Implementation Research Methodologies for Achieving Scientific Equity and Health Equity

Disparities Research for Pelvic Floor Disorders: A Systematic Review and Critique of Literature

IMPORTANCE

Understanding the status of pelvic floor disorder (PFD) disparities research will allow the opportunity to advance future pelvic floor equity efforts.

OBJECTIVES

The aims of the study were to (1) characterize the landscape of PFD disparities literature using the 3 phases of disparities research framework, (2) describe the characteristics of PFD disparities studies, and (3) identify critical knowledge gaps.

STUDY DESIGN

We performed a systematic review of peer-reviewed publications addressing disparities in PFDs among U.S. populations from PubMed, Embase, Scopus, or the Cochrane Database indexed between 1997 and 2022. Using the triphasic framework for advancing health disparities research by Kilbourne et al ( Am J Public Health . 2006;96(12):2113-21), we categorized the included studies into the detecting phase (identifies and measures disparities in historically marginalized populations), understanding phase (establishes disparity determinants), or reducing phase (conducts interventions to alleviate inequities). All screening, coding, and quality reviews were independently performed by at least 2 authors. We used descriptive analysis and the χ 2 test for comparisons.

RESULTS

The initial search identified 10,178 studies, of which 123 were included. Of the included studies, 98 (79.7%), 22 (17.9%), and 3 (2.4%) studies were detecting, understanding, and reducing phase research, respectively. The most common disparity category investigated was race and ethnicity (104 studies), and one third of these studies attributed drivers of racial and ethnic differences to structural influences. Publications of detecting phase studies outpaced the growth of understanding and reducing phase research.

CONCLUSIONS

Most PFD disparities research focused on identifying historically marginalized populations with inadequate progression to understanding and reducing phases. We recommend progressing PFD disparities research beyond the detecting phase to advance health equity in PFD care.

An Implementation of a Community-Engaged, Group-Level Mental Health Pilot for Black and Latina Transgender Women

The primary aim is to assess the implementation of an eight-session, group therapy pilot for Black and Latina transgender women in Chicago in terms of implementation outcomes regarding intervention effectiveness, acceptability, appropriateness, and feasibility. The Exploration Preparation Implementation Sustainment (EPIS) framework guided implementation processes, including community engagement as an implementation strategy, and an implementation taxonomy was used to evaluate outcomes of acceptability, appropriateness, and feasibility, in addition to intervention effectiveness regarding anxiety and community connectedness. Two rounds of the pilot were completed in 2020, during the COVID-19 pandemic, at a community-based organization serving LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning) youth on Chicago's West Side. Participants (N = 14) completed a baseline and postintervention assessment and evaluations after each of eight intervention modules. Descriptive statistics show improvement across measures of anxiety and community connectedness, and high mean scores across domains of acceptability, appropriateness, and feasibility. Pilot findings indicate intervention effectiveness, acceptability, appropriateness, and feasibility to address mental health and social support of Black and Latina transgender women. Additional resources are needed for transgender community-engaged mental health programs and research to establish core and adaptable intervention elements, scaled-up evidence for clinical effectiveness, and, most importantly, to improve mental health outcomes and the sustainability of such interventions.

Improving Delivery and Use of HIV Pre-Exposure Prophylaxis in the US: A Systematic Review of Implementation Strategies and Adjunctive Interventions

Implementation of pre-exposure prophylaxis (PrEP) to prevent HIV transmission is suboptimal in the United States. To date, the literature has focused on identifying determinants of PrEP use, with a lesser focus on developing and testing change methods to improve PrEP implementation. Moreover, the change methods available for improving the uptake and sustained use of PrEP have not been systematically categorized. To summarize the state of the literature, we conducted a systematic review of the implementation strategies used to improve PrEP implementation among delivery systems and providers, as well as the adjunctive interventions used to improve the uptake and persistent adherence to PrEP among patients. Between November 2020 and January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer reviewed articles. We identified 44 change methods (18 implementation strategies and 26 adjunctive interventions) across a variety of clinical and community-based service settings. We coded implementation strategies and adjunctive interventions in accordance with established taxonomies and reporting guidelines. Most studies focused on improving patient adherence to PrEP and most conducted pilot trials. Just over one-third of included studies demonstrated a positive effect on outcomes. In order to end the human immunodeficiency virus (HIV) epidemic in the U.S., future, large scale HIV prevention research is needed that develops and evaluates implementation strategies and adjunctive interventions for target populations disproportionately affected by HIV.

Understanding and Defining Young People's Involvement and Under-Representation in Mental Health Research: A Delphi Study

INTRODUCTION

The mental health of young people (aged 16-25 years) is a growing public health concern in the United Kingdom due to the increasing numbers of young people experiencing mental health difficulties, with many not in contact with mental health services. To design services that meet the needs of all young people, a diversity of young people must be involved in mental health research, beyond being participants. This Delphi study aimed to identify different types of 'involvement' and to define and describe 'under-representation' in young people's involvement in mental health research.

METHODS

Twenty-seven experts in young people's mental health research completed a series of online questionnaires. The experts were academic researchers, patient and public involvement (PPI) professionals and young 'experts by experience'. Round 1 generated panellists' views on 'involvement' and 'under-representation'. Round 2 summarised panellists' responses from Round 1 and sought consensus (minimum 70% agreement) in nine question areas. Round 3 validated the findings of the previous rounds.

RESULTS

Consensus was achieved in eight out of nine areas, resulting in a matrix (with definitions) of the different types of young people's involvement in mental health research, from being advisors to involvement ambassadors. The findings generated an agreed-upon definition of under-representation, an identification of when in the research process there is under-representation and the characteristics of the young people who are under-represented. Experts further agreed on demographic data that should be collected to improve reporting on involvement.

CONCLUSIONS

This study adds to our understanding of involvement and under-representation in the context of young people's mental health research through expert consensus. It provides a practical resource for researchers considering involving young people in the research process and suggests the data that should be collected to improve reporting on the diversity of the young people involved.

PATIENT AND PUBLIC CONTRIBUTION

A research oversight group of five young people advised on this study. They contributed throughout the project-from endorsing the research question to commenting on the findings and dissemination. Two of the group reviewed all participant materials and piloted the initial questionnaire.

Modifications of the readiness assessment for pragmatic trials tool for appropriate use with Indigenous populations

BACKGROUND

Inequities in health access and outcomes exist between Indigenous and non-Indigenous populations. Embedded pragmatic randomized, controlled trials (ePCTs) can test the real-world effectiveness of health care interventions. Assessing readiness for ePCT, with tools such as the Readiness Assessment for Pragmatic Trials (RAPT) model, is an important component. Although equity must be explicitly incorporated in the design, testing, and widespread implementation of any health care intervention to achieve equity, RAPT does not explicitly consider equity. This study aimed to identify adaptions necessary for the application of the 'Readiness Assessment for Pragmatic Trials' (RAPT) tool in embedded pragmatic randomized, controlled trials (ePCTs) with Indigenous communities.

