Implementation science should give higher priority to health equity

Strategies and Lessons Learned from a Home Delivery Food Prescription Program for Older Adults

Food insecurity (FI) is a growing health problem, worsening during the COVID-19 pandemic. Fresh food prescription programs (FFRx) have been shown to increase healthy eating and decrease FI, but few FFRx are community-informed, or theory based. Our FFRx was a delivery program developed to alleviate FI for older adults. It was implemented in an academic medical center and guided by the Capabilities, Opportunities, Motivations, and Behaviors and Theoretical Domains Framework. We tested impacts of the program on FI, Fruit and Vegetable (FV) intake, depression, and loneliness at six-month intervals. During the FFRx, 31 people completed surveys every six months. FI decreased by an average of 2.03 points (p = <.001) while FV intake increased from a mean of 2.8 servings per day to 2.9 servings per day (p = .53). Depression and loneliness scores stayed stable. Preliminary data from this FFRx program, a partnership between an academic medical center and community partners, had positive impacts on FI.

Impact of a school-based and primary care-based multicomponent intervention on HPV vaccination coverage among French adolescents: a cluster randomised controlled trial protocol (the PrevHPV study)

INTRODUCTION

Vaccination is an effective and safe strategy to prevent Human papillomavirus (HPV) infection and related harms. Despite various efforts by French authorities to improve HPV vaccine coverage (VC) these past few years, VC has remained far lower than in most other high-income countries. To improve it, we have coconstructed with stakeholders a school-based and primary care-based multicomponent intervention, and plan to evaluate its effectiveness, efficiency and implementation through a cluster randomised controlled trial (cRCT).

METHODS AND ANALYSIS

This pragmatic cRCT uses an incomplete factorial design to evaluate three components applied alone or in combination: (1) adolescents and parents' education and motivation at school, using eHealth tools and participatory learning; (2) general practitioners' training on HPV using motivational interviewing techniques and provision of a decision aid tool; (3) free-of-charge access to vaccination at school. Eligible municipalities (clusters) are located in one of 14 preselected French school districts and must have only one secondary school which enrols at least 2/3 of inhabitants aged 11-14 years. A randomisation stratified by school district and deprivation index allocated 90 municipalities into 6 groups of 15. The expected overall sample size estimate is 41 940 adolescents aged 11-14 years. The primary endpoint is the HPV VC (≥1 dose) among adolescents aged 11-14 years, at 2 months, at the municipality level (data from routine databases). Secondary endpoints include: HPV VC (≥1 dose at 6 and 12 months; and 2 doses at 2, 6 and 12 months); differences in knowledge, attitudes, behaviours, and intention among adolescents, parents and general practitioners between baseline and 2 months after intervention (self-administered questionnaires); incremental cost-effectiveness ratio. Implementation measures include dose, fidelity, adaptations, reached population and satisfaction (activity reports and self-administered questionnaires).

ETHICS AND DISSEMINATION

This protocol was approved by the French Ethics Committee 'CPP Sud-Est VI' on 22 December 2020 (ID-RCB: 2020-A02031-38). No individual consent was required for this type of research; all participants were informed of their rights, in particular not to participate or to oppose the collection of data concerning them. Findings will be widely disseminated (conference presentations, reports, factsheets and academic publications).

TRIAL REGISTRATION NUMBER

NCT04945655.

Placing equity at the heart of eHealth implementation: a qualitative pilot study

Background

There is a growing urgency to tackle issues of equity and justice in the implementation of eHealth technologies.

Methods

Qualitative interviews were conducted with 19 multidisciplinary health professionals to explore the implementation and uptake of eHealth technologies in practice. The aim of this article was to examine in more detail issues of equity and justice in the implementation and uptake of eHealth technologies in practice. Results were analysed using Braun and Clarke’s six-step reflexive thematic analysis approach.

Results

Nancy Fraser’s concept of social justice is introduced as a novel framework for inquiry into the implementation of digital health services. Health professionals reported that eHealth offered their clients a greater sense of safety, convenience, and flexibility, allowing them to determine the nature and pace of their healthcare, and giving them more control over their treatment and recovery. However, they also expressed concerns about the use of eHealth with clients whose home environment is unsafe. Application of Fraser’s framework revealed that eHealth technologies may not always provide a secure clinical space in which the voices of vulnerable clients can be recognised and heard. It also highlighted critical systemic and cultural barriers that hinder the representation of clients’ voices in the decision to use eHealth technologies and perpetuate inequalities in the distribution of eHealth services.

