Conceptual framework of equity-focused implementation research for health programs (EquIR)

An equity audit on program completion among women with a history of gestational diabetes in a state-funded diabetes and cardiovascular risk reduction program

PURPOSE

To assess the completion of the type 2 diabetes, heart disease and stroke prevention program (the Life!) among women with a history of gestational diabetes mellitus (GDM) according to participants' characteristics.

METHODS

Data from women with a history of GDM enrolled in the Life! program in Victoria, Australia, between 2014 and 2022 were analysed. Completion rates were assessed using the PROGRESS-Plus (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital Plus age and smoking) framework. Multivariable logistic regression model was fitted.

RESULTS

A total of 2399 women with a history of GDM were enrolled in the program, of which 55 % completed it. Characteristics associated with higher completion rates included being from metropolitan areas (AOR = 1.52, 95 % CI: 1.14-2.01) compared with being from regional areas, having a body mass index in a normal range (AOR = 1.50, 95 % CI: 1.06-2.15) compared with having overweight or obesity, having middle income (AOR = 1.41, 95 % CI: 1.01-1.98) compared with having low- or high-income, and enrolment after 2019 (AOR = 2.3, 95 % CI:1.80-3.06) compared with enrolment in 2019 or earlier. Conversely, having a South or Central Asian background (AOR = 0.65, 95 % CI: 0.46-0.92) is associated with a lower completion rate compared with being from Australia.

CONCLUSION

Characteristics associated with lower completion rates among women with prior GDM in a cardiometabolic risk reduction program included residing in rural and remote areas, having an elevated BMI (in the overweight or obesity range), low or high income, enrolment in 2019 or earlier and being of South or Central Asian background.

Paving the Road for More Ethical and Equitable Policies and Practices in Telerehabilitation in Psychology and Neuropsychology: Protocol for a Rapid Review

BACKGROUND

Virtual rehabilitation, or telerehabilitation (TR), has exponentially evolved in the last few years, gaining particular momentum since the COVID-19 pandemic. In response to a new reality of strict restrictions of physical contact necessitating the shift from in-person health services to tele-health visits, TR has seen widespread adoption. In this context, ensuring ethical and equitable TR services is crucial for establishing sustainable TR models for psychology and neuropsychology into health care systems. This requires complete and consistent guidance for clinicians and patients involved.

OBJECTIVE

The objective of this study is to synthesize existing evidence to provide timely insights on potential ethical and equitable benefits and pitfalls associated with the use of TR in a psychological and neuropsychological framework.

METHODS

A rapid review of TR practices will be conducted specifically within the context of neuropsychology and psychology rehabilitation. We will include review articles published between 2010 and 2020 as well as original articles published between 2020 and 2023, all addressing TR issues with a main focus on neuropsychological and/or psychological rehabilitation activities. This research protocol describes the methodology, including search strategy, screening process, data extraction, and analysis methods.

RESULTS

Guided by an experienced librarian, the search strategy was designed and performed in 3 relevant databases. Articles were screened in accordance with the inclusion and exclusion criteria, and data were collected by 2 independent reviewers. Data extraction is underway, and we expect to complete the rapid review in January 2025.

CONCLUSIONS

This study is part of a broader cross-Canadian initiative aimed at informing policy development and clinical practices in TR. By evaluating the ethical and equitable considerations specific to psychology and neuropsychology, this review aims to contribute to help shape future TR practices to ensure access to high-quality, accessible TR services supporting diverse patient needs in psychology and neuropsychology.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66639.

Innovation in Providing Equitable Pre-exposure Prophylaxis Services in the United States: Expanding Access in Nontraditional Settings

BACKGROUND

Pre-exposure prophylaxis (PrEP) usage has slowly increased in the United States, but significant disparities persist across race, ethnicity, sex, gender, age, and geography. Determinants of PrEP inequities include stigma and medical mistrust, lack of patient-centered services, lack of access to clinical care, and organizational resistance to change-within a health care system that neglects these barriers.

METHODS

We describe 5 implementation strategies to providing PrEP in nontraditional settings to underserved populations, using an equity-based approach to address key structural determinants. The alternative settings used in these Ending the HIV Epidemic projects (community-based organizations, telePrEP, mobile clinics, pharmacies, emergency departments) were chosen for the setting characteristics and their serving structurally underserved populations.

RESULTS

Community-based organizations have earned trust within communities and can serve as hubs for comprehensive sexual health services, including PrEP. Telehealth, which expanded significantly because of COVID-19, can help overcome transportation and scheduling barriers to PrEP access. Mobile clinics can also broaden PrEP delivery by bringing tailored services directly to communities, often providing shorter wait times and extended hours. Pharmacists can prescribe PrEP in certain states through legislation or collaborative practice agreements, offering a convenient, community-based option. Emergency departments provide an alternative site for PrEP delivery, with the potential to reach individuals not currently engaged in regular care.

CONCLUSION

These alternative PrEP approaches can expand options for accessing PrEP and alleviate key barriers to care in traditional settings, although they may not eliminate all inequities. Offering more choices increases the likelihood that a broader population will be reached, thereby enhancing overall access to PrEP.

Addressing health equity during design and implementation of health system reform initiatives: a scoping review and framework

BACKGROUND

Health equity is a commonly asserted goal of health systems. However, there is a limited understanding on how best to promote equity as a part of health system reform initiatives. We conducted a scoping review to (1) identify and characterise strategies that promote health equity during the design and implementation of health system reform initiatives; and (2) determine opportunities to strengthen health equity informed policy design and implementation processes and outcomes.

METHOD

We systematically searched peer-reviewed literature from 2013 to 2022 focussing on four search domains: (1) health equity; (2) implementation; (3) health system; and (4) reform, policy, or theories, and only included papers that represented a population health or system-wide intention. Health equity promoting strategies were categorised into those occurring at national, regional, state, or local levels. Themes common across system levels were mapped, which alongside theory, informed the development of a health equity promoting framework for reform initiatives.

RESULTS

The search returned 10,999 articles after duplicates were removed. 384 articles underwent full text review and 68 met the inclusion criteria. Thematic analysis of results identified health equity promoting themes derived from numerous strategies, with a median of 10 strategies (interquartile range 7,15) per article. Accountability, commitment, shared power, and adaptability emerged as some of the most prominent equity promoting themes applicable at all system levels. Across strategies, two cardinal conditions were identified: (1) the need for health equity implementation strategies to be made explicit, and (2) the need for alignment and complementarity of strategies. The framework developed demonstrates equity-oriented reform implementation, which embeds broader equity change throughout the system through inclusive and reflexive governance.

CONCLUSION

This review synthesises diverse literature about how health equity has been considered across levels of the health system during reform design and implementation, providing to our knowledge, the first comprehensive multi-level approach to this issue. Our resulting framework presents policymakers, implementers, and researchers a novel cross-scholarship perspective and process to support the implementation of health equity within system reform initiatives. Throughout design and implementation, consistent vision and a coordinated approach for equity across system levels, underpinned by reflexive governance, will be vital to ensuring that those most in need of healthcare benefit equitably.