METHODS

We surveyed and interviewed participants (researchers with experience in research involving Indigenous communities) over three phases (July-December 2022) in this mixed-methods study to explore the appropriateness and recommended adaptions of current RAPT domains and to identify new domains that would be appropriate to include. We thematically analyzed responses and used an iterative process to modify RAPT.

RESULTS

The 21 participants identified that RAPT needed to be modified to strengthen readiness assessment in Indigenous research. In addition, five new domains were proposed to support Indigenous communities' power within the research processes: Indigenous Data Sovereignty; Acceptability - Indigenous Communities; Risk of Research; Research Team Experience; Established Partnership). We propose a modified tool, RAPT-Indigenous (RAPT-I) for use in research with Indigenous communities to increase the robustness and cultural appropriateness of readiness assessment for ePCT. In addition to producing a tool for use, it outlines a methodological approach to adopting research tools for use in and with Indigenous communities by drawing on the experience of researchers who are part of, and/or working with, Indigenous communities to undertake interventional research, as well as those with expertise in health equity, implementation science, and public health.

CONCLUSION

RAPT-I has the potential to provide a useful framework for readiness assessment prior to ePCT in Indigenous communities. RAPT-I also has potential use by bodies charged with critically reviewing proposed pragmatic research including funding and ethics review boards.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Interventions to prevent obesity in children aged 12 to 18 years old

BACKGROUND

Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect.

AUTHORS' CONCLUSIONS

The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Using Participatory Implementation Science to Advance Health Equity

Participatory approaches to implementation science (IS) offer an inclusive, collaborative, and iterative perspective on implementing and sustaining evidence-based interventions (EBIs) to advance health equity. This review provides guidance on the principles and practice of participatory IS, which enables academic researchers, community members, implementers, and other actors to collaboratively integrate practice-, community-, and research-based evidence into public health and health care services. With a foundational focus on supporting academics in coproducing knowledge and action, participatory IS seeks to improve health, reduce inequity, and create transformational change. The three main sections of this review provide (a) a rationale for participatory approaches to research in implementation science, (b) a framework for integrating participatory approaches in research utilizing IS theory and methods, and (c) critical considerations for optimizing the practice and impact of participatory IS. Ultimately, participatory approaches can move IS activities beyond efforts to make EBIs work within harmful systems toward transformative solutions that reshape these systems to center equity.

Advancing the Science and Application of Implementation Science to Promote Health Equity: Commentary on the Symposium

There has been an increasing focus on making health equity a more explicit and foundational aspect of the research being conducted in public health and implementation science. This commentary provides an overview of five reviews in this Annual Review of Public Health symposium on Implementation Science and Health Equity. These articles reflect on and advance the application of core implementation science principles and concepts, with a focus on promoting health equity across a diverse range of public health and health care settings. Taken together, the symposium articles highlight critical conceptual, methodological, and empirical advances in the study designs, frameworks, and approaches that can help address equity considerations in the use of implementation science in both domestic and global contexts. Finally, this commentary highlights how work featured in this symposium can help inform future directions for rapidly taking public health to scale, particularly among systemically marginalized populations and communities.

'God is the one who give child': An abductive analysis of barriers to postnatal care using the Health Equity Implementation Framework

Background

Postnatal care is recommended as a means of preventing maternal mortality during the postpartum period, but many women in low- and middle-income countries (LMICs) do not access care during this period. We set out to examine sociocultural preferences that have been portrayed as barriers to care.

Methods

We performed an abductive analysis of 63 semi-structured interviews with women who had recently given birth in three regions of Ethiopia using the Health Equity Implementation Framework (HEIF) and an inductive-deductive codebook to understand why women in Ethiopia do not use recommended postnatal care.

Results

We found that, in many cases, health providers do not consider women's cultural safety a primary need, but rather as a barrier to care. However, women's perceived refusal to participate in postnatal visits was, for many, an expression of agency and asserting their needs for cultural safety.

Trial registration

n/a.

Conclusions

We propose adding cultural safety to HEIF as a process outcome, so that implementers consider cultural needs in a dynamic manner that does not ask patients to choose between meeting their cultural needs and receiving necessary health care during the postnatal period.

Predictive Utility of Irritability "In Context": Proof-of-Principle for an Early Childhood Mental Health Risk Calculator

OBJECTIVE

We provide proof-of-principle for a mental health risk calculator advancing clinical utility of the irritability construct for identification of young children at high risk for common, early onsetting syndromes.

METHOD

Data were harmonized from two longitudinal early childhood subsamples (total N = 403; 50.1% Male; 66.7% Nonwhite; Mage = 4.3 years). The independent subsamples were clinically enriched via disruptive behavior and violence (Subsample 1) and depression (Subsample 2). In longitudinal models, epidemiologic risk prediction methods for risk calculators were applied to test the utility of the transdiagnostic indicator, early childhood irritability, in the context of other developmental and social-ecological indicators to predict risk of internalizing/externalizing disorders at preadolescence (Mage = 9.9 years). Predictors were retained when they improved model discrimination (area under the receiver operating characteristic curve [AUC] and integrated discrimination index [IDI]) beyond the base demographic model.

RESULTS

Compared to the base model, the addition of early childhood irritability and adverse childhood experiences significantly improved the AUC (0.765) and IDI slope (0.192). Overall, 23% of preschoolers went on to develop a preadolescent internalizing/externalizing disorder. For preschoolers with both elevated irritability and adverse childhood experiences, the likelihood of an internalizing/externalizing disorder was 39-66%.

CONCLUSIONS

Predictive analytic tools enable personalized prediction of psychopathological risk for irritable young children, holding transformative potential for clinical translation.

Engaging primary care clinicians in the selection of implementation strategies for toddler social-emotional health promotion in community health centers

BACKGROUND

Social-emotional risk for subsequent behavioral health problems can be identified at toddler age, a period where prevention has a heightened impact. This study aimed to meaningfully engage pediatric clinicians, given the emphasis on health promotion and broad reach of primary care, to prepare an Implementation Research Logic Model to guide the implementation of a screening and referral process for toddlers with elevated social-emotional risk.

METHOD

Using an adaptation of a previously published community partner engagement method, six pediatricians from community health centers (CHCs) comprised a Clinical Partner Work Group. The group was engaged in identifying determinants (barriers/facilitators), selecting and specifying strategies, strategy-determinant matching, a modified Delphi approach for strategy prioritization, and user-centered design methods. The data gathered from individual interviews, two group sessions, and a follow-up survey resulted in a completed Implementation Research Logic Model.

RESULTS

The Clinical Partner Work Group identified 16 determinants, including barriers (e.g., patient access to electronic devices) and facilitators (e.g., clinician buy-in). They then selected and specified 14 strategies, which were prioritized based on ratings of feasibility, effectiveness, and priority. The highest-rated strategies (e.g., integration of the screener into the electronic health record) provided coverage of all identified barriers and comprised the primary implementation strategy "package" to be used and tested.

