Key Literature

Section lead: Jinying Chen, PhD

This section includes a reading list of editorials, calls to action, perspectives, and methods articles that provide guidelines and recommendations for integrating health equity into IS. Table 2 categorizes these articles based on their topic areas and summarizes the key points of each article.

General recommendations include incorporating a health equity focus into the study from the very beginning and continuing to apply this focus in all stages, from design and planning to implementation and evaluation, whenever possible. In addition, incorporating health equity constructs into implementation models and frameworks, conducting community engagement, and using equity-relevant measures are essential strategies for health equity-focused IS.

The summary column in Table 2 contains cross references to content in the articles (e.g., tables, figures, and page numbers).

Table 2. Annotated List of Literature on Integrating Equity Into IS

Articles Summary of Content
Recommendations, guidelines, and approaches to integrating a health equity lens into implementation science
Ramanadhan S, Davis MM, Armstrong R, et al. Participatory implementation science to increase the impact of evidence-based cancer prevention and control. Cancer Causes Control. 2018;29(3):363-369. doi:10.1007/s10552-018-1008-1 Discussed the utility of participatory implementation science for cancer prevention and control research:
1) the spectrum of participatory research approaches;
2) benefits of participatory implementation science; and
3) key considerations for conducting such projects.
Described six application areas of participatory implementation science (with example studies): identification of research question and evidence-based practice, study execution, data interpretation, dissemination, building the evidence base, and capacity building.
McNulty M, Smith JD, Villamar J, et al. Implementation research methodologies for achieving scientific equity and health equity. Ethn Dis. 2019;29(Suppl 1):83-92. doi:10.18865/ed.29.S1.83 Emphasized community engagement (e.g., community-based participatory research and community-partnered participatory research) as an important strategy to overcome disparities.
Reviewed three implementation science research paradigms and related methods, with example studies, to improve scientific and health equity:
1) analysis of existing data, using epidemiologic methods and simulation modeling (agent-based modeling) to understand and address disparities;
2) research with health equity as secondary focus of implementation; and
3) research focusing exclusively on vulnerable populations.
Baumann AA, Cabassa LJ. Reframing implementation science to address inequities in healthcare delivery. BMC Health Serv Res. 2020;20(1):190. doi:10.1186/s12913-020-4975-3 Reframed five core elements of implementation science to incorporate a health equity lens:
1) focus on reach from the very beginning;
2) design and select evidence-based interventions (EBIs) that best serve vulnerable populations;
3) develop implementation strategies to reduce health care inequities;
4) adapt implementation programs; and
5) examine equity issues when assessing implementation outcomes.
Brownson RC, Kumanyika SK, Kreuter MW, Haire-Joshu D. Implementation science should give higher priority to health equity. Implement Sci. 2021;16(1):28. doi:10.1186/s13012-021-01097-0 Outlined three challenges for addressing health equity in implementation science:
1) EBIs were not sensitive to health equity;
2) measures or methods lack a focus on health equity; and
3) factors driving health equity received less attention when assessing and addressing the implementation context.
Provided 10 recommendations, with action steps and examples, on how to address these challenges (table 2). Figure 1 shows four types of metrics for equity in implementation science.
Snell-Rood C, Jaramillo ET, Hamilton AB, Raskin SE, Nicosia FM, Willging C. Advancing health equity through a theoretically critical implementation science. Transl Behav Med. 2021;11(8):1617-1625. doi:10.1093/tbm/ibab008 Discussed three areas of anthropology theories that could complement implementation science theories and constructs to advance health equity:
1) theories of postcoloniality and reflexivity, to give attention to the role of power in knowledge production and to the ways that researchers and interventionists may perpetuate the inequalities shaping health (table 1);
2) theories of structural violence and intersectionality, to help understand and address health disparities at multiple levels and across sectors (table 2); and
3) theories of policy and governance, to examine the social-political forces of the “outer context” crucial for implementation and sustainability (table 3).
Key questions and relevant studies were provided (tables 1–3) to demonstrate how these theories can be operationalized to enhance each stage of health equity implementation research.
Loper A, Woo B, Metz A. Equity is fundamental to implementation science. Stanf Soc Innov Rev. 2021;19(3):A3-A5. doi:10.48558/QNGV-KG05 Proposed a new lens called equitable implementation and discussed five crucial elements:
1) design/select intervention by assessing root causes of inequity, including historical and structural racism;
2) focus on reach and equity from the very beginning;
3) conduct community engagement;
4) adapt intervention to fit the local community;
5) and develop new strategies.
Odeny B. Closing the health equity gap: A role for implementation science? PLoS Medicine. 2021;18(9):e1003762. doi:10.1371/journal.pmed.1003762 Recommended integrating health equity in three areas:
1) identify implementation strategies to promote equity;
2) develop metrics for quantifying and monitoring disparities during implementation; and
3) adopt pragmatic study designs (e.g., mixed methods, hybrid effectiveness–implementation research) to generate evidence related to health equity.
Kerkhoff AD, Farrand E, Marquez C, Cattamanchi A, Handley MA. Addressing health disparities through implementation science—A need to integrate an equity lens from the outset. Implement Sci. 2022;17(1):13. doi:10.1186/s13012-022-01189-5 Outlined four key pre-implementation steps and associated questions to guide selectin and design of interventions and implementation strategies to reduce health disparities:
1) engage relevant community partners and stakeholders;
2) select interventions and implementation strategies using a health equity lens;
3) evaluate existing performance gaps related to the intervention or program in vulnerable populations; and
4) identify and prioritize barriers faced by vulnerable populations.
Adsul P, Chambers D, Brandt HM, et al. Grounding implementation science in health equity for cancer prevention and control. Implement Sci Commun. 2022;3(1):56 (2022). doi:10.1186/s43058-022-00311-4 Highlighted recent advances in implementation science to promote health equity (e.g., theories, models, frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes).