Conceptualizing, operationalizing, and utilizing equity, diversity, and inclusion in clinical trials: a scoping review

OBJECTIVES

Equity, diversity, and inclusion (EDI) are social constructs which when used in clinical trials, or clinical research broadly help generate the highest quality evidence for interventions in the populations most likely to benefit. However, the incorporation of these constructs is unclear and inconsistent. This scoping review sought to understand how EDI is applied in clinical trials with broader application across clinical research.

METHODS

We reviewed literature from PubMed and Google Scholar, selecting studies 1) published from 2000 to 2023, 2) literature which described concepts, tools, metrics, or frameworks, and 3) provided information on conceptualization, operationalization (measuring) or utilization (analyzing). Additionally, internet searches were conducted to identify websites of research partners such as government institutions, funders, regulators and publishers across the research lifecycle. Websites retrieved were included for our review of EDI consideration (either concepts or statements) outside but impacting upon the published literature.

RESULTS

We reviewed 2385 titles and abstracts and included 75 (3%) in analyses. From gray literature searches of 269 identified key research partners, additional 49 records were included. Studies conceptualized EDI as interconnected rather than distinct constructs. These concepts were often reinforcing, such as efforts to enhance diversity which also promote equity and foster inclusion. Regarding operationalization, 12 frameworks, 20 tools/metrics were identified for EDI assessment across the research lifecycle. These metrics were primarily used for reporting EDI data, and utilization across research lifecycle remains limited. Among research partners, a third of publishers (6 of 20) had any EDI considerations; followed by 2 of 19 trial registries, 12 of 44 research funders, 7 of 60 journals, and none of ethics committee and data repositories reported statements on EDI.

CONCLUSION

This review highlights that a range of EDI relevant tools, frameworks and metrics, each with their unique strengths and limitations. We found a wider adoption of EDI considerations by research partners is still lacking. Future research could explore the impact of different EDI criteria on trial outcomes and the generalizability of trial results.

Public engagement with consumer sleep technology for obstructive sleep apnea screening: implications for equity, access, and practice

STUDY OBJECTIVES

To characterize public practices and perspectives on the use of consumer sleep technology (CST) and evaluate perspectives on using CST as a screening tool for obstructive sleep apnea.

METHODS

We designed a survey instrument incorporating content from validated instruments (STOP-Bang and the Epworth Sleepiness Scale) and hypothesis-generated questions. Survey development involved multidisciplinary collaboration among 3 board-certified sleep medicine experts, researchers, and consumers. The survey was disseminated across a national sample of adults living in the United States via an online platform.

RESULTS

Among 897 respondents, the mean (standard deviation) age was 47.5 (16.9) years; 73.1% were female, 81.8% were White, and 505 respondents (56.3%) reported having tracked sleep using CST. Factors associated with decreased odds of CST use included household income < $30,000 (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.28-0.79; P = .004), Medicaid insurance (OR 0.43, 95% CI 0.26-0.69; P = .001), Medicare insurance (OR 0.59, 95% CI 0.41-0.84; P = .004), and lack of a primary care physician (OR 0.55, 95% CI 0.33-0.91; P = .021). Most respondents (91.1%) agreed or strongly agreed that screening for obstructive sleep apnea would be a useful feature of CST, but respondents reporting an education of high school diploma or less (OR 0.48, 95% CI 0.29-0.79; P = .004) were less likely to agree with this statement.

CONCLUSIONS

Attitudes toward and use of CST differed based on demographic and socioeconomic factors. Further study is needed to understand and address barriers to CST adoption and to characterize implications for equitable access to care for sleep disorders.

CITATION

Lenze NR, Kazemi RJ, Ikeda AK, et al. Public engagement with consumer sleep technology for obstructive sleep apnea screening: implications for equity, access, and practice. J Clin Sleep Med. 2025;21(2):345-353.

Medically Tailored Grocery Deliveries to Improve Food Security and Hypertension in Underserved Groups: A Student-Run Pilot Randomized Controlled Trial

BACKGROUND/OBJECTIVES

Randomized controlled trials (RCTs) are needed to evaluate the impact of food is medicine (FIM) programs, such as medically tailored groceries (MTGs) to treat hypertension among diverse populations. Partnerships between academic centers' student-run organizations (SROs) and community-based organizations (CBOs) offer critical safety nets for historically underserved groups, positioning these organizations to effectively undertake FIM programs among populations disproportionately affected by hypertension. We conducted an unblinded pilot RCT whose objectives were to assess the feasibility and acceptability of an SRO-coordinated, CBO-partnered MTGs intervention targeting blood pressure (BP) and food insecurity (FI) in underserved groups.

METHODS

Adult Black/African American and Hispanic/Latinx patients in Durham, North Carolina, where essential hypertension and FI were randomized (parallel arm, computerized 1:1 ratio) to 12 weeks of home-delivered, hypertension-focused MTGs plus in-person nutrition education sessions with compensation (intervention) versus data collection sessions with compensation (control). We offered transportation, childcare, and home visits to facilitate session attendance. The primary outcomes were the eligibility, enrollment, and retention rates (feasibility), and the survey feedback from the participants and CBO partners (acceptability). The secondary outcomes included the changes in the mean BP and median FI score with associated 95% confidence intervals.

RESULTS

Medical record screening identified 1577 eligible participants. Of the 94 reached to confirm eligibility, 77 met the enrollment criteria, and 50 were randomized (82% post-screen eligibility, 65% enrollment). A conventional content analysis of 15 participant surveys and CBO partner feedback affirmed the acceptability, noting intervention components that enhanced the retention (e.g., home delivery, transportation support, home visits). Pre-post analyses of secondary outcomes for 13/25 intervention and 15/25 control participants completing ≥2 sessions ≥2 months apart were performed. The intervention was associated with an average change in systolic BP of -14.2 mmHg (-27.5, -4.5) versus -3.5 mmHg (-11.7, 5.9) in the control group. The FI scores improved by -2 (-2.2, -0.5) in the intervention group and -1 (-1.3, -0.2) in the control group. No adverse events were reported.

CONCLUSIONS

SRO-CBO partnerships could be feasible and acceptable avenues for conducting FIM trials among underserved populations. This multi-component FIM approach enhanced the study equity by addressing the participants' disease-related social needs and warrants expansion into a powered RCT.

Applying health equity implementation science frameworks to population genetic screening

Introduction

Implementation science frameworks with a focus on health equity have emerged to help guide the introduction of new interventions into healthcare and community settings while limiting health disparities. The purpose of this research was to explore the applicability of such frameworks to guide the equitable implementation of population genetic screening programs.

Methods

We searched PubMed and reference lists for relevant frameworks and examples of their use in health settings. We then assessed if and how selected frameworks provide guidance for different stages of population genetic screening: recruitment, sample collection, result return, follow-up care and long-term management, and cascade screening. Findings were synthesized into a list of health equity considerations specific to each stage.

Results

We identified 5 implementation frameworks that focus on health equity. Guidance varied by framework type: determinant (explaining what affects implementation outcomes), process (translating research into practice), or evaluation (assessing implementation). Common characteristics included focusing implementation efforts on populations who have historically experienced health inequities and adapting interventions to fit local contexts. Process models also highlighted the importance of community partnerships.

Discussion

Overall, frameworks offered broad recommendations applicable to population genetic screening program implementation. However, gaps still exist in guidance provided for later stages of population genetic screening. To improve the equitable implementation of genetic screening, future programs may benefit from utilizing one or more of these frameworks or by incorporating the health equity considerations and outcomes compiled in this analysis.