Conclusions

To facilitate broad participation, eHealth tools need to be adaptable to the needs and circumstances of diverse groups. Future implementation science efforts must also be directed at identifying and addressing the underlying structures that hinder equitable recognition, representation, and distribution in the implementation of eHealth resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01640-5.

Moving toward equity: fostering transdisciplinary research between the social and behavioral sciences and implementation science to end the HIV epidemic

PURPOSE OF REVIEW

Since the beginning of the HIV epidemic, social and behavioral scientists have developed interventions to stem the spread of the virus. The dissemination of these interventions has traditionally been a lengthy process; however, implementation science (IS) offers a route toward hastening delivery of effective interventions. A transdisciplinary approach, wherein IS informs and is informed by social and behavioral sciences (SBS) as well as community participation, offers a strategy for more efficiently moving toward health equity and ending the HIV epidemic.

RECENT FINDINGS

There has been considerable growth in HIV research utilizing IS theories, methods and frameworks. Many of these studies have been multi or interdisciplinary in nature, demonstrating the ways that IS and SBS can strengthen one another. We also find areas for continued progress toward transdisciplinarity.

SUMMARY

We review literature from 2020 to 2021, exploring the ways IS and SBS have been used in tandem to develop, evaluate and disseminate HIV interventions. We highlight the interplay between disciplines and make a case for moving toward transdisciplinarity, which would yield new, integrated frameworks that can improve prevention and treatment efforts, moving us closer to achieving health equity.

Cases of intervention refusal encountered by public health nurses in Japan and characteristics of their support- qualitative analysis of described mother-child and elderly cases

Background

The purpose of this study is to clarify the actual situation of the cases and the characteristics of support, focusing on mothers and their children, and elderly persons among the cases of intervention refusal encountered by public health nurses (PHNs) in Japan.

Methods

The data were descriptions of intervention refusal cases that were freely described by PHNs working for prefectural and municipal governments in questionnaire surveys nationwide. The characteristics of the cases and the support were categorized according to the situation of the case, and the number of descriptions was summarized and interpreted.

Results

The results revealed that interventions involving mothers and children were refused in most of by mother or parents. The refusals were related to child abuse, parental mental illness, obsessiveness, and complex backgrounds. The actual status of intervention refusal in elderly persons, interventions are frequently refused by elderly persons themselves in the case of self-neglect and by family members living with the elderly in the case of abuse. The refusals were related to mental disorders or dementia and living alone. In both cases, PHNs provided support in collaboration with multi-disciplinary and multi-agencies, and attempts were made to alleviate the situation of refusal to intervene, from detecting cases through contact during home visits and in other settings, and by coordinating with appropriate team members as required.

Conclusions

It is suggested that PHNs need to acquire practical skills depending on the characteristics of the case to cope with critical situations throughout the process of engagement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00706-z.

Achieving Greater Health Equity: An Opportunity for Anesthesiology

Anesthesiology and anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and to achieve health equity. We thus examine health disparity and health equity through the lens of anesthesiology and the perspective of anesthesiologists. In this paper, we define health disparity and health care disparities and provide tangible, representative examples of the latter in the practice of anesthesiology. We define health equity, primarily as the desired antithesis of health disparity. Finally, we propose a framework for anesthesiologists, working toward mitigating health disparity and health care disparities, advancing health equity, and documenting improvements in health care access and health outcomes. This multilevel and interdependent framework includes the perspectives of the patient, clinician, group or department, health care system, and professional societies, including medical journals. We specifically focus on the interrelated roles of social identity and social determinants of health in health outcomes. We explore the foundational role that clinical informatics and valid data collection on race and ethnicity have in achieving health equity. Our ability to ensure patient safety by considering these additional patient-specific factors that affect clinical outcomes throughout the perioperative period could substantially reduce health disparities. Finally, we explore the role of medical journals and their editorial boards in ameliorating health disparities and advancing health equity.

Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study

Importance

Overwhelming evidence that anti-Black racism is associated with health inequities is driving clinician demand for antiracism practices that promote health equity.

Objective

To investigate how nonmedical professionals address personally mediated, institutional, and internalized racism and to adapt these practices for the clinical setting.

Design, Setting, and Participants

Using an approach from human-centered design for this qualitative study, virtual qualitative interviews were conducted among 40 professionals from nonmedical fields to investigate antiracism practices used outside of medicine. Inductive thematic analysis was conducted to identify latent themes and practices that may be adaptable to health care, subsequently using an established theoretical framework describing levels of racism to interpret and organize themes. Convenience and purposive sampling was used to recruit participants via email, social media, and electronic flyers.

Main Outcomes and Measures

Antiracism practices adapted to medicine.