CONCLUSIONS

Clinical partners provided important context and insights for implementation strategy selection and specification to support the implementation of social-emotional risk screening and referral in pediatric primary care. The methodology described herein can improve partner engagement in implementation efforts and increase the likelihood of success. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Radical Welcome Engagement Restoration Model and Assessment Tool for Community-Engaged Partnerships

People experiencing addiction, houselessness, or who have a history of incarceration have worse health outcomes compared with the general population. This is due, in part, to practices and policies of historically White institutions that exclude the voices, perspectives, and contributions of communities of color in leadership, socio-economic development, and decision-making that matters for their wellbeing. Community-based participatory research (CBPR) approaches hold promise for addressing health inequities. However, full engagement of people harmed by systemic injustices in CBPR partnerships is challenging due to inequities in power and access to resources. We describe how an Allentown-based CBPR partnership-the Health Equity Activation Research Team of clinicians, researchers, and persons with histories of incarceration, addiction, and houselessness-uses the Radical Welcome Engagement Restoration Model (RWERM) to facilitate full engagement by all partners. Data were collected through participatory ethnography, focus groups, and individual interviews. Analyses were performed using deductive coding in a series of iterative meaning-making processes that involved all partners. Findings highlighted six defining phases of the radical welcome framework: (a) passionate invitation, (b) radical welcome, (c) authentic sense of belonging, (d) co-creation of roles, (e) prioritization of issues, and (f) individual and collective action. A guide to assessing progression across these phases, as well as a 32-item radical welcome instrument to help CBPR partners anticipate and overcome challenges to engagement are introduced and discussed.

A Systematic Review of Implementation Research on Determinants and Strategies of Effective HIV Interventions for Men Who Have Sex with Men in the United States

Men who have sex with men (MSM) are disproportionately affected by HIV, accounting for two-thirds of HIV cases in the United States despite representing ∼5% of the adult population. Delivery and use of existing and highly effective HIV prevention and treatment strategies remain suboptimal among MSM. To summarize the state of the science, we systematically review implementation determinants and strategies of HIV-related health interventions using implementation science frameworks. Research on implementation barriers has focused predominantly on characteristics of individual recipients (e.g., ethnicity, age, drug use) and less so on deliverers (e.g., nurses, physicians), with little focus on system-level factors. Similarly, most strategies target recipients to influence their uptake and adherence, rather than improving and supporting implementation systems. HIV implementation research is burgeoning; future research is needed to broaden the examination of barriers at the provider and system levels, as well as expand knowledge on how to match strategies to barriers-particularly to address stigma. Collaboration and coordination among federal, state, and local public health agencies; community-based organizations; health care providers; and scientists are important for successful implementation of HIV-related health innovations.

Re-envisioning, Retooling, and Rebuilding Prevention Science Methods to Address Structural and Systemic Racism and Promote Health Equity

The historic momentum from national conversations on the roots and current impacts of racism in the USA presents an incredible window of opportunity for prevention scientists to revisit how common theories, measurement tools, methodologies, and interventions can be radically re-envisioned, retooled, and rebuilt to dismantle racism and promote equitable health for minoritized communities. Recognizing this opportunity, the NIH-funded Prevention Science and Methodology Group (PSMG) launched a series of presentations focused on the role of Prevention Science to address racism and discrimination guided by a commitment to social justice and health equity. The current manuscript aims to advance the field of Prevention Science by summarizing key issues raised during the series' presentations and proposing concrete research priorities and steps that hold promise for promoting health equity by addressing systemic racism. Being anti-racist is an active practice for all of us, whether we identify as methodologists, interventionists, practitioners, funders, community members, or an intersection of these identities. We implore prevention scientists and methodologists to take on these conversations with us to promote science and practice that offers every life the right to live in a just and equitable world.

Deciphering Disparities: The NHLBI Program on Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR)

Despite several ambitious national health initiatives to eliminate health disparities, spanning more than 4 decades, health disparities remain pervasive in the United States. In an attempt to bend the curve in disparities elimination, the National Heart, Lung, and Blood Institute (NHLBI) issued a funding opportunity on Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) in March 2019. Seven implementation research centers and 1 research coordinating center were funded in September 2020 to plan, develop, and test effective implementation strategies for eliminating disparities in heart and lung disease risk. In the 16 articles presented in this issue of Ethnicity & Disease, the DECIPHeR Alliance investigators and their NHLBI program staff address the work accomplished in the first phase of this biphasic research endeavor. Included in the collection are an article on important lessons learned during technical assistance sessions designed to ensure scientific rigor in clinical study designs, and 2 examples of clinical study process articles. Several articles show the diversity of clinical and public health settings addressed including schools, faith-based settings, federally qualified health centers, and other safety net clinics. All strategies for eliminating disparities tackle a cardiovascular or pulmonary disease and related risk factors. In an additional article, NHLBI program staff address expectations in phase 2 of the DECIPHeR program, strategies to ensure feasibility of scaling and spreading promising strategies identified, and opportunities for translating the DECIPHeR research model to other chronic diseases for the elimination of related health disparities.

A scoping review of equity-focused implementation theories, models and frameworks in healthcare and their application in addressing ethnicity-related health inequities

BACKGROUND

Inequities in implementation contribute to the unequal benefit of health interventions between groups of people with differing levels of advantage in society. Implementation science theories, models and frameworks (TMFs) provide a theoretical basis for understanding the multi-level factors that influence implementation outcomes and are used to guide implementation processes. This study aimed to identify and analyse TMFs that have an equity focus or have been used to implement interventions in populations who experience ethnicity or 'race'-related health inequities.

METHODS

A scoping review was conducted to identify the relevant literature published from January 2011 to April 2022 by searching electronic databases (MEDLINE and CINAHL), the Dissemination and Implementation model database, hand-searching key journals and searching the reference lists and citations of studies that met the inclusion criteria. Titles, abstracts and full-text articles were screened independently by at least two researchers. Data were extracted from studies meeting the inclusion criteria, including the study characteristics, TMF description and operationalisation. TMFs were categorised as determinant frameworks, classic theories, implementation theories, process models and evaluation frameworks according to their overarching aim and described with respect to how equity and system-level factors influencing implementation were incorporated.

RESULTS

Database searches yielded 610 results, 70 of which were eligible for full-text review, and 18 met the inclusion criteria. A further eight publications were identified from additional sources. In total, 26 papers describing 15 TMFs and their operationalisation were included. Categorisation resulted in four determinant frameworks, one implementation theory, six process models and three evaluation frameworks. One framework included elements of determinant, process and evaluation TMFs and was therefore classified as a 'hybrid' framework. TMFs varied in their equity and systems focus. Twelve TMFs had an equity focus and three were established TMFs applied in an equity context. All TMFs at least partially considered systems-level factors, with five fully considering macro-, meso- and micro-level influences on equity and implementation.

CONCLUSIONS

This scoping review identifies and summarises the implementation science TMFs available to support equity-focused implementation. This review may be used as a resource to guide TMF selection and illustrate how TMFs have been utilised in equity-focused implementation activities.

Assessment of Institutional Implementation Research Capacity of the National Institutes of Health D43 Network

Implementation science enhances the efficient practice of solutions from research to real-world application. Low- and lower- to middle-income countries may benefit significantly from implementation research given their limited resources. The National Institutes of Health Fogarty International Center D43 network consists of partnerships between foreign and U.S.-based institutions and aims to strengthen global health research. This paper assesses the D43 network's implementation research focus and training capacity. A survey was distributed to 387 program directors of ongoing and completed D43 projects. Preliminary results show 51.7% of respondents describe "increasing implementation research capacity" as a "high priority." Only 24.8% of faculty in implementation science received formal training, and 60.3% of D43 programs lacked an implementation research training program. Results show there is an increasing need for implementation research but that more can be done to develop implementation research capacity and training. The low response rate of 18% is a limitation of this study.