Practitioner perspectives on equitable implementation of evidence-based interventions for cancer prevention and control

Longstanding inequities in cancer prevention and control require novel approaches to improve evidence-based intervention implementation. Exploring and elevating the perspectives of cancer prevention and control practitioners working to advance health equity and equitably implement evidence-based interventions is an important yet underutilized step among researchers working in this space. The purpose of this study was to explore practitioners' perspectives of how health equity is defined and integrated into their work, challenges of advancing health equity for implementation in local settings, and associated strategies. We conducted virtual key informant interviews and focus groups with 16 US practitioners (e.g. clinicians, health administrators, public health professionals) in 2021-2022. Interviews and focus groups were audio recorded and transcribed. Data were coded using inductive content analysis and summarized into themes. Four major themes emerged: (i) how health equity is conceptualized as a process and outcome; (ii) need to shift equity mindsets; (iii) importance of community partnerships; (iv) organizational policies and strategies for fostering equity in implementation. Respondents noted the need for research and medical communities to learn about the importance and benefits of allowing communities to shape implementation to advance equity in the delivery of evidence-based interventions and outcomes. Additionally, respondents emphasized that institutional leaders should initiate changes regarding equitable implementation at the organizational- and system-levels. Respondents endorsed the need to address equity issues related to the implementation of cancer prevention and control programs, practices, and policies. Many findings can be applied beyond cancer prevention and control to support equitable implementation and outcomes more generally.

Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers

RATIONALE & OBJECTIVE

Developing strategies to improve home dialysis use requires a comprehensive understanding of barriers. We sought to identify the most important barriers to home dialysis use from the perspective of patients, care partners, and providers.

STUDY DESIGN

This is a convergent parallel mixed-methods study.

SETTING & PARTICIPANTS

We convened a 7-member advisory board of patients, care partners, and providers who collectively developed lists of major patient/care partner-perceived barriers and provider-perceived barriers to home dialysis. We used these lists to develop a survey that was distributed to patients, care partners, and providers-through the American Association of Kidney Patients and the National Kidney Foundation. The surveys asked participants to (1) rank their top 3 major barriers (quantitative) and (2) describe barriers to home dialysis (qualitative).

ANALYTICAL APPROACH

We compiled a list of the top 3 patient/care partner-perceived and top 3 provider-perceived barriers (quantitative). We also conducted a directed content analysis of open-ended survey responses (qualitative).

RESULTS

There were 522 complete responses (233 providers; 289 patients/care partners). The top 3 patient/care partner-perceived barriers were fear of performing home dialysis; lack of space; and the need for home-based support. The top 3 provider-perceived barriers were poor patient education; limited mechanisms for home-based support staff, mental health, and education; and lack of experienced staff. We identified 9 themes through qualitative analysis: limited education; financial disincentives; limited resources; high burden of care; built environment/structure of care delivery that favors in-center hemodialysis; fear and isolation; perceptions of inequities in access to home dialysis; provider perspectives about patients; and patient/provider resiliency.

LIMITATIONS

This was an online survey that is subject to nonresponse bias.

CONCLUSIONS

The top 3 barriers to home dialysis for patient/care partners and providers incompletely overlap, suggesting the need for diverse strategies that simultaneously address patient-perceived barriers at home and provider-perceived barriers in the clinic.

PLAIN-LANGUAGE SUMMARY

There are many barriers to home dialysis use in the United States. However, we know little about which barriers are the most important to patients and clinicians. This makes it challenging to develop strategies to increase home dialysis use. In this study, we surveyed patients, care partners, and clinicians across the country to identify the most important barriers to home dialysis, namely (1) patients/care partners identified fear of home dialysis, lack of space, and lack of home-based support; and (2) clinicians identified poor patient education, limited support for staff and patients, and lack of experienced staff. These findings suggest that patients and clinicians perceive different barriers and that both sets of barriers should be addressed to expand home dialysis use.

Using Collective Impact to Examine Direct Service Worker Training and Credentialing in North Carolina: Recommendations for Change

Older adults and people living with disabilities receive home- and community-based services (HCBS) from approximately 113,000 often under-resourced and inadequately supported direct service workers (e.g., personal care aides, direct support professionals, nurse aides) in North Carolina. The demand in NC is projected to be ∼ 23,000 new direct service jobs from 2020 to 2030. We conducted a Medicaid-funded landscape analysis of direct service training/credentialing requirements and practices across service delivery models using the Collective Impact (CI) framework. With input from HCBS, licensing entities, advocates, and those with lived experience, we characterized NC's HCBS training/credentialing landscape and generated a first-of-its-kind comprehensive crosswalk resource. This project revealed the complexity and limitations of the multiple and varied training and credentialing requirements for direct service workers in NC. Robust community engagement efforts drove the development of preliminary findings and recommendations for improving the training and credentialing requirements for direct service workers in NC.

How to leverage implementation research for equity in global health

Implementation research (IR) is important for addressing equity in global health. However, there is limited knowledge on how to operationalize IR for health equity, and pathways for improving health equity through IR in global health settings. This paper provides an overview of guidance and frameworks for thinking about health equity as part of IR while noting the gaps in how this guidance and frameworks apply to global health. It proposes an approach to guide implementation teams in the application of IR for achieving equity in global health considering these gaps. It describes key equity considerations for different aspects of IR (i.e., implementation contexts, strategies, outcomes, and research designs). These considerations can be applied prospectively and retrospectively, and at different stages of IR. The paper further describes causal pathways, intervention levers, and strategies for achieving health equity in global health settings through IR. Central to these pathways is the power asymmetries among different actors involved in IR in global health and how these contribute to health inequities. The paper suggests recommendations and strategies for shifting the balance of power among these actors while addressing the structural and systemic determinants of health inequities as part of IR. Explicit considerations for health equity as part of implementation research and practice are needed for the achievement of global health goals. Such explicit considerations should look back as much as possible, and entail defining and analyzing health inequities and intervening on the underlying causes and mechanisms of health inequities as part of IR on a routine basis.

Applying the dissemination and implementation sciences to allergy and immunology: A Work Group Report from the AAAAI Quality, Adherence, and Outcomes Committee

Translating evidence-based practice (EBP) into real-world clinical settings often takes a considerable amount of time and resources. In allergy and immunology, the dissemination and implementation (D&I) sciences facilitate the study of how variations in knowledge, resources, patient populations, and staffing models lead to differences in the clinical care of asthma, allergic disease, and primary immunodeficiency. Despite the need for validated approaches to study how to best apply EBP in the real world, the D&I sciences are underutilized. To address this gap, an American Academy of Allergy, Asthma & Immunology (AAAAI) work group was convened to provide an overview for the role of the D&I sciences in clinical care and future research within the field. For the D&I sciences to be leveraged effectively, teams should be multidisciplinary and inclusive of community and clinical partners, and multimethods approaches to data collection and analyses should be used. Used appropriately, the D&I sciences provide important tools to promote EBP and health equity as well as optimization of clinical practice in allergy and immunology.