Described opportunities for integration of broader health equity research with implementation science (figure 1), which include incorporating an explicit focus on health equity in:
1) conducting and reviewing implementation science;
2) theories, models, and frameworks guiding implementation science; and
3) identifying methods for understanding and documenting influences on the context of implementation.
Recommendations apply to cancer prevention and control—and beyond.

The Discussion section described methods for integrating implementation science and health equity research (under recommendations 1 and 2; e.g., community engagement, tracking adaptations, key questions to consider regarding implementation strategies, intervention mapping).
Addressing structural and institutional racism and power in implementation science
Shelton RC, Adsul P, Oh A. Recommendations for addressing structural racism in implementation science: A call to the field. Ethn Dis. 2021;31(Suppl 1):357-364. doi:10.18865/ed.31.S1.357 Provided recommendations for addressing structural racism in implementation science, with example studies, in three areas:
1) include structural racism as a construct and determinant within implementation science frameworks and models;
2) use a multi-level approach to select, develop, and adapt EBIs and implementation strategies to address structural racism; and
3) conduct transdisciplinary and intersectoral collaborations and engagement (e.g., community-based participatory research and stakeholder engagement) as essential methods to address structural racism.

Discussed measures of structural racism (p. 4, within recommendation 1) and study designs (pp. 6–7, within recommendation 3).
Shelton RC, Adsul P, Oh A, Moise N, Griffith DM. Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity. Implement Res Pract. 2021;2. doi:10.1177/26334895211049482 Provided guidance for applying an antiracism lens to implementation science, focusing on select core elements in implementation research:
1) stakeholder engagement;
2) conceptual frameworks and models;
3) development, selection, adaptation of EBIs;
4) evaluation approaches; and
5) implementation strategies.

Table 1 summarized the recommendations, along with key questions for each element. The article also provided helpful examples and references for community engagement and community-based participatory research (pp. 3, 7) and assessing SDoH/structural racism (p. 7).
Stanton MC, Ali SB; SUSTAIN Center Team. A typology of power in implementation: Building on the exploration, preparation, implementation, sustainment (EPIS) framework to advance mental health and HIV health equity. Implement Res Pract. Jan 2022. doi:10.1177/26334895211064250 Identified three types of power working through implementation:
1) discursive power is enacted through defining health-related problems to be targeted and through health narratives emerging through implementation;
2) epistemic power influences whose knowledge is valued in decision-making; and
3) material power is created through resource distribution and patterns of access to health resources and acquisition of health benefits provided by the intervention.

Explained how these forms of power influence factors and phases of implementation, using the EPIS (exploration, preparation, implementation, sustainment) framework.
Policy implementation science to address health inequity
Emmons KM, Chambers DA. Policy implementation science—an unexplored strategy to address social determinants of health. Ethn Dis. 2021;31(1):133-138. doi:10.18865/ed.31.1.133 An elaboration of key points discussed in the 2021 Policy Implementation Science paper in the context of cancer control research. Discussed capacity building and potential areas for applying implementation science approaches and methods to health-related policy:
1) develop measures and data infrastructure to support evaluation of policy-relevant implementation processes and outcomes;
2) train scholars to conduct policy implementation science;
3) understand and improve the connection of scientific evidence and policy implementation; and evaluate and track the equity-relevant impact of policies (long term, multiple levels and sectors).
Emmons KM, Chambers D, Abazeed A. Embracing policy implementation science to ensure translation of evidence to cancer control policy. Transl Behav Med. 2021;11(11):1972-1979. doi:10.1093/tbm/ibab147 An elaboration of key points discussed in the 2021 Policy Implementation Science paper in the context of cancer control research. Discussed six key gap areas (table 1) that could be addressed by implementation science related to cancer control policy implementation:
1) bring a focus of policy implementation to implementation science frameworks;
2) develop and use policy-relevant measures;
3) study the intersection between policy instruments (strategies) and the policy context;
4) develop collaboration structures that support policy implementation science;
5) clarify factors that influence transfer from knowledge to policy; and
6) evaluate the impact of all aspects of policy implementation on health equity.