Applying hybrid effectiveness-implementation studies in equity-centered policy implementation science

Policy implementation science (IS) is complex, dynamic, and fraught with unique study challenges that set it apart from biomedical or clinical research. One important consideration is the ways in which policy interacts with local contexts, such as power and social disadvantage (e.g., based on ability, race, class, sexual identity, geography). The complex nature of policy IS and the need for more intentional integration of equity principles into study approaches calls for creative adaptations to existing implementation science knowledge and guidance. Effectiveness-implementation hybrid studies were developed to enhance translation of clinical research by addressing research questions around the effectiveness of an intervention and its implementation in the same study. The original work on hybrid designs mainly focused on clinical experimental trials; however, over the last decade, researchers have applied it to a wide range of initiatives and contexts, including more widespread application in community-based studies. This perspectives article demonstrates how effectiveness-implementation hybrid studies can be adapted for and applied to equity-centered policy IS research. We draw upon principles of targeted universalism and Equity in Implementation Research frameworks to guide adaptations to hybrid study typologies, and suggest research and engagement activities to enhance equity considerations; for example, in the design and testing of implementing strategies. We also provide examples of equity-centered policy IS studies. As the field of policy IS rapidly evolves, these adapted hybrid type studies are offered to researchers as a starting guide.

Similar skills, different frames: a thematic analysis exploring conceptualizations held by community-based organization practitioners and academics regarding skills to use evidence-based interventions to address cancer inequities

BACKGROUND

Community-based organizations (CBOs) are critical partners in delivering evidence-based interventions (EBIs) to address cancer inequities. However, CBO practitioners do not typically have access to opportunities to build the necessary capacity (skills, knowledge, motivation, and resources) for using EBIs. Although capacity-building interventions can offer a solution, inconsistent definitions and measurements of capacity limit the ability to develop and evaluate such efforts. We explored how and why conceptualizations of core skills for EBI use differ between practitioners and academics addressing cancer and other health inequities. We anchored the inquiry with a commonly used set of target skills for EBI capacity-building efforts.

METHODS

The study was conducted by an interdisciplinary team of academic researchers and CBO practitioners. We gathered data through semi-structured, hour-long interviews with practitioners and academics working to address cancer and other health inequities (n = 19). After hearing a brief vignette about a CBO addressing cervical cancer inequities, participants considered a widely accepted list of skills for EBI use that included assessing needs, engaging stakeholders, and selecting, adapting, implementing, evaluating, and sustaining the EBI. We used a team-based, reflexive thematic analysis approach grounded in critical and constructivist perspectives.

RESULTS

Overall, the original list resonated with practitioners and academics and they added new skills to the list (cultural humility and systems change). Practitioners' responses described skills from the reference point of addressing broader community needs and context and achieving change over the long term, emphasizing aspects of health promotion in their descriptions. Academics offered a mix of perspectives, with some focused on addressing community needs (and related flexibility regarding EBIs) but more emphasized skills needed to deliver a specific EBI to achieve a focused set of health and equity outcomes.

CONCLUSIONS

There is a significant opportunity to leverage complementary expertise and perspectives held by practitioners and academics addressing cancer inequities. However, the different frames utilized suggest proactive efforts will be required to find alignment across groups, particularly in valuing diverse contributions and identifying relevant outcomes of interest for each group. Such alignment is critical to designing effective capacity-building interventions and supporting the routine utilization of EBIs to address cancer inequities.

Ten years of implementation outcomes research: a scoping review

BACKGROUND

Proctor and colleagues' 2011 paper proposed a taxonomy of eight implementation outcomes and challenged the field to address a research agenda focused on conceptualization, measurement, and theory building. Ten years later, this paper maps the field's progress in implementation outcomes research. This scoping review describes how each implementation outcome has been studied, research designs and methods used, and the contexts and settings represented in the current literature. We also describe the role of implementation outcomes in relation to implementation strategies and other outcomes.

METHODS

Arksey and O'Malley's framework for conducting scoping reviews guided our methods. Using forward citation tracing, we identified all literature citing the 2011 paper. We conducted our search in the Web of Science (WOS) database and added citation alerts sent to the first author from the publisher for a 6-month period coinciding with the WOS citation search. This produced 1346 titles and abstracts. Initial abstract screening yielded 480 manuscripts, and full-text review yielded 400 manuscripts that met inclusion criteria (empirical assessment of at least one implementation outcome).

RESULTS

Slightly more than half (52.1%) of included manuscripts examined acceptability. Fidelity (39.3%), feasibility (38.6%), adoption (26.5%), and appropriateness (21.8%) were also commonly examined. Penetration (16.0%), sustainability (15.8%), and cost (7.8%) were less frequently examined. Thirty-two manuscripts examined implementation outcomes not included in the original taxonomy. Most studies took place in healthcare (45.8%) or behavioral health (22.5%) organizations. Two-thirds used observational designs. We found little evidence of progress in testing the relationships between implementation strategies and implementation outcomes, leaving us ill-prepared to know how to achieve implementation success. Moreover, few studies tested the impact of implementation outcomes on other important outcome types, such as service systems and improved individual or population health.

CONCLUSIONS

Our review presents a comprehensive snapshot of the research questions being addressed by existing implementation outcomes literature and reveals the need for rigorous, analytic research and tests of strategies for attaining implementation outcomes in the next 10 years of outcomes research.

Rapid-cycle designs to adapt interventions for COVID-19 in safety-net healthcare systems

Racial/ethnic minority, low socioeconomic status, and rural populations are disproportionately affected by COVID-19. Developing and evaluating interventions to address COVID-19 testing and vaccination among these populations are crucial to improving health inequities. The purpose of this paper is to describe the application of a rapid-cycle design and adaptation process from an ongoing trial to address COVID-19 among safety-net healthcare system patients. The rapid-cycle design and adaptation process included: (a) assessing context and determining relevant models/frameworks; (b) determining core and modifiable components of interventions; and (c) conducting iterative adaptations using Plan-Do-Study-Act (PDSA) cycles. PDSA cycles included: Plan. Gather information from potential adopters/implementers (e.g., Community Health Center [CHC] staff/patients) and design initial interventions; Do. Implement interventions in single CHC or patient cohort; Study. Examine process, outcome, and context data (e.g., infection rates); and, Act. If necessary, refine interventions based on process and outcome data, then disseminate interventions to other CHCs and patient cohorts. Seven CHC systems with 26 clinics participated in the trial. Rapid-cycle, PDSA-based adaptations were made to adapt to evolving COVID-19-related needs. Near real-time data used for adaptation included data on infection hot spots, CHC capacity, stakeholder priorities, local/national policies, and testing/vaccine availability. Adaptations included those to study design, intervention content, and intervention cohorts. Decision-making included multiple stakeholders (e.g., State Department of Health, Primary Care Association, CHCs, patients, researchers). Rapid-cycle designs may improve the relevance and timeliness of interventions for CHCs and other settings that provide care to populations experiencing health inequities, and for rapidly evolving healthcare challenges such as COVID-19.