Holyoke Early Access to Recovery and Treatment (HEART): A case study of a court-based intervention to reduce opioid overdose

The District Court in Holyoke, Massachusetts, is among the first courts nationwide to provide access to medications for opioid use disorder (MOUD) and other treatment. The program uses an innovative multisectoral approach to serve a primarily Latinx population living in communities of concentrated poverty with high opioid overdose rates. We document the origins, adaptations, and current status of program operations, including the use of on-site peer recovery specialists and robust data collection efforts. From August 16, 2021, to February 28, 2022, of the 1040 individuals who entered the court for an arraignment, 47.9% (n = 498) were eligible for program participation. Of those 498 individuals, 54.2% (n = 270) spoke with a recovery specialist. Many self-identified as Latinx (53.0%) and male (69.3%). Over one-fourth (27.0%) were connected to a long-term peer recovery specialist and 11.5% were directly connected to a MOUD provider. Semi-structured interviews with key implementers and participants revealed a shared appreciation for the life-saving efforts of the program. We conclude with practical and theoretical considerations required to offer linkage to MOUD in court-based contexts. Future efforts will assess participant outcomes to determine whether the program is an effective and feasible intervention that can be adopted by other court-based settings.

Trends and geographical variations in outpatient antimicrobial consumption in Ireland in relation to socio-economic deprivation

Background

Different factors have been associated with changes in antimicrobial consumption rates in Ireland, however the relationship between socio-economic deprivation and antimicrobial consumption has not been explored. The presented ecological analysis explores the temporal and geographical variation in outpatient antimicrobial consumption and socio-economic deprivation in Ireland from January 2015 to March 2022.

Method

Deprivation index (DI) was used as a socio-economic proxy. A multilevel mixed model was applied to explore temporal variation and analyse the longitudinal antimicrobial consumption (DID) in relation to DI. Furthermore, maps were generated based on antimicrobial consumption rates, and spatial autocorrelation analyses were carried out to study geographical variation in antimicrobial consumption rates.

Results

The antimicrobial consumption rates per month varied from 26.2 DID (January 2015) to 22.1 DID (March 2022) showing an overall reduction of 16 %. Overall, total antimicrobial consumption in the multilevel model showed a consistent correlation with higher DI score (6.6 (95%CI 3.9 to 9.3)), and winter season (3.6 (95%CI 3.2 to 3.9)). In contrast, before COVID-19 showed significant lower antimicrobial consumption rates compared to during COVID-19 (-4.0 (95%CI -4.7 to -3.23)). No consistent trends were observed for geographical variation between areas.

Conclusion

Antimicrobial consumption rates decreased from 2015 to 2021 in Ireland. No geographical patterns were observed in antimicrobial consumption rates but associations between deprivation and antimicrobial consumption rates were observed.

Precision public health in the era of genomics and big data

Precision public health (PPH) considers the interplay between genetics, lifestyle and the environment to improve disease prevention, diagnosis and treatment on a population level-thereby delivering the right interventions to the right populations at the right time. In this Review, we explore the concept of PPH as the next generation of public health. We discuss the historical context of using individual-level data in public health interventions and examine recent advancements in how data from human and pathogen genomics and social, behavioral and environmental research, as well as artificial intelligence, have transformed public health. Real-world examples of PPH are discussed, emphasizing how these approaches are becoming a mainstay in public health, as well as outstanding challenges in their development, implementation and sustainability. Data sciences, ethical, legal and social implications research, capacity building, equity research and implementation science will have a crucial role in realizing the potential for 'precision' to enhance traditional public health approaches.

Leveraging the health equity implementation framework to foster an equity focus in medical education

Teaching equitable clinical practice is of critical importance, yet how best to do so remains unknown. Educators utilize implementation science frameworks to disseminate clinical evidence-based practices (EBP). The Health Equity Implementation Framework (HEIF) is one of these frameworks, and it delineates how health equity may be concomitantly assessed and addressed in planning the implementation of an EBP. The HEIF therefore lays a strong foundation to understand and explain barriers and facilitators to implementation through an equity lens, making it well-suited for use by medical educators. Three equity-focused frames of reference within the model include (1) the clinical encounter, (2) societal context, and (3) culturally relevant factors, herein referred to as domains. The HEIF provides a structure for prospective and retrospective assessment of how EBP are taught and ultimately incorporated into clinical practice by trainees, with specific attention to delivering equitable care. We present three examples of common topics in internal medicine, contextualized by the three equity domains of the HEIF. We additionally acknowledge the limitations of this framework as a research tool with complex features that may not be suitable for brief teaching in the clinical environment. We propose a 360-degree learner assessment to ensure implementation of this framework is successful. By encouraging trainees to explore the narrative experiences of their patients and examine their own implicit biases, the HEIF provides a structure to address gaps in knowledge about delivering equitable care.

Leveraging Implementation Science to Advance Environmental Justice Research and Achieve Health Equity through Neighborhood and Policy Interventions

Environmental justice research is increasingly focused on community-engaged, participatory investigations that test interventions to improve health. Such research is primed for the use of implementation science-informed approaches to optimize the uptake and use of interventions proven to be effective. This review identifies synergies between implementation science and environmental justice with the goal of advancing both disciplines. Specifically, the article synthesizes the literature on neighborhood-, community-, and policy-level interventions in environmental health that address underlying structural determinants (e.g., structural racism) and social determinants of health. Opportunities to facilitate and scale the equitable implementation of evidence-based environmental health interventions are highlighted, using urban greening as an illustrative example. An environmental justice-focused version of the implementation science subway is provided, which highlights these principles: Remember and Reflect, Restore and Reclaim, and Reinvest. The review concludes with existing gaps and future directions to advance the science of implementation to promote environmental justice.

Construction of the Digital Health Equity-Focused Implementation Research Conceptual Model - Bridging the Divide Between Equity-focused Digital Health and Implementation Research

Digital health implementations and investments continue to expand. As the reliance on digital health increases, it is imperative to implement technologies with inclusive and accessible approaches. A conceptual model can be used to guide equity-focused digital health implementations to improve suitability and uptake in diverse populations. The objective of this study is expand an implementation model with recommendations on the equitable implementation of new digital health technologies. The Digital Health Equity-Focused Implementation Research (DH-EquIR) conceptual model was developed based on a rigorous review of digital health implementation and health equity literature. The Equity-Focused Implementation Research for Health Programs (EquIR) model was used as a starting point and merged with digital equity and digital health implementation models. Existing theoretical frameworks and models were appraised as well as individual equity-sensitive implementation studies. Patient and program-related concepts related to digital equity, digital health implementation, and assessment of social/digital determinants of health were included. Sixty-two articles were analyzed to inform the adaption of the EquIR model for digital health. These articles included digital health equity models and frameworks, digital health implementation models and frameworks, research articles, guidelines, and concept analyses. Concepts were organized into EquIR conceptual groupings, including population health status, planning the program, designing the program, implementing the program, and equity-focused implementation outcomes. The adapted DH-EquIR conceptual model diagram was created as well as detailed tables displaying related equity concepts, evidence gaps in source articles, and analysis of existing equity-related models and tools. The DH-EquIR model serves to guide digital health developers and implementation specialists to promote the inclusion of health-equity planning in every phase of implementation. In addition, it can assist researchers and product developers to avoid repeating the mistakes that have led to inequities in the implementation of digital health across populations.

Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

Challenges and Strategies in Implementing Novel Kidney Protective and Cardioprotective Therapies in Patients With Diabetes and Kidney Disease

Chronic kidney disease (CKD) is highly prevalent, estimated to affect over 800 million people worldwide. Diabetes is a leading cause of kidney disease. Both diabetes and CKD are associated with a high risk of cardiovascular disease and related morbidity and mortality. Over the last several years, there has been a shift in focus toward integrating kidney and cardiovascular care, particularly in diabetes. Sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists have rapidly become cornerstones of kidney and cardiovascular risk-focused care in diabetes and CKD. However, present-day use of these agents is low, and disparities in use by race, ethnicity, age, sex, and comorbidities are apparent. Challenges in implementation of kidney protective and cardioprotective therapies include low rates of diabetes and CKD screening, lack of provider comfort and subspecialty reliance, inconsistencies across professional society guidelines, high rates of drug discontinuation, and prohibitive costs. Effective implementation of kidney protective and cardioprotective therapies necessitates a multifaceted approach and active engagement of patients, pharmacists, primary care providers, subspecialty providers, and health care system leaders as key stakeholders. Implementation efforts should be practical and incorporate collaborative, multidisciplinary team-based approaches. Successful implementation of kidney protective and cardioprotective therapies has the potential to improve overall health outcomes and ameliorate health care disparities.

Optimizing Glycemic Outcomes for Minoritized and Medically Underserved Adults Living with Type 1 Diabetes

Individuals living with type 1 diabetes (T1D) from medically underserved communities have poorer health outcomes. Efforts to improve outcomes include a focus on team-based care, activation of behavior change, and enhancing self-management skills and practices. Advanced diabetes technologies are part of the standard of care for adults with T1D. However, health care providers often carry implicit biases and may be uncomfortable with recommending technologies to patients who have traditionally been excluded from efficacy trials or have limited real-world exposure to devices. We review the literature on this topic and provide an approach to address these issues in clinical practice.

Using implementation research to understand lessons in reducing child mortality

Under-5 mortality decreased significantly worldwide between 2000 and 2015, but there is still progress to be made, particularly in lower- and middle-income countries. This supplement shares the work over the last four years on a project to understand how six countries (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) were more successful in decreasing child mortality than many of their regional and economic peers. The use of implementation research across these countries identifies common implementation strategies and contextual factors that can facilitate or impede successful implementation of an evidence-based intervention and explores a common pathway to implementation. The work highlights how the use of implementation research to understand the "how" and the "why" behind countries' success provides important actionable knowledge and lessons to country-level decision-makers, donors, and implementers as we arrive at the midpoint of the Sustainable Development Goal era.

Racial and ethnic inequities in stillbirth in the US: Looking upstream to close the gap: Seminars in Perinatology

Though stillbirth rates in the United States improved over the previous decades, inequities in stillbirth by race and ethnicity have persisted nearly unchanged since data collection began. Black and Indigenous pregnant people face a two-fold greater risk of experiencing the devastating consequences of stillbirth compared to their White counterparts. Because race is a social rather than biological construct, inequities in stillbirth rates are a downstream consequence of structural, institutional, and interpersonal racism which shape a landscape of differential access to opportunities for health. These downstream consequences can include differences in the prevalence of chronic health conditions as well as structural differences in the quality of health care or healthy neighborhood conditions, each of which likely plays a role in racial and ethnic inequities in stillbirth. Research and intervention approaches that utilize an equity lens may identify ways to close gaps in stillbirth incidence or in responding to the health and socioemotional consequences of stillbirth. A community-engaged approach that incorporates experiential wisdom will be necessary to create a full picture of the causes and consequences of inequity in stillbirth outcomes. Investigators working in tandem with community partners, utilizing a combination of qualitative, quantitative, and implementation science approaches, may more fully elucidate the underpinnings of racial and ethnic inequities in stillbirth outcomes.

Adapting an equity-focused implementation process framework with a focus on ethnic health inequities in the Aotearoa New Zealand context

BACKGROUND

Health intervention implementation in Aotearoa New Zealand (NZ), as in many countries globally, usually varies by ethnicity. Māori (the Indigenous peoples of Aotearoa) and Pacific peoples are less likely to receive interventions than other ethnic groups, despite experiencing persistent health inequities. This study aimed to develop an equity-focused implementation framework, appropriate for the Aotearoa NZ context, to support the planning and delivery of equitable implementation pathways for health interventions, with the intention of achieving equitable outcomes for Māori, as well as people originating from the Pacific Islands.

METHODS

A scoping review of the literature to identify existing equity-focused implementation theories, models and frameworks was undertaken. One of these, the Equity-based framework for Implementation Research (EquIR), was selected for adaptation. The adaptation process was undertaken in collaboration with the project's Māori and consumer advisory groups and informed by the expertise of local health equity researchers and stakeholders, as well as the international implementation science literature.

RESULTS

The adapted framework's foundation is the principles of Te Tiriti o Waitangi (the written agreement between Māori rangatira (chiefs) and the British Crown), and its focus is whānau (extended family)-centred implementation that meets the health and wellbeing aspirations, priorities and needs of whānau. The implementation pathway comprises four main steps: implementation planning, pathway design, monitoring, and outcomes and evaluation, all with an equity focus. The pathway is underpinned by the core constructs of equitable implementation in Aotearoa NZ: collaborative design, anti-racism, Māori and priority population expertise, cultural safety and values-based. Additionally, the contextual factors impacting implementation, i.e. the social, economic, commercial and political determinants of health, are included.

CONCLUSIONS

The framework presented in this study is the first equity-focused process-type implementation framework to be adapted for the Aotearoa NZ context. This framework is intended to support and facilitate equity-focused implementation research and health intervention implementation by mainstream health services.

NIH-supported implementation science and nutrition research: a portfolio review of the past decade

Objective

This portfolio analysis aims to describe the scope of NIH-funded extramural research grants at the intersection of nutrition research and implementation science (IS) from 2011 to 2022 and to offer insights into future research opportunities relevant to the Strategic Plan for NIH Nutrition Research 2020-2030.

Methods

A portfolio analysis of funded grants using NIH reporting systems was conducted to identify nutrition research and IS awarded between fiscal years 2011 and 2022. The authors screened the titles and abstracts for inclusion criteria: research and career development awards involved a nutrition and/or dietary intervention and measured a stated implementation outcome or used an IS theory, model, or framework.

Results

In total, 33 NIH-funded awards met the inclusion criteria. Almost half of the awards (48.5%) were investigator-initiated research projects compared to research career awards and cooperative agreements. While studies were predominantly conducted in the United States, 15.2% were conducted in low- and middle-income countries in Africa, Latin America, and Asia. Adults aged 19-64 years and children aged 2-11 years represented most of the study populations (45.5 and 15.2%, respectively). Studies provided nutrition/dietary guidelines and created culturally tailored interventions, which were then adapted in collaboration with community partners in schools, hospitals, and religious settings. The most cited IS outcomes were feasibility, costs, adoption, and acceptability. Sixteen awards (48.5%) used an IS theory, model, or framework to guide their work.

Discussion

The findings show the breadth of NIH-funded nutrition and implementation research and highlight potential research opportunities.

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.

