was strongly associated with financial strain (r = .63, p < .01), social isolation (r = .62, p < .01) and health and discrimination concerns (r = .63, p < .01), thus demonstrating the wide-ranging negative impact of pandemic stressors on the mental health of SMW in Los Angeles during the third wave of COVID-19. Recommendations for future research, practice and policy implications are discussed.
... While interest continues to grow in applying equity approaches in implementation science, many investigators in the field are inexperienced with regard to how to operationalize or sustain a focus on health equity in their research [15]. Key questions and literature [16], with some guidance for integrating a focus on equity in implementation frameworks and methods [4,[16][17][18][19]. However, with some exceptions [20,21], there are limited instructive examples that can guide or inform the field. ...
Full-text available
Background A Health Equity Task Force (HETF) of members from seven Centers funded by the National Cancer Institute’s (NCI) Implementation Science in Cancer Control Centers (ISC ³ ) network sought to identify case examples of how Centers were applying a focus on health equity in implementation science to inform future research and capacity-building efforts. Methods HETF members at each ISC ³ collected information on how health equity was conceptualized, operationalized, and addressed in initial research and capacity-building efforts across the seven ISC ³ Centers funded in 2019–2020. Each Center completed a questionnaire assessing five health equity domains central to implementation science (e.g., community engagement; implementation science theories, models, and frameworks (TMFs); and engaging underrepresented scholars). Data generated illustrative examples from these five domains. Results Centers reported a range of approaches focusing on health equity in implementation research and capacity-building efforts, including (1) engaging diverse community partners/settings in making decisions about research priorities and projects; (2) applying health equity within a single TMF applied across projects or various TMFs used in specific projects; (3) evaluating health equity in operationalizing and measuring health and implementation outcomes; (4) building capacity for health equity-focused implementation science among trainees, early career scholars, and partnering organizations; and (5) leveraging varying levels of institutional resources and efforts to engage, include, and support underrepresented scholars. Conclusions Examples of approaches to integrating health equity across the ISC ³ network can inform other investigators and centers’ efforts to build capacity and infrastructure to support growth and expansion of health equity-focused implementation science.
... Embedding technology successfully in health care requires evaluation of the technology in the context of real-world practice within the health system [28]. To understand if technology can improve sleep treatment across patient groups and settings [13], approaches must be tested in real-world settings like the safety net and among patients who face barriers to technology access and use [29][30][31][32][33][34][35]. ...
Full-text available
Background: Sleep disorders are common and disproportionately affect marginalized populations. Technology such as wearable devices holds the potential to improve sleep quality and reduce sleep disparities, but most devices have not been designed or tested with racially, ethnically, and socioeconomically diverse patients. Inclusion and engagement of diverse patients throughout digital health development and implementation are critical to achieving health equity. Objective: This study aims to evaluate the usability and acceptability of a wearable sleep monitoring device - SomnoRing® - and its accompanying mobile application among patients treated in a safety net clinic. Methods: The study team recruited English- and Spanish-speaking patients from a mid-sized pulmonary and sleep medicine practice serving publicly insured patients. Eligibility criteria included initial evaluation of obstructed sleep apnea which is most appropriate for limited cardiopulmonary testing. Patients with primary insomnia or other suspected sleep disorders were not included. Patients tested the SomnoRing® over a seven-night period and participated in a one-hour semi-structured virtual qualitative interview covering perceptions of the device, motivators and barriers to use, and general experiences with digital health tools. The study team used inductive/deductive processes to code interview transcripts, guided by the Technology Acceptance Model. Results: Twenty-one individuals participated in the study. All participants owned a smartphone, almost all (19/21) felt comfortable using their phone, and few already owned a wearable (6/21). Almost all participants wore the SomnoRing® for seven nights and found it comfortable. Four themes emerged from qualitative data: 1) the SomnoRing® was easy to use compared to other wearable devices or traditional home sleep testing alternatives such as the standard polysomnogram technology for sleep studies; 2) the patient's context and environment such as family and peer influence, housing status, access to insurance, and device cost affected overall acceptance of the SomnoRing®; 3) clinical champions motivated use in supporting effective onboarding, interpretation of data, and, ongoing technical support; and 4) participants desired more assistance and information to best interpret their own sleep data summarized in the companion app. Conclusions: Racially, ethnically, and socioeconomically diverse patients with sleep disorders perceived a wearable as useful and acceptable for sleep health. Participants also uncovered external barriers related to the perceived usefulness of the technology, such as housing status, insurance coverage, and clinical support. Future studies should further examine how to best address these barriers so that wearables, such as the SomnoRing®, can be successfully implemented in the safety-net health setting. Clinicaltrial: This manuscript does not report on a clinical trial.
... 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. ...
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]. ...
Full-text available
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]. ...
Full-text available
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.
During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.
This chapter serves as an introduction to the fourth part of the Handbook, which focuses on implementation and scale-up of evidence-based school mental health programming. The research on evidence-based practices and effective programs in school mental health has increased substantially over the past several decades. Despite the persistent need for more efficacious programs and supports that reduce the risk for mental health problems and treat the symptoms of those concerns, there is increasing recognition that a major challenge facing the field is how to implement the existing research-based programs with fidelity, and how to scale those models, while ensuring high quality implementation. This part of the Handbook includes several chapters by leading experts who address this timely issue by reviewing various models, frameworks, and approaches for optimizing implementation and increasing the reach of school mental health programs. We also consider issues related to fidelity of implementation in the context of scale-up efforts of various programs, frameworks (e.g., Positive Behavioral Interventions and Supports), and mental health screening processes. Two chapters focus on the role the Internet plays in supporting scale-up efforts and broad dissemination of evidence-based programming, whereas another chapter focuses on the role policy plays in promoting wide adoption and scale-up of evidence-based practices. We also consider issues such as the cost of implementation and scale-up of school mental health programming. After highlighting some common themes across these chapters, we conclude with some recommendations for future research, training, and practice, which are based on this collection of chapters focused on implementation science in relation to school mental health.
Full-text available
Background: In recent years, the United States has witnessed increased transphobic rhetoric and legislation aimed at restricting the rights of transgender youth, ranging from banning transgender youth from school sports, to denying access to gender-affirming care. This climate has a detrimental impact on the mental health of transgender youth - a community that already experiences profound mental health risks due to their exposure to transphobia across multiple levels and in myriad settings. To combat transphobia and its negative effects on transgender youth’s mental health, scientific studies and methods addressing multiple levels and forms of transphobia are needed.Discussion: We review research on negative impacts of multilevel transphobia on transgender youth mental health, the benefits of gender-affirming psychotherapy practices, and argue that these practices should be re-defined as evidence-based practices (EBP). We then describe how dissemination and implementation (D&I) science—the scientific study of multilevel strategies and methods that facilitate the uptake of EBP —can be used to promote the mental health of transgender youth. We call for increased D&I research to support the mental health needs of transgender youth. We recommend two broad domains of D&I research: (1) identify, test, and scale EBPs for transgender youth and (2) address contextual barriers to implementing these EBPs - specifically, state-level laws/policies, and lack of access to gender-affirming psychotherapy. Methodological recommendations and example studies are included in each domain.Conclusions: To enhance mental health equity for transgender youth, we must leverage D&I science to identify, test and scale EBPs for transgender youth, which we define as practices that have been shown to be effective and acceptable for transgender people based on qualitative data, observational research, and/or pilot studies. These research efforts must also address law/policy barriers through advocacy and policy dissemination research, and overcome lack of access to appropriate care via online/mobile interventions.
Full-text available
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.
Full-text available
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.
Full-text available
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.
Full-text available
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.
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.
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.