Systematic Review of Variables Related to Instruction in Augmentative and Alternative Communication Implementation: Group and Single-Case Design

PURPOSE

This article provides a systematic review and analysis of group and single-case studies addressing augmentative and alternative communication (AAC) intervention with school-aged persons having autism spectrum disorder (ASD) and/or intellectual/developmental disabilities resulting in complex communication needs (CCNs). Specifically, we examined participant characteristics in group-design studies reporting AAC intervention outcomes and how these compared to those reported in single-case experimental designs (SCEDs). In addition, we compared the status of intervention features reported in group and SCED studies with respect to instructional strategies utilized.

PARTICIPANTS

Participants included school-aged individuals with CCNs who also experienced ASD or ASD with an intellectual delay who utilized aided or unaided AAC.

METHOD

A systematic review using descriptive statistics and effect sizes was implemented.

RESULTS

Findings revealed that participant features such as race, ethnicity, and home language continue to be underreported in both SCED and group-design studies. Participants in SCED investigations more frequently used multiple communication modes when compared to participants in group studies. The status of pivotal skills such as imitation was sparsely reported in both types of studies. With respect to instructional features, group-design studies were more apt to utilize clinical rather than educational or home settings when compared with SCED studies. In addition, SCED studies were more apt to utilize instructional methods that closely adhered to instructional features more typically characterized as being associated with behavioral approaches.

CONCLUSION

The authors discuss future research needs, practice implications, and a more detailed specification of treatment intensity parameters for future research.

Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control

BACKGROUND

Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science.

METHODS

We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project.

DISCUSSION

The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.

Acceptability of reproductive goals assessment in public mental health care

OBJECTIVE

To assess patient and provider perspectives on the acceptability of reproductive goals assessment in public mental health clinics and inform potential tailoring for these settings.

DATA SOURCES AND STUDY SETTING

Primary qualitative data from patients and providers at four clinics in an urban public mental health system serving individuals with chronic mental illness (collected November 2020-October 2021).

STUDY DESIGN

This was an exploratory qualitative study with patients (English-speaking women of reproductive age, primarily Black or Latina) and mental health providers (psychiatrists, psychotherapists, case managers, nurses). We examined the acceptability of reproductive goals assessment within mental health care and obtained feedback on two reproductive goals assessment conversation guides: PATH (Pregnancy Attitudes, Timing, and How Important is Pregnancy Prevention) and OKQ (One Key Question).

DATA COLLECTION

We conducted semi-structured telephone interviews with 22 patients and 36 providers. We used rapid qualitative analysis to summarize interview transcripts and identified themes using matrix analysis.

PRINCIPAL FINDINGS

Perceptions of reproductive goals assessment were generally positive. Providers said the conversation guides would "open the door" to important discussions, support a better understanding of patients' goals, and facilitate medication counseling and planning. A minority of patients expressed discomfort or ambivalence; several suggested providers ask permission or allow patients to raise the topic. Additional themes included the need for framing to provide context for these personal questions, the need to build rapport before asking them, and the challenge of balancing competing priorities. Many participants found both PATH and OKQ prompts acceptable; some preferred the "conversational" and "open-ended" PATH phrasing.

CONCLUSIONS

Participants perceived reproductive goals assessment as a promising practice in mental health care with unique functions in this setting. Areas of discomfort highlight the sensitivity of these topics for some women with chronic mental illness and suggest opportunities to tailor language, framing, and provider training to support effective and appropriate implementation.

Categorising implementation determinants and strategies within the US HIV implementation literature: a systematic review protocol

INTRODUCTION

Despite decreased rates of new infections, HIV/AIDS continues to impact certain US populations. In order to achieve the goals laid out in the Ending the HIV Epidemic (EHE) in the US initiative, implementation science is needed to expand the sustained use of effective prevention and treatment interventions, particularly among priority populations at risk for and living with HIV/AIDS. Over 200 HIV-related implementation studies have been funded by the US National Institutes of Health. Therefore, a comprehensive review of the literature identifying implementation determinants (barriers and facilitators) and categorising implementation strategies across the continuum of HIV prevention and care in the USA is appropriate and needed to enhance current knowledge and help achieve the goals laid out in the EHE national strategic plan.

METHODS AND ANALYSIS

This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Between November 2020 and January 2022, a broad database search strategy of Ovid MEDLINE, PsycINFO and Web of Science was conducted to capture implementation-related studies along the HIV prevention and care continuum. Articles were eligible for inclusion if they were: conducted in the USA, published after the year 2000, written in English, related to HIV/AIDS, focused on outcomes related to dissemination and implementation (ie, did not test/evaluate/explore implementation determinants or strategies) and were behavioural studies (ie, not basic science). We plan to conduct three systematic reviews to identify and categorise determinants and strategies associated with three HIV focus areas: pre-exposure prophylaxis, testing/diagnosing and linkage to care, and treatment. Determinants will be coded according to an adapted Consolidated Framework for Implementation Research 2.0. Implementation strategies and outcomes will be categorised in accordance with existing taxonomies and frameworks.

ETHICS AND DISSEMINATION

Ethics approval is not applicable. No original data will be collected. Results will be disseminated through peer-reviewed publications, conference presentations and via online tools.

PROSPERO REGISTRATION NUMBER

CRD42021233089.

Randomized trial protocol for remote monitoring for equity in advancing the control of hypertension in safety net systems (REACH-SNS) study

BACKGROUND

Self-measured blood pressure monitoring (SMBP) is essential to effective management of hypertension. This study aims to evaluate effectiveness and implementation of SMBP that leverages: cellular-enabled home BP monitors without a need for Wi-Fi or Bluetooth; simple communication modalities such as text messaging to support patient engagement; and integration into existing team-based workflows in safety-net clinics.

METHODS

This study will be conducted with patients in San Francisco who are treated within a network of safety-net clinics. English and Spanish-speaking patients with diagnosed hypertension will be eligible for the trial if they have recent BP readings ≥140/90 mmHg and do not have co-morbid conditions that make home BP monitoring more complex to manage. This study will implement a three-arm randomized controlled trial to compare varying levels of implementation support: 1) cellular-enabled BP monitors (with minimal implementation support), 2) cellular-enabled BP monitors with protocol-based implementation support (text reminders for patients; aggregated BP summaries sent to primary care providers), and 3) cellular-enabled BP monitors and pharmacist-led support (pharmacist coaching and independent medication adjustments).

RESULTS

For the main analysis, we will use mixed effects linear regression to compare the change in primary outcome of systolic BP. Secondary outcomes include BP control (<140/90 mmHg), medication intensification, patient-reported outcomes, and implementation processes (i.e., engagement with the intervention).

DISCUSSION

This study will design and test a digital health intervention for use in marginalized populations treated within safety net settings, evaluating both effectiveness and implementation to advance more equitable health outcomes.