A scoping review of implementation science theories, models, and frameworks - an appraisal of purpose, characteristics, usability, applicability, and testability

BACKGROUND

A proliferation of theories, models, and frameworks (TMFs) have been developed in the implementation science field to facilitate the implementation process. The basic features of these TMFs have been identified by several reviews. However, systematic appraisals on the quality of these TMFs are inadequate. To fill this gap, this study aimed to assess the usability, applicability, and testability of the current TMFs in a structured way.

METHODS

A scoping review method was employed. Electronic databases were searched to locate English and Chinese articles published between January 2000 and April 2022. Search terms were specific to implementation science. Additionally, hand searches were administered to identify articles from related reviews. Purpose and characteristics such as the type of TMF, analytical level, and observation unit were extracted. Structured appraisal criteria were adapted from Birken et al.'s Theory Comparison and Selection Tool (T-CaST) to conduct an in-depth analysis of the TMFs' usability, applicability, and testability.

RESULTS

A total of 143 TMFs were included in this analysis. Among them, the most common purpose was to identify barriers and facilitators. Most TMFs applied the descriptive method to summarize the included constructs or the prescriptive method to propose courses of implementation actions. TMFs were mainly mid-range theories built on existing conceptual frameworks or demonstrated grand theories. The usability of the TMFs needs to be improved in terms of the provision of conceptually matched strategies to barriers and facilitators and instructions on the TMFs usage. Regarding the applicability, little attention was paid to the constructs of macro-level context, stages of scale-up and sustainability, and implementation outcomes like feasibility, cost, and penetration. Also, fewer TMFs could propose recommended research and measurement methods to apply the TMFs. Lastly, explicit hypotheses or propositions were lacking in most of the TMFs, and empirical evidence was lacking to support the claimed mechanisms between framework elements in testability.

CONCLUSIONS

Common limitations were found in the usability, application, and testability of the current TMFs. The findings of this review could provide insights for developers of TMFs for future theoretical advancements.

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.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Adaptation of a community health outreach model during the COVID-19 pandemic: the case of the Mexican consulates in the United States of America

The Ventanillas de Salud (VDS - "Health Windows") are a culturally sensitive outreach program within the 49 Mexican Consulates in the United States that provides information and health care navigation support to underserved and uninsured Mexican immigrants. During the COVID-19 pandemic the VDS rapidly transitioned to remote operations adding new services. Based on the EquIR implementation framework, this qualitative study investigates how adaptations to improve emergency preparedness were performed. We conducted motivational interviews with three actors - six VDS coordinators, eight partner organizations, and ten VDS users- in two VDS, Los Angeles and New York, to document specific needs of the target population and identify implementation processes to adapt and continue operating. The VDS adapted their model by adding new services for emerging needs, by switching service provision modalities, and by expanding the network of partner organizations. According to the VDS staff, these adaptations increased their topics, depth, reach, and diversified their users. Users had mostly positive opinions about the VDS adaptation, although they highlighted some heterogeneity across service provision. The VDS is a public health intervention able to serve a marginalized population and its implementation offers valuable lessons to complement health systems and to improve preparedness and resiliency for future crises.

Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions

STUDY OBJECTIVES

This review synthesizes the pediatric behavioral sleep intervention (BSI) evidence base, summarizes challenges in translating BSIs from research to practice, and provides recommendations for integrating implementation science methods to advance pediatric BSI research.

METHODS

We briefly review the common behavioral sleep disturbances among youth, discuss the pediatric BSIs with well-established evidence, and identify gaps in pediatric BSI research. We then identify contributors to the dearth of research evaluating pediatric BSIs in accessible settings and present a model for applying implementation science strategies to address identified gaps across the continuum of translational research.

RESULTS

Relatively few BSI trials include older children and adolescents. Similarly, there is limited research evaluating BSIs among racially and ethnically minoritized children and families and/or those of lower socioeconomic status backgrounds. Access to scalable and easily disseminable tools to treat pediatric sleep disturbances early in their development is crucial for promoting positive child outcomes. To address these gaps, researchers should apply implementation science theories, models, and frameworks to design new interventions for implementation, adapt existing interventions with end users and settings in mind, conduct hybrid effectiveness-implementation trials, and test implementation strategies.

CONCLUSIONS

Given the prevalence and consequences of poor sleep across developmental periods, pediatric BSIs must be effective as well as adaptable, scalable, and easily disseminable. Implementation science theories, models, and frameworks can enhance access to, engagement in, and the implementation and dissemination of scalable BSIs across diverse pediatric care settings and heterogeneous populations.

CITATION

Levenson JC, Williamson AA. Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions. J Clin Sleep Med. 2023;19(7):1321-1336.

"I Have a Lotta Sad Feelin'" - Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

OBJECTIVE

To investigate mental health needs and barriers to seeking mental health support in Medicaid-funded Assisted Living Facility (M-ALF).

DESIGN

A multimethod, qualitative-dominant descriptive design using questionnaires and semistructured interviews.

SETTING AND PARTICIPANTS

The study occurred at a M-ALF in the Bronx, New York. A researcher in residence recruited 13 residents (11 Black or African American, 2 Asian) using purposive sampling.

METHODS

Demographic data and mental health indicators (depression, anxiety, stress, hopelessness) were measured with questionnaires (Center for Epidemiological Studies Depression Scale, Edmonton Symptom Assessment System, Perceived Stress Scale, Beck Hopelessness Survey) and analyzed with descriptive statistics. Interviews were conducted between June and November 2021, transcribed, and analyzed using conventional content analysis.

RESULTS

Thirteen residents (mean age: 73.4 years, mean length of stay: 3.5 years; range: 1.0-7.5) completed data collection. Quantitatively indicators of unmet mental health were common. Qualitatively, residents reported barriers to mental health access to address depression, anxiety, and substance use. This was accompanied by concerns surrounding loss of autonomy, mistrust for M-ALF organizational support, isolation and uncertainty about how to receive mental health support. Perspectives were shaped by past experiences with institutional living, serious illness, and being unhoused. Themes and subthemes were (1) mental health need (unmet mental health need, depression, and anxiety and seeking support through non-mental health resources) and (2) barriers to mental health support (dissatisfaction with M-ALF care, perceived threats to autonomy, desire for autonomy that leads to diminished care seeking).

CONCLUSION AND IMPLICATIONS

Residents of M-ALF have mental health needs for which care is stymied by loss of autonomy, lack of resources, and the M-ALF environment. Residents use unconventional resources to address needs that may be neither efficient nor effective. Novel mental health interventions and processes are needed to improve mental health access and should prioritize residents' desire for autonomy and the unique circumstances of living in M-ALF.

Improved access yet inequitable experience: gay, bisexual and other men who have sex with men's views of more inclusive criteria for source plasma donation

BACKGROUND

Canada has incrementally reduced restrictions to blood and plasma donation that impact men who have sex with men, gay, bisexual, and queer men, and some Two Spirit, transgender and non-binary individuals (MSM/2SGBTQ+). Prior to the launch of a pilot program in 2021 enabling some MSM/2SGBTQ + to donate source plasma, we explored the acceptability of the program among individuals who could become eligible to donate in the program.

METHODS

We invited men identifying as MSM/2SGBTQ + to participate in two consecutive semi-structured interviews to explore their views on blood and plasma donation policy, plasma donation, and the proposed Canadian plasma donation program. Interview transcripts were analyzed thematically and acceptability-related themes were mapped onto the Theoretical Framework of Acceptability.