Results

Among 40 professionals from nonmedical fields, most were younger than age 40 years (23 individuals [57.5%]) and there were 20 (50.0%) women; there were 25 Black or African American individuals (62.5%); 4 East Asian, Southeast Asian, or South Asian individuals (10.0%); 3 individuals with Hispanic, Latinx, or Spanish origin (7.5%); and 3 White individuals. Participants described personally mediated, institutional, and internalized antiracism practices that may be adaptable to promote health equity for Black patients. Personally mediated antiracism practices included dialogue and humble inquiry, building trust, and allyship and shared humanity; clinicians may be able to adopt these practices by focusing on patient successes, avoiding stigmatizing language in the electronic health record, and using specific phrases to address racism in the moment. Institutional antiracism practices included education, representation, and mentorship; in the health care setting, clinics may be able to develop staff affiliate groups, focus on improving racial health equity outcomes, and conduct antiracism trainings. Internalized antiracism practices centered on authenticity; clinicians may be able to write positionality statements reflecting their identity and the expertise they bring to clinical encounters.

Conclusions and Relevance

This study's findings suggest that antiracism practices from outside the health care sector may offer innovative strategies to promote health equity by addressing personally mediated, institutional, and internalized racism in clinical care.

Addressing health disparities through implementation science-a need to integrate an equity lens from the outset

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.

The Prevalence of Dissemination and Implementation Research and Training Grants at National Cancer Institute-Designated Cancer Centers

Background

Dissemination and implementation (D&I) research is a key factor in the uptake and use of evidence-based cancer control interventions. National Cancer Institute (NCI)–designated cancer centers are ideal settings in which to further D&I knowledge. The purpose of this study was to summarize the characteristics of NCI-funded D&I science grants in the nation’s cancer centers to understand the nature, extent, and opportunity for this key type of translational work.

Methods

We used the National Institutes of Health Research Portfolio Online Reporting Tool to identify active NCI-funded grants in D&I science at NCI clinical cancer centers (n = 13) and comprehensive cancer centers (n = 51) as well as their academic affiliates. Active projects were eligible for inclusion if they 1) were awarded directly to an NCI cancer center or an academic or research affiliate, and 2) identified D&I content in the abstract. Portfolio data were collected in February 2021.

Results

We identified 104 active NCI-funded D&I research or training grants across the 64 cancer centers; 57.8% of cancer centers had at least 1 NCI-funded D&I grant. Most awards (71.1%) were for research grants. Training grants constituted 29.1% of D&I-focused grants. Overall, 50.0% of grants (n = 52) concentrated on specific cancers. Almost two-thirds of grants (n = 68, 65.4%) had a stated health equity focus.

Conclusions

More than one-half of NCI-designated cancer centers have active funding in D&I science, reflecting a substantial investment by NCI. There remains considerable room for further development, which would further support NCI’s translational mission.

Adaptation of a social risk screening and referral initiative across clinical populations, settings, and contexts in the Department of Veterans Affairs Health System

Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks-RE-AIM, the Adaptome, and FRAME-to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population.

Reviewing fair subject selection considerations for the unique case of post sequelae COVID-19 translational studies

Fair inclusion of research subjects is necessary to ensure that post-acute sequelae COVID-19 (PASC) research results benefit all members of society. Scientists should conduct research on a broad sample of individuals who represent clinically relevant factors influencing a disease. Without demographic diversity and sociological and environmental variability, research outputs are less likely to apply to different populations and would thus increase health disparities. The goal of this narrative literature review and ethical analysis is to apply fair selection criteria to PASC research studies. We briefly highlight the importance of fair subject selection in translational research and then identify features of PASC, as well as PASC research, that hinder fair inclusion of research participants. We will demonstrate that determining an adequate and representative sample is not simply a matter of ensuring greater diversity; rather, fairness requires a broader evaluation of risks, burdens, and benefits specific to underrepresented populations. We provide recommendations to ensure fair subject selection in PASC research and promote translation toward positive health outcomes for all individuals, including the most vulnerable.

“There’s no money in community dissemination”: A mixed methods analysis of researcher dissemination-as-usual

Background:

The field of dissemination and implementation science has the potential to narrow the translational research-to-practice gap and improve the use of evidence-based practices (EBPs) within community-based settings. Yet, foundational research related to dissemination efforts, such as understanding researcher attitudes, practices, and the determinants to sharing research findings, is lacking within extant literature.

Methods:

A sequential explanatory (QUAN $$ \to $$ qual) mixed methods design was used to examine 85 academic researchers’ perspectives and self-reported dissemination methods used to share research outcomes with community stakeholders to better understand researcher’s usual dissemination practices (referred to as dissemination-as-usual). Quantitative surveys collected researcher demographic data, attitudes toward dissemination efforts, and dissemination strategy use.