Introduced concepts in policy science (e.g., the five-stream framework of the policy process, policy instruments) useful for policy implementation science.
De-implementation to reduce health inequities
Helfrich CD, Hartmann CW, Parikh TJ, Au DH. Promoting health equity through de-implementation research. Ethn Dis. 2019;29(Suppl 1):93-96. doi:10.18865/ed.29.S1.93 Discussed three reasons why de-implementation is critical for advancing equity. Proposed several actions for closing current research gaps, including:
1) measure inequity in medical overuse of low-value practices/interventions;
2) study potential mechanisms related to equity in overuse; and
3) test de-implementation strategies to reduce inequity.
COVID-19 pandemic
Jacobson TA, Smith LE, Hirschhorn LR, Huffman MD. Using implementation science to mitigate worsening health inequities in the United States during the COVID-19 pandemic. Int J Equity Health. 2020;19(1):170. doi:10.1186/s12939-020-01293-2 Discussed opportunities for using implementation science methods and strategies to improve reach and effectiveness (and thus health equity) of interventions and policies for controlling the COVID-19 pandemic. The discussion was organized by types of policies, related to testing, tracing, social distancing, and public mask use. Implementation science can support policy design, implementation, and evaluation.
Provided an example of using implementation science implementation outcomes framework to evaluate COVID-19 testing strategies (table 1).
Galaviz KI, Breland JY, Sanders M, et al. Implementation science to address health disparities during the coronavirus pandemic. Health Equity. 2020;4(1):463-467. doi:10.1089/heq.2020.0044 Discussed three ways (figure 1), with recommended actions, in which implementation science can help guide the equitable development and deployment of preventive interventions, testing, and, eventually, treatment and vaccines during the COVID-19 pandemic:
1) quantify and understand disparities;
2) design equitable interventions; and
3) test, refine, and retest interventions.
Riley WT, Mensah GA. Social determinants of health and implementation research: Lessons from the COVID-19 pandemic. Ethn Dis. 2021;31(1):5-8. doi:10.18865/ed.31.1.5 Highlighted health disparities during the COVID-19 pandemic and discussed how social determinants of health contributed to these disparities. Advocated for the development and application of implementation strategies to reduce health inequity.
Kwan BM, Sobczak C, Gorman C, Roberts S, Owen V, Wynia MK, Ginde AA, Pena-Jackson G, Ziegler O, Ross DeCamp L. "All of the things to everyone everywhere": A mixed methods analysis of community perspectives on equitable access to monoclonal antibody treatment for COVID-19. PLoS One. 2022 Nov 23;17(11):e0274043. doi: 10.1371/journal.pone.0274043. PMID: 36417457; PMCID: PMC9683597. Assessed community perspectives on Monoclonal antibodies (mAbs) treatment for COVID-19 through a mixed methods study using surveys and focus groups. The studies identified little awareness but high interest in getting mAb treatment among participants. Compared with White, Non-Hispanic respondents, Hispanic/Latino and Non-Hispanic People of Color (POC) reported less awareness and trust in mAb safety and effectiveness. Major barriers of using mAb treatment are cost, lacking sources of care, and transportation. Tailored messaging strategies using multiple media and trusted community leaders are needed to improve reach and equitable access to mAb treatment.
Other topics
Westfall JM, Roper R, Gaglioti A, Nease DE Jr. Practice-based research networks: Strategic opportunities to advance implementation research for health equity. Ethn Dis. 2019;29(Suppl 1):113-118. doi:10.18865/ed.29.S1.113 Introduced the history and infrastructure of practice-based research networks (PBRN), and existing work in PBRN that addresses health equity. Described new PBRN opportunities to address health disparities (e.g., serving as an ideal laboratory for studying interventions to address health equity issues).
Baumann A, Woodward E, Adsul P, Singh S, Shelton RC. Assessing researchers’ capabilities, opportunities, and motivation to conduct equity-oriented dissemination and implementation research, an exploratory cross-sectional study. BMC Public Health. 2022;22(1):731. doi:10.1186/s12913-022-07882-x A survey study of 180 participants about aspects of engaging in and conducting equity-oriented dissemination and implementation (D&I) research. Participants reported high motivation but low capability to conduct equity-oriented D&I research (e.g., lack of information needed for promoting health equity and experience in using measures to examine equity in D&I projects). Lack of skills and funding are two major factors perceived to influence ability to conduct equity-oriented D&I research.