RESULTS

Twenty-seven men identifying as having sex with men participated in 53 interviews. Eighteen themes were mapped onto the seven construct domains of the Theoretical Framework of Acceptability. Underlying all aspects of acceptability was a tension between four primary values influencing participants' views: altruism, equity, supply sufficiency, and evidence-based policy. The program was viewed as welcome progress on a discriminatory policy, with many excited to participate, yet tension with inequitable aspects of the program undermined support for the program and interest to contribute to it. The high demands of the program are unique for MSM/2SGBTQ + and are only tolerable as part of a program that is an incremental and instrumental step to more equitable donation policies.

CONCLUSION

Findings highlight past experiences of exclusion in Canada as a unique and critical part of the context of the donation experience among MSM/2SGBTQ+. Despite the program's goals of greater inclusivity of MSM/2SGBTQ + individuals, the anticipated experience of the program included continued stigmatization and inequities. Future research should seek to understand the experienced views of MSM/2SGBTQ + donors to ensure that as policies change, policies are implemented equitably.

Positive Psychology Interventions in Medical Populations: Critical Issues in Intervention Development, Testing, and Implementation

Positive psychological well-being is prospectively associated with superior health outcomes. Positive psychology interventions have promise as a potentially feasible and effective means of increasing well-being and health in those with medical illness, and several initial studies have shown the potential of such programs in medical populations. At the same time, numerous key issues in the existing positive psychology literature must be addressed to ensure that these interventions are optimally effective. These include (1) assessing the nature and scope of PPWB as part of intervention development and application; (2) identifying and utilizing theoretical models that can clearly outline potential mechanisms by which positive psychology interventions may affect health outcomes; (3) determining consistent, realistic targets for positive psychology interventions; (4) developing consistent approaches to the promotion of positive psychological well-being; (5) emphasizing the inclusion of diverse samples in treatment development and testing; and (6) considering implementation and scalability from the start of intervention development to ensure effective real-world application. Attention to these six domains could greatly facilitate the generation of effective, replicable, and easily adopted positive psychology programs for medical populations with the potential to have an important impact on public health.

Caregivers of Black and Latino/a/x Students and School Personnel Perspectives on School-Based SARS-CoV-2 Testing: Implications for Testing and Test-to-Stay Programs in K-12 Schools

BACKGROUND

"Test-to-stay" (TTS) is an effective approach for keeping students in school post-exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To prepare for school-based SARS-CoV-2 testing, we implemented formative research to gather perspectives on school-based testing among school personnel, as well as caregivers of Black and Latino/a/x students given systemic racism, existing school inequalities, and the disproportionate effect of COVID-19 on Black and Latino/a/x populations.

METHODS

We conducted in-depth interviews with caregivers of K-12 grade Black and Latino/a/x students and focus group discussions with K-12 school personnel. We described the forthcoming school-based SARS-CoV-2 testing program and explored potential benefits and concerns, including concerns about testing-related stigma and discrimination, particularly toward Black and Latino/a/x students, and implementation recommendations.

RESULTS

Perceived testing benefits included school community reassurance and preventing school outbreaks. Concerns included potential student anxiety, classroom disruption, inaccurate results, and limited information for caregivers. Some participants mentioned that testing-related stigma and discrimination could happen based on the testing selection process or results but not due to race or ethnicity. Participants provided numerous testing recommendations, including suggestions to prevent negative outcomes.

CONCLUSIONS

Participants believed that stigma and discrimination from SARS-CoV-2 testing is possible, although differential treatment based on race or ethnicity was not anticipated. Participants' narratives provide support for school-based testing and the testing component of TTS.

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.

A realist evaluation of a support and training program for family caregivers in the municipality of Envigado: A research protocol

AIMS

In Envigado, Colombia, the Secretariat of Health has implemented, since 2011, an interprofessional program involving nurses to support and train relatives to improve the quality of life of people with a loss of autonomy and their family caregivers. The objectives of this study are to assess the outcomes of this program and to explore the contextual elements and mechanisms that can explain these outcomes.

DESIGN

This article presents the research protocol for a realist evaluation that will be carried out to gather the perspectives of various local stakeholders involved.

METHODS

Four outcomes on family caregivers will be measured quantitatively using self-administered questionnaires and numerical scales. Contextual elements and mechanisms will then be explored qualitatively through focus groups and individual interviews. An iterative analysis will enable the refinement of a program theory.

RESULTS

The results will inform a program theory that underlies the outcomes of the family caregiver support and training program.

PATIENT OR PUBLIC CONTRIBUTION

Community stakeholders, family caregivers, people with a loss of autonomy and their relatives will be involved in data collection and/or in the validation of the program theory.

Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border

Background

Preterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC).

Materials and methods

This sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care.

Results

From 2008-2017, mortality was reduced by 68% and 53% in very (EGA 28-32 weeks) and moderate (EGA 33-36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting.

Discussion

This study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.

Facilitators and Barriers to Implementation and Sustainability of Nutrition and Physical Activity Interventions in Early Childcare Settings: a Systematic Review

A stronger understanding of the factors influencing implementation of interventions in community-based early childcare settings is needed. The purpose of this systematic review was to synthesize existing research on facilitators and barriers to implementation and sustainability of nutrition and physical activity interventions in early childcare settings targeting 2-5-year-old children, including considerations for equitable implementation. This review adhered to PRISMA 2020 guidelines. Peer-reviewed literature was searched in PubMed, EMBASE, CINAHL, ERIC, and PsycINFO databases up to September 2020. Primary research studies that examined facilitators and barriers (or related synonyms) to the implementation and sustainability of nutrition and physical activity interventions in early childcare settings were eligible for inclusion. The search yielded 8092 records that were screened by four analysts in Covidence software with a final review of 24 studies. Two independent reviewers conducted study selection, data extraction, and quality appraisal (Mixed Methods Appraisal Tool). A "best fit" framework was applied using the Consolidated Framework for Implementation Research (CFIR) constructs to code barriers and facilitators. The most salient constructs were (1) "Available Resources," which was composed of time, staffing, space, and staff trainings; (2) adaptability; and (3) compatibility, the latter two indicating that easily modifiable interventions facilitated a smoother "fit" and were more likely to be successful, given adequate site-level resources. Only nine (28%) reported the use of a theory, model, or framework to guide evaluation; six studies (24%) included factors related to sustainability; and nine studies (38%) conducted their interventions with low-income or minoritized groups. The findings point to the need for intervention evaluations examining nutrition and physical activity to more consistently consider (a) sustainability factors early on in design and adoption phases; (b) use of theory, model, or framework to guide evaluation; and (c) equity-related frameworks and considerations for how equitable implementation.

Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

Framework for health care quality and evidence-based practice in radiology departments: A regional study on radiographer's perceptions

INTRODUCTION

The main goals of this study were to describe, in an integrated and multidimensional way, the conditions related to the quality of care in radiology departments from Algarve (Portugal), to assess the perspective of radiographers on the use of scientific evidence in clinical practice and to validate a model that characterizes the conditions for continuous improvement.

METHODS

A cross sectional study was performed in four radiology departments from public and private healthcare facilities from Algarve region (Portugal). A paper-based survey was sent to all radiographers to assess the quality systems implemented in their radiology departments and their perspective on the use of scientific evidence in clinical practice.