Results:

Multiple linear regression examined predictors of the quantity of dissemination strategies utilized by researchers, finding that years since earning their degree, time spent disseminating, and the number of reasons for engaging in dissemination efforts predicted greater numbers of dissemination strategies utilized by researchers. Individual, semi-structured interviews with a subset of researchers (n = 18) expanded upon quantitative findings, identifying barriers and facilitators to their dissemination efforts. Data strands were integrated using a joint display, and the Dissemination of Research model guided data interpretation. More established researchers experienced fewer barriers and more facilitators to support their use of a variety of dissemination strategies to share findings with community stakeholders. However, researchers reported needing specific training, institutional support, and/or dedicated time to plan and enact dissemination strategies.

Conclusion:

The necessary first step in research translation is the dissemination of research evidence, and understanding dissemination-as-usual can identify areas of need to advance translational science.

Promoting rigor and sustainment in implementation science capacity building programs: A multi-method study

Background

The field of Implementation science (IS) continues to evolve, and the number and type of IS capacity building Programs (ISCBPs) are in flux. These changes push the field to revisit the accepted IS competencies and to guide sustainment of ISCBPs. Our objectives were: (1) compare characteristics of current ISCBPs; (2) identify recommendations to support ISCBP sustainment; (3) measure how often ISCBPs address IS competencies; (4) identify novel and important IS competencies for the field.

Method

This multi-method study included ISCBPs delivering structured, longitudinal IS training, excluding single courses and brief workshops. We used three complementary methods to meet our objectives. First, we identified ISCBPs via an internet search and snowball sampling methods. Second, we surveyed these ISCBPs to identify areas of program focus, types of trainees, IS competencies addressed, and recommendations to sustain ISCBPs. Third, we conducted a modified Delphi process with IS researchers/leaders to reach consensus on the IS competencies that were both important and novel as compared to the IS competencies published to date.

Results

Among 74 eligible ISCBPs identified, 46 responded (62% response rate). Respondent ISCBPs represented diverse areas of focus (e.g., global health, cardiopulmonary disease) and trainee stages (e.g., graduate students, mid-career faculty). While most respondent ISCBPs addressed core IS methods, targeting IS competencies was less consistent (33% for nongraduate/non-fellowship ISCBPs; >90% for graduate/national ISCBPs). Our modified Delphi process identified eight novel and important IS competencies related to increasing health equity or the speed of translation. Recommendations to sustain ISCBPs included securing financial administrative support.

Conclusions

Current ISCBPs train learners across varying career stages in diverse focus areas. To promote rigor, we recommend ISCBPs address specific IS competencies, with consideration of these eight novel/emerging competencies. We also recommend ISCBPs report on their IS competencies, focus area(s), and trainee characteristics. ISCBP programs need administrative financial support.

Plain Language Summary

There is a limited workforce capacity to conduct implementation science (IS) research. To address this gap, the number and type of IS capacity building Programs (ISCBPs) focusing on training researchers and practitioners in IS methods continue to increase. Our efforts to comprehensively identify and describe ISCBPs for researchers and practitioners highlighted four implications for leaders of ISCBPs related to program sustainment and rigor. First, we identified a range of contextual characteristics of ISCBPs, including the research topics, methods, and IS competencies addressed, and the types of trainees accepted. Second, given the variability of trainee types and research, rigorous ISCBP programs should tailor the IS competencies and methods addressed to the skills needed by the types of trainees in their program. Third, the field of IS needs to periodically revisit the competencies needed with attention to the skills needed in the field. We used a consensus-building process with ISCBP leaders and other IS experts to expand existing IS competencies and identified eight important, novel IS competencies that broadly relate to promoting health equity and speeding the translation of research to practice. Finally, as more institutions consider developing ISCBPs, we identified factors needed to support ISCBP sustainment, including ongoing financial support. In addition to these implications for ISCBP leaders, there are also policy implications. For example, IS journals may enact policies to require manuscripts evaluating ISCBP performance to report on certain contextual characteristics, such as the IS competencies addressed and types of trainees accepted. The field may also consider developing an accreditation body to evaluate the rigor of ISCBP curricula.

Quantitative measures used in empirical evaluations of mental health policy implementation: A systematic review

Background

Mental health is a critical component of wellness. Public policies present an opportunity for large-scale mental health impact, but policy implementation is complex and can vary significantly across contexts, making it crucial to evaluate implementation. The objective of this study was to (1) identify quantitative measurement tools used to evaluate the implementation of public mental health policies; (2) describe implementation determinants and outcomes assessed in the measures; and (3) assess the pragmatic and psychometric quality of identified measures.