Evidence Clearinghouses as Tools to Advance Health Equity: What We Know from a Systematic Scan

Evidence clearinghouses evaluate and summarize literature to help decision-makers prioritize and invest in evidence-informed interventions. Clearinghouses and related practice-oriented tools are continuously evolving; however, it is unclear the extent to which these tools assess and summarize evidence describing an intervention's impact on health equity. We conducted a systematic scan to explore how clearinghouses communicated an intervention's equity impact and reviewed their underlying methods and how they defined and operationalized health equity. In 2021, we identified 18 clearinghouses that were US-focused, web-based registries of interventions that assigned an intervention effectiveness rating for improving community health and the social determinants of health. We reviewed each clearinghouse's website and collected publicly available information about their health equity impact review, review methods, and health equity definitions and values. We conducted a comparative analysis among select clearinghouses using qualitative methods. Among the 18 clearinghouses, fewer than half (only seven) summarized an intervention's potential impact on health equity. Overall, those seven clearinghouses defined and operationalized equity differently, and most lacked transparency in their review methods. Clearinghouses used one or more approaches to communicate findings from their review: summarize study findings on differential impact for subpopulations, curate interventions that reduce health disparities, and/or assign a disparity/equity rating to each intervention. Evidence clearinghouses can enhance equity-focused methods and be transparent in their underlying values to better support the uptake and implementation of evidence-informed interventions to advance health equity. However, clearinghouses are unable to do so without underlying equity-focused empirical evidence.

Supporting implementation of interventions to address ethnicity-related health inequities: frameworks, facilitators and barriers - a scoping review protocol

INTRODUCTION

Health inequities are differences in health between groups of people that are avoidable, unfair and unjust. Achieving equitable health outcomes requires approaches that recognise and account for the differences in levels of advantage between groups. Implementation science, which studies how to translate evidence-based interventions into routine practice, is increasingly recognised as an approach to address health inequities by identifying factors and processes that enable equitable implementation of interventions. This article describes the protocol for a scoping review of the literature relating to the equitable implementation of interventions, focusing on ethnicity-related health inequities. The scoping review aims to identify equity-focused implementation science theories, models and frameworks (TMFs) and to synthesise and analyse the evidence relating to the factors that aid or inhibit equitable implementation of health interventions.

METHODS AND ANALYSIS

The scoping review is guided by the methodology developed by Arksey and O'Malley and enhanced by Levac and colleagues. Relevant literature will be identified by searching electronic databases, grey literature, hand-searching key journals and searching the reference lists and citations of studies that meet the inclusion criteria. We will focus on literature published from 2011 to the present. Titles, abstracts and full-text articles will be screened independently by two researchers; any disagreements will be resolved through discussion with another researcher. Extracted data will be summarised and analysed to address the scoping review aims.

ETHICS AND DISSEMINATION

The scoping review will map the available literature on equity-focused implementation science TMFs and the facilitators and barriers to equitable implementation of interventions. Ethical approval is not required. Dissemination of the results of the review will include publications in peer-review journals and conference and stakeholder presentations. Findings from the review will support those implementing interventions to ensure that the implementation pathway and processes are equitable, thereby improving health outcomes and reducing existing inequities.

Process adaptations to community-engaged research for preventing victimization against trans women: Failure as a blueprint toward nonexploitative implementation science

Effective violence prevention interventions are largely inaccessible to trans women and trans femmes, despite clear evidence that disproportionate exposure to experiences of victimization is a social determinant of health disparity. Community-engaged implementation science paradigms hold promise for guiding research psychologists in the delivery of evidence-based programming to address drivers of health disparities impacting trans women and trans femmes. Unfortunately, guidance on how to engage in a process of real-time self-reflection to note where implementation is failing in its goals to establish reciprocal and sustainable (i.e., nonexploitative) community partnerships are lacking. We describe our application of a modified failure modes and effects analysis to guide data-informed adaptations to our community-engaged implementation research project, tailoring and delivering an evidence-based intervention to prevent victimization of trans women and trans femmes. By mapping our failure modes, we offer a blueprint for other research psychologists invested in advancing nonexploitative research in partnership with community. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Shifting the narrative: equity, evidence, effectiveness, and innovation in the era of Ending the HIV Epidemic

BACKGROUND

The use of evidence-based (EB) and evidence-informed (EI) criteria in determining the effectiveness of health interventions has been widely adopted by national and international agencies in their attempt to address health gaps, particularly around Ending the HIV Epidemic (EHE) initiatives. Utilization of these rigorous standards has proven critical in making progress towards achieving EHE goals, yet many communities remain unreached and underserved despite widespread adoption of EB/EI standards in public health research and practice. Although a crucial tool for innovative healthcare delivery, emphasis on the use of EB/EI parameters has created bias within the cycle of knowledge creation that favors well-resourced institutions given their capacity to meet the rigorous evaluation standards required of EB/EI science. This bias can systematically exclude institutions more aligned with community needs, such as community-based organizations and other grass-roots initiatives, which may have long-standing interventions that more effectively engage marginalized groups but do not have the capacity to meet EB/EI standards.

MAIN BODY

This paper will explore the manifestation of systematic bias and research inequity in the process of identifying and assessing EB/EI HIV care interventions through the lens of a Health Resources and Services Administration funded initiative, coined the Center for Innovation and Engagement, which supports people living with HIV in the United States. An overview of the initiative is provided along with examples of how promising interventions with positive outcomes for members of marginalized communities are excluded in place of interventions that meet traditional standards of scientific rigor but are not novel or particularly innovative. Themes around academic imperialism and power hierarchies will be considered along with key barriers, lessons learned, and recommendations for promoting more equitable EB/EI research practice.

CONCLUSIONS

It is crucial for entities supporting public health interventions to prioritize equity and inclusion in all stages of funding, design, and implementation. This is particularly true for conditions, such as HIV, that disproportionally impact the most marginalized. This will require approaching EB/EI research with a critical lens towards power and a willingness to dismantle historical dynamics that perpetuate inequities as a way of encouraging truly innovative solutions to support those who need it most.

Exploring determinants and strategies for implementing self-management support text messaging interventions in safety net clinics

Background

Text message-delivered interventions for chronic disease self-management have potential to reduce health disparities, yet limited research has explored implementing these interventions into clinical care. We partnered with safety net clinics to evaluate a texting intervention for type 2 diabetes called REACH (Rapid Encouragement/Education And Communications for Health) in a randomized controlled trial. Following evaluation, we explored potential implementation determinants and recommended implementation strategies.

Methods

We interviewed clinic staff (n = 14) and a subset of intervention participants (n = 36) to ask about REACH's implementation potential. Using the Consolidated Framework for Implementation Research (CFIR) as an organizing framework, we coded transcripts and used thematic analysis to derive implementation barriers and facilitators. We integrated the CFIR-ERIC (Expert Recommendations for Implementing Change) Matching Tool, interview feedback, and the literature to recommend implementation strategies.