RESULTS

In total, 62 radiographers (61.4%) completed the survey. The quality dimensions that obtained the highest degree of compliance were the existence of quality assurance and improvement activities (43.0%), existence of standards in clinical practice of radiographers (42.7%) and the existence of special provisions (37.6%). The quality dimension related to patient's involvement was the one with the lowest level of compliance. Moreover, from the radiographers perspective, positive responses were obtained related to evidence-based actions (83.0%), sources of evidence (76.0%) and the significance of research activities (74.0%).

CONCLUSION

These findings suggest that a new framework based on four factors (Support for Information; Organizational Capability to Technical Quality of Care; Patient Involvement and Evidence-Based Radiology), should be considered in the establishment of strategic policies that better define the provision of diagnostic procedures and professional practices in radiology departments from Algarve region, based on quality improvement systems and better patient safety.

IMPLICATIONS FOR PRACTICE

There is a need to include patients in the decision-making process, to involve radiographers in quality assurance and improvement activities and to implement quality monitoring mechanisms within radiology departments under study.

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.

Methodological guidance for incorporating equity when informing rapid-policy and guideline development

OBJECTIVES

We provide guidance for considering equity in rapid reviews through examples of published COVID-19 rapid reviews.

STUDY DESIGN AND SETTING

This guidance was developed based on a series of methodological meetings, review of internationally renowned guidance such as the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for equity-focused systematic reviews (PRISMA-Equity) guideline. We identified Exemplar rapid reviews by searching COVID-19 databases and requesting examples from our team.

RESULTS

We proposed the following key steps: 1. involve relevant stakeholders with lived experience in the conduct and design of the review; 2. reflect on equity, inclusion and privilege in team values and composition; 3. develop research question to assess health inequities; 4. conduct searches in relevant disciplinary databases; 5. collect data and critically appraise recruitment, retention and attrition for populations experiencing inequities; 6. analyse evidence on equity; 7. evaluate the applicability of findings to populations experiencing inequities; and 8. adhere to reporting guidelines for communicating review findings. We illustrated these methods through rapid review examples.

CONCLUSION

Implementing this guidance could contribute to improving equity considerations in rapid reviews produced in public health emergencies, and help policymakers better understand the distributional impact of diseases on the population.

Social determinants of recovery

PURPOSE OF REVIEW

The purpose of this review is to examine evidence describing the influence of social determinants on recovery following hospitalization with critical illness. In addition, it is meant to provide insight into the several mechanisms through which social factors influence recovery as well as illuminate approaches to addressing these factors at various levels in research, clinical care, and policy.

RECENT FINDINGS

Social determinants of health, ranging from individual factors like social support and socioeconomic status to contextual ones like neighborhood deprivation, are associated with disability, cognitive impairment, and mental health after critical illness. Furthermore, many social factors are reciprocally related to recovery wherein the consequences of critical illness such as financial toxicity and caregiver burden can put essential social needs under strain turning them into barriers to recovery.

SUMMARY

Recovery after hospitalization for critical illness may be influenced by many social factors. These factors warrant attention by clinicians, health systems, and policymakers to enhance long-term outcomes of critical illness survivors.

Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults

Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.

Using Implementation Mapping to develop protocols supporting the implementation of a state policy on screening children for Adverse Childhood Experiences in a system of health centers in inland Southern California

Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accidents, harsh migration experiences, or violence. Screening for ACEs includes asking questions about an individual's early exposure to these types of events. ACEs screenings have potential value in identifying children exposed to chronic and significant stress that produces elevated cortisol levels (i.e., toxic stress), and its associated physical and mental health conditions, such as heart disease, diabetes, depression, asthma, ADHD, anxiety, and substance dependence. However, ACEs screenings are seldom used in primary care settings. The Surgeon General of California has addressed this care gap by introducing ACEs Aware, an ACEs screening fee-for-service healthcare policy signed into law by Gov. Gavin Newsom. Since January 2020, Medi-Cal, California's Medicaid health care program, has reimbursed primary care providers for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children and adults for ACEs during wellness visits. To achieve the goals set by the ACEs Aware state policy, it is essential to develop and test implementation strategies that are informed by the values, priorities, and resources of clinical settings, healthcare professionals, and end-users. To address this need, we partnered with a system of federally qualified health centers in Southern California on a pilot study to facilitate the implementation of ACEs screenings in five community-based clinics. The health centers had broad ideas for an implementation strategy, as well as best practices to improve adoption of screenings, such as focusing on staff training to improve clinic workflow. This knowledge was incorporated into the development of an implementation strategy template, used at the outset of this study. We used the Exploration, Preparation, Implementation and Sustainment (EPIS) framework to guide the study and inform a participatory planning process called Implementation Mapping. In this paper, we describe how Implementation Mapping was used to engage diverse stakeholders and guide them through a systematic process that resulted in the development of the implementation strategy. We also detail how the EPIS framework informed each Implementation Mapping Task and provide recommendations for developing implementation strategies using EPIS and Implementation Mapping in health-care settings.

A Qualitative Assessment of the Essential Health and Nutrition Service Delivery in the Context of COVID-19 in Bangladesh: The Perspective of Divisional Directors

Bangladesh suffered disruptions in the utilization of essential health and nutrition services (EHNS) during the COVID-19 pandemic. The magnitude of the pandemic has been documented, but little is known from the perspectives of health administrators. A rapid qualitative assessment of division-level capacity identified successes and bottlenecks in providing EHNS- and COVID-19-related services during the first months of the pandemic in Bangladesh. Semi-structured interviews were held with the Health and Family Planning Divisional Directors of the Ministry of Health and Family Welfare. The Primary Health Care System Framework guided the content analysis, focusing on (i) service delivery, (ii) communication and community outreach, and (iii) surveillance and service monitoring. Our findings identified low care seeking due to fears of getting infected and unawareness that EHNS were still available. Adaptations to telemedicine were highly heterogeneous between divisions, but collaboration with NGOs were fruitful in reinstating outreach activities. Guidelines were centered on COVID-19 information and less so on EHNS. The inflexibility of spending capacities at divisional and clinic levels hindered service provision. Misinformation and information voids were difficult to handle all around the country. Community health workers were useful for outreach communication. EHNS must be guaranteed during sanitary emergencies, and Bangladesh presented with both significant efforts and areas of opportunity for improvement.

Advancing Health Equity Efforts to Reduce Obesity: Changing the Course

Population-based solutions are needed to stabilize and then reverse the continued upward trends in obesity prevalence in the US population and worldwide. This review focuses on the related, urgent issue of disparities in obesity prevalence affecting US racial/ethnic minority and other socially marginalized populations. The review provides background on these disparities from a health equity perspective and highlights evidence of progress in equity-focused obesity efforts. Five recommendations for advancing equity efforts are offered as potential approaches to build on progress to date: (a) give equity issues higher priority, (b) adopt a health equity lens, (c) strengthen approaches by using health equity frameworks, (d) broaden the types of policies considered, and (e) emphasize implementation science concepts and tools. Potential challenges and opportunities are identified, including the prospect of longer-term, transformative solutions that integrate global and national initiatives to address obesity, undernutrition, and climate change.