Method

Guided by the Consolidated Framework for Implementation Research, Policy Implementation Determinants Framework, and Implementation Outcomes Framework, we conducted a systematic review of peer-reviewed journal articles published in 1995-2020. Data extracted included study characteristics, measure development and testing, implementation determinants and outcomes, and measure quality using the Psychometric and Pragmatic Evidence Rating Scale.

Results

We identified 34 tools from 25 articles, which were designed for mental health policies or used to evaluate constructs that impact implementation. Many measures lacked information regarding measurement development and testing. The most assessed implementation determinants were readiness for implementation, which encompassed training (n  =  20, 57%) and other resources (n  =  12, 34%), actor relationships/networks (n  =  15, 43%), and organizational culture and climate (n  =  11, 31%). Fidelity was the most prevalent implementation outcome (n  =  9, 26%), followed by penetration (n  =  8, 23%) and acceptability (n  =  7, 20%). Apart from internal consistency and sample norms, psychometric properties were frequently unreported. Most measures were accessible and brief, though minimal information was provided regarding interpreting scores, handling missing data, or training needed to administer tools.

Conclusions

This work contributes to the nascent field of policy-focused implementation science by providing an overview of existing measurement tools used to evaluate mental health policy implementation and recommendations for measure development and refinement. To advance this field, more valid, reliable, and pragmatic measures are needed to evaluate policy implementation and close the policy-to-practice gap.

Plain Language Summary

Mental health is a critical component of wellness, and public policies present an opportunity to improve mental health on a large scale. Policy implementation is complex because it involves action by multiple entities at several levels of society. Policy implementation is also challenging because it can be impacted by many factors, such as political will, stakeholder relationships, and resources available for implementation. Because of these factors, implementation can vary between locations, such as states or countries. It is crucial to evaluate policy implementation, thus we conducted a systematic review to identify and evaluate the quality of measurement tools used in mental health policy implementation studies. Our search and screening procedures resulted in 34 measurement tools. We rated their quality to determine if these tools were practical to use and would yield consistent (i.e., reliable) and accurate (i.e., valid) data. These tools most frequently assessed whether implementing organizations complied with policy mandates and whether organizations had the training and other resources required to implement a policy. Though many were relatively brief and available at little-to-no cost, these findings highlight that more reliable, valid, and practical measurement tools are needed to assess and inform mental health policy implementation. Findings from this review can guide future efforts to select or develop policy implementation measures.

Power and resistance in schools: Implementing institutional change to promote health equity for sexual and gender minority youth

Introduction

Schools in the United States are hierarchical institutions that actively (re)produce the power relations of the wider social world, including those associated with heteronormativity. Structural stigma, informed by heteronormativity and perpetuated through schools, contributes to the production of academic and health disparities among youth who are lesbian, gay, bisexual, transgender, queer, or of other gender and sexual identities (LGBTQ+). We draw upon 5 years of qualitative data from a cluster randomized controlled trial conducted in New Mexico that used implementation science frameworks to promote the uptake and sustainment of evidence-informed practices (EIPs) to examine how power operates to hinder or promote the ability of school staff to change school environments, disrupt structural stigma, and increase safety and support for LGBTQ+ youth.

Methods

Data sources included annual individual and small group qualitative interviews with school professionals (e.g., administrators, school nurses, teachers, and other staff), several of whom took part in Implementation Resource Teams (IRTs) charged with applying the EIPs. Other data sources included bi-weekly periodic reflections with implementation coaches and technical assistance experts. Data were recorded, transcribed, and analyzed using deductive and inductive coding techniques.

Results

The IRTs experienced variable success in implementing EIPs. Their efforts were influenced by: (1) constraining school characteristics, including staff turnover and resource scarcity; (2) community-based opposition to change and concerns about community backlash; (3) the presence or absence of supportive school leadership; and (4) variations in school, district, and state policies affecting LGBTQ+ students and attitudes about their importance. Findings illustrate how diverse power structures operated in and across outer and inner contexts to bound, shift, amplify, and otherwise shape how new practices were received and implemented.

Conclusion

Findings indicate that the efforts of IRTs were often a form of resistant power that operated within and against school hierarchies to leverage epistemic, discursive, and material power toward implementation. To improve health equity, implementation scientists must attend to the multiple real and perceived power structures that shape implementation environments and influence organizational readiness and individual motivation. Implementers must also work to leverage resistant power to counter the institutional structures and social norms that perpetuate inequities, like heteronormativity and structural stigma.