Results

Implementation facilitators included low complexity, strong evidence and quality, available clinic resources, the need for a program to support diabetes self-management, and strong fit between REACH and both the clinics' existing workflows and patients' needs and resources. The barriers included REACH only being available in English, a lack of interoperability with electronic health record systems, patients' concerns about diabetes stigma, limited funding, and high staff turnover. Categories of recommended implementation strategies included training and education, offering flexibility and adaptation, evaluating key processes, and securing funding.

Conclusion

Text message-delivered interventions have strong potential for integration in low-resource settings as a supplement to care. Pursuing implementation can ensure patients benefit from these innovations and help close the research to practice gap.

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

Are Training and Experience Adapting Evidence-Based Interventions Associated With Self-Efficacy and Attitudes? A Cross-Sectional Survey of Students and Practitioners With Varying Levels of Adaptation Experience

Increasing use of evidence-based interventions (EBIs) in local settings will help reduce the research-practice gap and improve health equity. Because adaptation to new settings and populations is essential to effective EBI use, frameworks to guide practice are receiving more attention; most, however, only provide broad guidelines without instructions for making adaptations in practice. Therefore, practitioners may need additional training or technical assistance (TA) to implement and adapt EBIs. This study explores whether practitioners' and students' general EBI training or TA and level of adaptation experience are associated with self-efficacy in adapting EBIs and with attitudes toward EBI use. We analyzed baseline survey data of participants in an evaluation of IM-Adapt Online, a newly developed decision support tool. We asked about previous training on EBIs, general and specific adaptation behaviors, and attitudes toward EBIs and found an association between previous training or TA in using EBIs with higher self-efficacy for using and adapting EBIs. Respondents with prior EBI training were significantly more likely to have higher self-efficacy in EBI behaviors across subdomains and in total than those without training. Respondents reported lowest self-efficacy for planning adaptations (M = 3.35) and assessing fit of EBIs to their local context (M = 3.41). This study suggests the importance of EBI adaptation training and TA to increase adoption and adaptation of EBIs, subsequently. More adaptation-specific training is warranted to assist students, practitioners, and researchers undertaking the adaptation process and implement EBIs. Future training on EBI adaptation can help practitioners tailor EBIs to meet the specific needs of their populations.

Agent-based model projections for reducing HIV infection among MSM: Prevention and care pathways to end the HIV epidemic in Chicago, Illinois

Our objective is to improve local decision-making for strategies to end the HIV epidemic using the newly developed Levers of HIV agent-based model (ABM). Agent-based models use computer simulations that incorporate heterogeneity in individual behaviors and interactions, allow emergence of systemic behaviors, and extrapolate into the future. The Levers of HIV model (LHM) uses Chicago neighborhood demographics, data on sex-risk behaviors and sexual networks, and data on the prevention and care cascades, to model local dynamics. It models the impact of changes in local preexposure prophylaxis (PrEP) and antiretroviral treatment (ART) (ie, levers) for meeting Illinois' goal of "Getting to Zero" (GTZ) -reducing by 90% new HIV infections among men who have sex with men (MSM) by 2030. We simulate a 15-year period (2016-2030) for 2304 distinct scenarios based on 6 levers related to HIV treatment and prevention: (1) linkage to PrEP for those testing negative, (2) linkage to ART for those living with HIV, (3) adherence to PrEP, (4) viral suppression by means of ART, (5) PrEP retention, and (6) ART retention. Using tree-based methods, we identify the best scenarios at achieving a 90% HIV infection reduction by 2030. The optimal scenario consisted of the highest levels of ART retention and PrEP adherence, next to highest levels of PrEP retention, and moderate levels of PrEP linkage, achieved 90% reduction by 2030 in 58% of simulations. We used Bayesian posterior predictive distributions based on our simulated results to determine the likelihood of attaining 90% HIV infection reduction using the most recent Chicago Department of Public Health surveillance data and found that projections of the current rate of decline (2016-2019) would not achieve the 90% (p = 0.0006) reduction target for 2030. Our results suggest that increases are needed at all steps of the PrEP cascade, combined with increases in retention in HIV care, to approach 90% reduction in new HIV diagnoses by 2030. These findings show how simulation modeling with local data can guide policy makers to identify and invest in efficient care models to achieve long-term local goals of ending the HIV epidemic.

Promoting community stakeholder engagement in research on treatment for pregnant women with opioid use disorder

Aim: Community stakeholder engagement in research (CSER) can improve research relevance and efficiency as well as prevent harmful practices, particularly for vulnerable populations. Despite potential benefits, researchers lack familiarity with CSER methods. Methods: We describe CSER strategies used across the research continuum, including proposal development, study planning and the first years of a comparative effectiveness study of care for pregnant women with opioid use disorder. Results: We highlight successful strategies, grounded in principles of engagement, to establish and maintain stakeholder relationships, foster bidirectional communication and trust and support active participation of women with opioid use disorder in the research process. Conclusion: CSER methods support research with a disenfranchised population. Future work will evaluate the impact of CSER strategies on study outcomes and dissemination.

Diversifying Implementation Science: A Global Perspective

We present a joint global perspective about the urgent need to diversify the loci of knowledge creation and sharing in global implementation science. We underscore the imperative of addressing implementation research questions relevant to practitioners, policy makers, and researchers from low- and middle-income countries.

Supporting the Growth of Domestic HIV Implementation Research in the United States Through Coordination, Consultation, and Collaboration: How We Got Here and Where We Are Headed

BACKGROUND

The Ending the HIV Epidemic (EHE) initiative sets a goal to virtually eliminate new HIV infections in the United States by 2030. The plan is predicated on the fact that tools exist for diagnosis, prevention, and treatment, and the current scientific challenge is how to implement them effectively and with equity. Implementation research (IR) can help identify strategies that support effective implementation of HIV services.

SETTING

NIH funded the Implementation Science Coordination Initiative (ISCI) to support rigorous and actionable IR by providing technical assistance to NIH-funded projects and supporting local implementation knowledge becoming generalizable knowledge.

METHODS

We describe the formation of ISCI, the services it provided to the HIV field, and data it collected from 147 NIH-funded studies. We also provide an overview of this supplement issue as a dissemination strategy for HIV IR.

CONCLUSION

Our ability to reach EHE 2030 goals is strengthened by the knowledge compiled in this supplement, the services of ISCI and connected hubs, and a myriad of investigators and implementation partners collaborating to better understand what is needed to effectively implement the many evidence-based HIV interventions at our disposal.

High-Fidelity Agent-Based Modeling to Support Prevention Decision-Making: an Open Science Approach

Preventing adverse health outcomes is complex due to the multi-level contexts and social systems in which these phenomena occur. To capture both the systemic effects, local determinants, and individual-level risks and protective factors simultaneously, the prevention field has called for adoption of system science methods in general and agent-based models (ABMs) specifically. While these models can provide unique and timely insight into the potential of prevention strategies, an ABM's ability to do so depends strongly on its accuracy in capturing the phenomenon. Furthermore, for ABMs to be useful, they need to be accepted by and available to decision-makers and other stakeholders. These two attributes of accuracy and acceptability are key components of open science. To ensure the creation of high-fidelity models and reliability in their outcomes and consequent model-based decision-making, we present a set of recommendations for adopting and using this novel method. We recommend ways to include stakeholders throughout the modeling process, as well as ways to conduct model verification, validation, and replication. Examples from HIV and overdose prevention work illustrate how these recommendations can be applied.

A Relational Framework for Engaging Latino Sexual Minority Men in Sexual and Behavioral Health Research

Latino sexual minority men (LSMM) experience sexual and behavioral health disparities. Yet, LSMM are underrepresented in sexual and behavioral health research, creating scientific inequity. There is, therefore, a need to identify the barriers and facilitators to LSMM's participation in sexual and behavioral health research, which is the gap that the current study sought to fill. We interviewed LSMM (n = 28; age 18-40, 57% US born) and key informants (n = 10) regarding LSMM's barriers and facilitators to participating in sexual and behavioral health research and suggestions for increasing participation. The research team coded the data via thematic analysis. We found that relational factors are central to understanding LSMM's participation in sexual and behavioral health research. Some relational experiences (e.g., interpersonal stigma) interfered with participation, whereas others (e.g., altruistic desires to contribute to community well-being) facilitated participation. The findings are consolidated within a new relational framework for understanding LSMM's participation in sexual and behavioral health research. Study findings highlight the centrality of relational factors in influencing LSMM's participation in sexual and behavioral health research. Relational factors can be used to inform the development of culturally relevant recruitment strategies to improve representation of LSMM in sexual and behavioral health research. Implementing these recommendations may address scientific inequity, whereby LSMM are disproportionately impacted by sexual and behavioral health concerns yet underrepresented in related research.

Grounding implementation science in health equity for cancer prevention and control

BACKGROUND

The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions.

DISCUSSION

In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Assessing researchers' capabilities, opportunities, and motivation to conduct equity-oriented dissemination and implementation research, an exploratory cross-sectional study

BACKGROUND

A recent paradigm shift has led to an explicit focus on enhancing health equity through equity-oriented dissemination and implementation (D&I) research. However, the integration and bidirectional learning across these two fields is still in its infancy and siloed. This exploratory study aimed to examine participants' perceived capabilities, opportunities, and motivations to conduct equity-oriented D&I research.

METHODS

We conducted an exploratory cross-sectional survey distributed online from December 2020 to April 2021. Participants were recruited at either D&I or health disparities-oriented conferences, meetings, through social media, or personal outreach via emails. Informed by the Capability, Opportunity, and Motivation Model (COM-B), the survey queried respondents about different aspects of engaging in and conducting equity-oriented D&I research. All analyses were conducted in SPSS Version 27.0.

RESULTS

A total of 180 participants responded to the survey. Most participants were women (81.7%), white (66.1%), academics (78.9%), and faculty members (53.9%). Many reported they were advanced (36.7%) or advanced beginners (27.8%) in the D&I field, and a substantial proportion (37.8%) reported being novice in D&I research that focused on health equity. Participants reported high motivation (e.g., 62.8% were motivated to apply theories, models, frameworks for promoting health equity in D&I research), but low capability to conduct equity-oriented D&I research (e.g., 5% had the information needed for promoting health equity in D&I research). Most participants (62.2%) reported not having used measures to examine equity in their D&I projects, and for those who did use measures, they mainly used individual-level measures (vs. organizational- or structural-level measures). When asked about factors that could influence their ability to conduct equity-oriented D&I research, 44.4% reported not having the skills necessary, and 32.2% stated difficulties in receiving funding for equity-oriented D&I research.

CONCLUSIONS

Study findings provide empirical insight into the perspectives of researchers from different backgrounds on what is needed to conduct equity-oriented D&I research. These data suggest the need for a multi-pronged approach to enhance the capability and opportunities for conducting equity-oriented D&I work, such as: training specifically in equity-oriented D&I, collaboration between D&I researchers with individuals with expertise and lived experience with health equity research, funding for equity-oriented D&I research, and recognition of the value of community engaged research in promotion packages.

Don't Get Lost in Translation: Integrating Developmental and Implementation Sciences to Accelerate Real-World Impact on Children's Development, Health, and Wellbeing

Translation of developmental science discoveries is impeded by numerous barriers at different stages of the research-to-practice pipeline. Actualization of the vast potential of the developmental sciences to improve children's health and development in the real world is imperative but has not yet been fully realized. In this commentary, we argue that an integrated developmental-implementation sciences framework will result in a translational mindset essential for accelerating real world impact. We delineate key principles and methods of implementation science of salience to the developmental science audience, lay out a potential synthesis between implementation and developmental sciences, provide an illustration of the Mental Health, Earlier Partnership (MHE-P), and set actionable steps for realization. Blending these approaches along with wide-spread adoption of the translational mindset has transformative potential for population-level impact of developmental science discovery.

Revisiting concepts of evidence in implementation science

BACKGROUND

Evidence, in multiple forms, is a foundation of implementation science. For public health and clinical practice, evidence includes the following: type 1 evidence on etiology and burden; type 2 evidence on effectiveness of interventions; and type 3: evidence on dissemination and implementation (D&I) within context. To support a vision for development and use of evidence in D&I science that is more comprehensive and equitable (particularly for type 3 evidence), this article aims to clarify concepts of evidence, summarize ongoing debates about evidence, and provide a set of recommendations and tools/resources for addressing the "how-to" in filling evidence gaps most critical to advancing implementation science.

MAIN TEXT

Because current conceptualizations of evidence have been relatively narrow and insufficiently characterized in our opinion, we identify and discuss challenges and debates about the uses, usefulness, and gaps in evidence for implementation science. A set of questions is proposed to assist in determining when evidence is sufficient for dissemination and implementation. Intersecting gaps include the need to (1) reconsider how the evidence base is determined, (2) improve understanding of contextual effects on implementation, (3) sharpen the focus on health equity in how we approach and build the evidence-base, (4) conduct more policy implementation research and evaluation, and (5) learn from audience and stakeholder perspectives. We offer 15 recommendations to assist in filling these gaps and describe a set of tools for enhancing the evidence most needed in implementation science.

CONCLUSIONS

To address our recommendations, we see capacity as a necessary ingredient to shift the field's approach to evidence. Capacity includes the "push" for implementation science where researchers are trained to develop and evaluate evidence which should be useful and feasible for implementers and reflect community or stakeholder priorities. Equally important, there has been inadequate training and too little emphasis on the "pull" for implementation science (e.g., training implementers, practice-based research). We suggest that funders and reviewers of research should adopt and support a more robust definition of evidence. By critically examining the evolving nature of evidence, implementation science can better fulfill its vision of facilitating widespread and equitable adoption, delivery, and sustainment of scientific advances.

Reimagining Rural: Shifting Paradigms About Health and Well-Being in the Rural United States

Rural health disparities have attracted increased national attention, compelling an expanded focus on rural health research. In this article, we deconstruct the definitions and narratives of "rural" communities and suggest that a paradigm shift is needed that centers the complexity and strength of rural places. We discuss the relevance of health equity frameworks, implementation science, and community-engaged approaches to promote rural well-being. Focusing on rural in its own right will lead to intervention innovations and reinvention with implications beyond rural areas. We conclude with suggestions for research and practice to inspire renewed interest in partnering with rural communities to promote health equity.

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.