Implementation Science and Implementation Science Communications: a refreshed description of the journals' scope and expectations

This editorial provides a comprehensive consolidated overview of the scope and expectations of Implementation Science and Implementation Science Communications. We remain most interested in rigorous empirical studies of the implementation of evidence-based healthcare practices (including interventions, technologies, and policies) and the de-implementation of practices that are demonstrated to be of low or no benefit. Implementation strategies (e.g., continuing professional education, organizational changes, and financial incentives to enhance the uptake of evidence-based practices) are of central interest to the journals. We see the field as large and complex, with a wide literature that is published in many venues. We urge people for whom it is new to spend some time reading the existing literature, and learning the scope of the work that has already been done, and published, in our journals and in an increasing number of other journals in the field.

Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity

Background

Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts.

Methods

Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations.

Results

We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration.

Conclusion

We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact.

Plain language abstract

There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.

Barriers and Facilitators to Resuming In-Person Psychotherapy with Perinatal Patients amid the COVID-19 Pandemic: A Multistakeholder Perspective

During the COVID-19 pandemic, outpatient psychotherapy transitioned to telemedicine. This study aimed to examine barriers and facilitators to resuming in-person psychotherapy with perinatal patients as the pandemic abates. We conducted focus group and individual interviews with a sample of perinatal participants (n = 23), psychotherapy providers (n = 28), and stakeholders (n = 18) from Canada and the U.S. involved in the SUMMIT trial, which is aimed at improving access to mental healthcare for perinatal patients with depression and anxiety. Content analysis was used to examine perceived barriers and facilitators. Reported barriers included concerns about virus exposure in a hospital setting (77.8% stakeholders, 73.9% perinatal participants, 71.4% providers) or on public transportation (50.0% stakeholders, 26.1% perinatal participants, 25.0% providers), wearing a mask during sessions (50.0% stakeholders, 25.0% providers, 13.0% participants), lack of childcare (66.7% stakeholders, 46.4% providers, 43.5% perinatal participants), general transportation barriers (50.0% stakeholders, 47.8% perinatal participants, 25.0% providers), and the burden of planning and making time for in-person sessions (35.7% providers, 34.8% perinatal participants, 27.8% stakeholders). Reported facilitators included implementing and communicating safety protocols (72.2% stakeholders, 47.8% perinatal participants, 39.3% providers), conducting sessions at alternative or larger locations (44.4% stakeholders, 32.1% providers, 17.4% perinatal participants), providing incentives (34.8% perinatal participants, 21.4% providers, 11.1% stakeholders), and childcare and flexible scheduling options (31.1% perinatal participants, 16.7% stakeholders). This study identified a number of potential barriers and illustrated that COVID-19 has fostered and amplified barriers. Future interventions to facilitate resuming in-person sessions should focus on patient-centered strategies based on empathy regarding ongoing risk-aversion among perinatal patients despite existing safety protocols, and holistic thinking to make access to in-person psychotherapy easier and more accessible for perinatal patients.

Systemic and Environmental Contributors to Obesity Inequities in Marginalized Racial and Ethnic Groups

Obesity is a multifactorial disease that disproportionally affects diverse racial and ethnic groups. Structural racism influences racial inequities in obesity prevalence through environmental factors, such as racism and discrimination, socioeconomic status, increased levels of stress, and bias in the health care delivery system. Researchers, clinicians, and policy makers must work to address the environmental and systematic barriers that contribute to health inequities in the United States. Specifically, clinicians should quantitatively and qualitatively assess environmental and social factors and proactively engage in patient-centered care to tailor available treatments based on identified needs and experiences.

Dissemination and Implementation Science Approaches for Occupational Safety and Health Research: Implications for Advancing Total Worker Health

Total Worker Health^® (TWH), an initiative of the U.S. National Institute for Occupational Safety and Health, is defined as policies, programs, and practices that integrate protection from work-related health and safety hazards by promoting efforts that advance worker well-being. Interventions that apply the TWH paradigm improve workplace health more rapidly than wellness programs alone. Evidence of the barriers and facilitators to the adoption, implementation, and long-term maintenance of TWH programs is limited. Dissemination and implementation (D&I) science, the study of methods and strategies for bridging the gap between public health research and practice, can help address these system-, setting-, and worker-level factors to increase the uptake, impact, and sustainment of TWH activities. The purpose of this paper is to draw upon a synthesis of existing D&I science literature to provide TWH researchers and practitioners with: (1) an overview of D&I science; (2) a plain language explanation of key concepts in D&I science; (3) a case study example of moving a TWH intervention down the research-to-practice pipeline; and (4) a discussion of future opportunities for conducting D&I science in complex and dynamic workplace settings to increase worker safety, health, and well-being.

A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

BACKGROUND

There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse.

METHODS

This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process.

RESULTS

Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening.

CONCLUSIONS

Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Applying an Equity Lens to Characterizing the Process and Reasons for an Adaptation to an Evidenced-based Practice

Background

Adaptations to evidence-based practices (EBPs) are common but can impact implementation and patient outcomes. In our prior research, providers in routine care made a fidelity-inconsistent adaptation to an EBP that improved health outcomes in people with serious mental illness (SMI). The purpose of this study was to characterize the process and reasons for the adaptation using a framework for reporting adaptations and modifications to EBPs, with a focus on equity.

Methods

This study used qualitative data collected during a national implementation of the InSHAPE EBP addressing obesity in persons with SMI. We reviewed transcripts from five behavioral health organizations that made a successful fidelity-inconsistent adaptation to a core component of InSHAPE that was associated with cardiovascular risk reduction. We coded the data using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) with an emphasis on exploring whether the adaptation addressed inequities in using the EBP related to social determinants of health.

Results

Across the five agencies, the fidelity-inconsistent adaptation was characterized as unplanned and reactive in response to challenges InSHAPE teams experienced delivering the intervention in community fitness facilities as intended. In all cases, the goal of the adaptation was to improve intervention access, feasibility and fit. Social and economic disadvantage were noted obstacles to accessing fitness facilities or gyms among participants with SMI, which led agencies to adapt the program by offering sessions at the mental health center.

Conclusions

Findings from this study show the advantages of applying a health equity lens to evaluate how obstacles such as poverty and discrimination influence EBP adaptations. Recommendations can also assist researchers and community partners in making proactive decisions about allowable adaptations to EBPs.

Implementation of the JOIN for ME Program for Families from Low-Income Backgrounds: The Use of Theory-Driven Formative Evaluation: Rhode Island CORD 3.0

Advances have been made in the development of effective interventions to address pediatric obesity; however, research findings often do not translate into clinical practice and a limited number of programs have been designed toward wide-spread dissemination and implementation. The Rhode Island (RI)-Childhood Obesity Research Demonstration (CORD) 3.0 Project involves adapting and testing an evidence-based pediatric weight management intervention (PWMI), JOIN for ME, for wide-scale dissemination and implementation in communities with a high proportion of families from low-income backgrounds. In this article, we describe the robust developmental formative evaluation (FE) process employed by RI-CORD as a model for the use of FE to drive dissemination of evidence-based PWMIs. The current project was guided by the Consolidated Framework for Implementation Research and Proctor Implementation Outcomes. This article also showcases examples of how the use of key informant interviews from engaged stakeholders in the community during a developmental FE process can drive selection of implementation strategies. The use of FE, driven by evidence-based theory, can help provide a roadmap to successful implementation of a pediatric weight management program, such as JOIN for ME.

Mental Health Services for Autistic Individuals Across the Lifespan: Recent Advances and Current Gaps

PURPOSE OF REVIEW

This synthesis of recent mental health services research with autistic individuals presents significant advances, current gaps, and recommendations for improving mental healthcare for this population.

RECENT FINDINGS

Recent advances include improved understanding of co-occurring mental health conditions among autistic individuals, a growing evidence base for interventions to address them, the development and implementation of new service models to support mental health for this population, and a substantial increase in mental health services and implementation research focused on autism. Ongoing challenges include a lack of mental health interventions designed for community implementation with autistic individuals, limited workforce capacity, complex and disconnected service systems, and racial, ethnic, and socioeconomic disparities in accessibility and quality of mental health services. Despite the advances in our understanding of mental health needs and mental health services for autistic individuals, several critical gaps remain. We encourage future efforts to develop and test interventions that can be used in community settings, train and incentivize the workforce to provide them, realign policies and funding with best practice, and embrace an equity-focused approach to autism research and care.

Examining the concept of equity in community psychology with natural language processing

Large amounts of text-based data, like study abstracts, often go unanalyzed because the task is laborious. Natural language processing (NLP) uses computer-based algorithms not traditionally implemented in community psychology to effectively and efficiently process text. These methods include examining the frequency of words and phrases, the clustering of topics, and the interrelationships of words. This article applied NLP to explore the concept of equity in community psychology. The COVID-19 crisis has made pre-existing health equity gaps even more salient. Community psychology has a specific interest in working with organizations, systems, and communities to address social determinants that perpetuate inequities by refocusing interventions around achieving health and wellness for all. This article examines how community psychology has discussed equity thus far to identify strengths and gaps for future research and practice. The results showed the prominence of community-based participatory research and the diversity of settings researchers work in. However, the total number of abstracts with equity concepts was lower than expected, which suggests there is a need for a continued focus on equity.

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation

OBJECTIVE

To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia.

METHODS

A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff.

RESULTS

Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy.

CONCLUSION

The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.

Toward a New Strategic Public Health Science for Policy, Practice, Impact, and Health Equity

The COVID-19 pandemic and its social and health impact have underscored the need for a new strategic science agenda for public health. To optimize public health impact, high-quality strategic science addresses scientific gaps that inform policy and guide practice. At least 6 scientific gaps emerge from the US experience with COVID-19: health equity science, data science and modernization, communication science, policy analysis and translation, scientific collaboration, and climate science. Addressing these areas within a strategic public health science agenda will accelerate achievement of public health goals. Public health leadership and scientists have an unprecedented opportunity to use strategic science to guide a new era of improved and equitable public health.

A systematic review of school health policy measurement tools: implementation determinants and outcomes

BACKGROUND

Governments in some countries or states/provinces mandate school-based policies intended to improve the health and well-being of primary and secondary students and in some cases the health of school staff. Examples include mandating a minimum time spent per week in programmed physical activity, mandating provision of healthy foods and limiting fat content of school meals, and banning tobacco products or use on school campuses. Although school health researchers have studied whether schools, districts, or states/provinces are meeting requirements, it is unclear to what extent implementation processes and determinants are assessed. The purposes of the present systematic review of quantitative measures of school policy implementation were to (1) identify quantitative school health policy measurement tools developed to measure implementation at the school, district, or state/provincial levels; (2) describe the policy implementation outcomes and determinants assessed and identify the trends in measurement; and (3) assess pragmatic and psychometric properties of identified implementation measures to understand their quality and suitability for broader application.

METHODS

Peer-reviewed journal articles published 1995-2020 were included if they (1) had multiple-item quantitative measures of school policy implementation and (2) addressed overall wellness, tobacco, physical activity, nutrition, obesity prevention, or mental health/bullying/social-emotional learning. The final sample comprised 86 measurement tools from 67 peer-review articles. We extracted study characteristics, such as psychometric and pragmatic measure properties, from included articles based on three frameworks: (1) Implementation Outcomes Framework, (2) Consolidated Framework for Implementation Research, and (3) Policy Implementation Determinants Framework.

RESULTS

Most implementation tools were developed to measure overall wellness policies which combined multiple policy topics (n = 35, 40%) and were in survey form (n = 75, 87%). Fidelity was the most frequently prevalent implementation outcome (n = 70, 81%), followed by adoption (n = 32, 81%). The implementation determinants most assessed were readiness for implementation, including resources (n = 43, 50%), leadership (n = 42, 49%), and policy communication (n = 41, 48%). Overall, measures were low-cost and had easy readability. However, lengthy tools and lack of reported validity/reliability data indicate low transferability.

CONCLUSIONS

Implementation science can contribute to more complete and rigorous assessment of school health policy implementation processes, which can improve implementation strategies and ultimately the intended health benefits. Several high-quality measures of implementation determinants and implementation outcomes can be applied to school health policy implementation assessment. Dissemination and implementation science researchers can also benefit from measurement experiences of school health researchers.

Scoping Review: Suicide Specific Intervention Programmes for People Experiencing Homelessness

Background: The homeless population are among the most vulnerable groups to experience suicide ideation and behavior. Several studies have shown that people who are homeless experience more significant suicidal ideation and behavior than the general population. However, there is limited information about what suicide interventions exist, to what extent they are grounded in robust research, and which intervention components effectively reduce suicidal ideation and behavior in the homeless community. This research aimed to characterise the current evidence base in the area of suicide prevention for homeless individuals. Methods: A scoping review guided by Arksey and O’Malley’s five-stage framework was conducted and a narrative synthesis was performed. Pubmed, EMBASE, PsychInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, and Bielefeld Academic Search Engine were searched up to 8 May 2020. Results: A total of 3209 records were identified through database and grey literature searching. Three studies are included in this review. Key outcomes identify suicide intervention prevention programmes; similarities and differences across interventions, and examples of staff training. A quality review of the studies was completed. Conclusion: A stark gap in the evidence of suicide specific prevention interventions targeted at homeless populations.

A call for diversity, equity, and inclusion: Highlights from the Consortium of Universities for Global Health 2021 conference

Beryne Odeny reports from the CUGH 2021 virtual conference.