A more practical guide to incorporating health equity domains in implementation determinant frameworks

Woodward et al. Implementation Science Communications
                                                                           (2021) 2:61
                                                                                                                             Implementation Science

 METHODOLOGY                                                                                                                                         Open Access

A more practical guide to incorporating
health equity domains in implementation
determinant frameworks
Eva N. Woodward1,2* , Rajinder Sonia Singh2,3, Phiwinhlanhla Ndebele-Ngwenya4, Andrea Melgar Castillo5,
Kelsey S. Dickson6 and JoAnn E. Kirchner2,7

  Background: Due to striking disparities in the implementation of healthcare innovations, it is imperative that
  researchers and practitioners can meaningfully use implementation determinant frameworks to understand why
  disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted
  the first published adaptation of an existing implementation determinant framework with health equity domains to
  create the Health Equity Implementation Framework. We recommended integrating these three health equity
  domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical
  encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants
  of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams
  have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance.
  Methods: We completed a consensus process with our authorship team to clarify steps to incorporate a health
  equity lens into an implementation determinant framework.
  Results: We describe steps to integrate health equity domains into implementation determinant frameworks for
  implementation research and practice. For each step, we compiled examples or practical tools to assist
  implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions
  with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative
  Conclusion: Incorporating health equity domains within implementation determinant frameworks may optimize
  the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and
  equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers
  and practitioners to concretely capture and understand barriers and facilitators to implementation disparities.
  Keywords: Health equity, Implementation, Health disparities, Framework, Theory, Implementation science,

* Correspondence: Eva.woodward2@va.gov
 Center for Mental Healthcare and Outcomes Research, U.S. Department of
Veterans Affairs, North Little Rock, AR, USA
 Department of Psychiatry, University of Arkansas for Medical Sciences, Little
Rock, AR, USA
Full list of author information is available at the end of the article

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Woodward et al. Implementation Science Communications          (2021) 2:61                                               Page 2 of 16

                                                                         communities in developing implementation science and
 Contributions to the literature
                                                                         practice [8], lack of consistent methods and data ele-
  Applications of how the Health Equity Implementation                  ments related to equity across implementation studies
    Framework guided other implementation efforts                        [9], and exclusivity and social injustice within the imple-
                                                                         mentation science workforce perpetuated by structures
  Practical tools, including a table of sample measures for
                                                                         making it harder for institutions to recruit and retain
    health equity determinants, a qualitative interview guide,
                                                                         marginalized people (e.g., school-to-prison pipeline).
    and a qualitative codebook                                           Also, disparities exist for innovations being implemented
  Clarified broad steps for integrating a health equity lens into       and, if not adapted for marginalized populations, imple-
    an implementation determinant framework                              mentation may perpetuate the exclusion of marginalized
                                                                         communities and widen health inequities [6]. Similar to
Background                                                               implementation studies, marginalized populations have
Health equity occurs when all people have socially just                  historically been excluded from clinical trials and effi-
opportunities for optimal well-being. Disparities in                     cacy studies [10]. Further, innovations are often not de-
healthcare implementation exist when a healthcare                        signed nor as efficacious for marginalized populations
innovation, such as a program or treatment, is delivered                 [11–13]. Thus, the limitations of disparities in
with significantly worse access, receipt, use, quality, or               innovation development can be inherited by implemen-
outcomes for certain populations compared to others                      tation science and likely perpetuated if the implementa-
[1]. Structural factors and systems greatly contribute to                tion does not systematically consider disparity
different as well as unjust or unfair treatment of certain               determinants, cultural adaptations, and other ways to
populations. Populations that experience worse health or                 ensure health equity.
healthcare might be defined by race, ethnicity, sexual                      Outside the U.S., health equity and implementation re-
orientation, gender identity, socioeconomic status, func-                search predominantly focus on a specific marginalized
tional limitation, or other characteristics [2]; we refer to             population, which is an important and valid path toward
these groups as marginalized populations based on so-                    equity [9, 14–16]. Examples in low- and middle-income
cial, economic, and/or environmental disadvantage that                   countries include measurement tools normed with par-
accompanies health inequities [3]. One example of an                     ticipants from those countries [17], adapting innovations
implementation disparity in United States (U.S.)                         or delivery methods specifically to those populations
pediatric healthcare is screening and diagnosis of autism                [18] and reviewing or developing frameworks specific to
spectrum disorder. Although there are valid and reliable                 those countries [14, 19, 20]. Although adaptations to
autism screenings and clear criteria for diagnosis, racial               local contexts are important, there remain gaps in apply-
and ethnic minority children who meet the criteria are                   ing principles of health equity to implementation re-
less likely to be diagnosed than non-Hispanic white chil-                search broadly, partly because locally adapted
dren [4]. Thus, effective screenings and diagnoses are                   frameworks are not easily generalizable to other coun-
implemented inequitably for racial and ethnic minority                   tries or contexts. The current charges to implementation
children, resulting in delayed treatment for children of                 researchers to ensure health equity in their efforts [6,
color. This implementation disparity is exacerbated                      21] are not possible without adapting implementation
when children are finally diagnosed properly with aut-                   determinant frameworks to first capture and under-
ism, as children of color are less likely to receive quality             standing barriers to equitable implementation.
treatment [5]. Unfortunately, several implementation
disparities may be undetected. As Braveman wrote,                        Implementation determinant frameworks with an equity
“Health disparities are the metric we use to measure                     focus are needed
progress toward achieving health equity” [3].                            Implementation science frameworks have been catego-
  Overall, implementation science has yet to actively and                rized into three types: determinant (establishing what
systematically assess, address, and evaluate unique fac-                 factors determine or predict implementation success),
tors contributing to healthcare inequities, including in-                process (clarifying how to address determinants to
stitutional and structural problems, such as racism, that                achieve implementation success), and evaluation (deter-
are economic, regulatory, social, historical, and political              mining metrics and assessment to know when imple-
determinants of implementation for marginalized groups                   mentation success is achieved) [22]. Implementation
[6]. There are many reasons why implementation re-                       determinant frameworks are key to inform study design
searchers have yet to showcase solutions to healthcare                   and selection of strategies to match contextual needs;
inequities including underrepresentation of marginalized                 yet, we have only recently considered determinants
and resource-poor communities in implementation stud-                    unique to health inequities, starting with the Health
ies [6, 7], lack of true engagement with marginalized                    Equity Implementation Framework [23]. We first piloted
Woodward et al. Implementation Science Communications   (2021) 2:61                                               Page 3 of 16

health equity domains within the context of a determinant         more depth than in prior work, showcase two applica-
framework as this type of framework represents the key            tions of this determinant framework from the literature,
first step to detecting (and eventually addressing) imple-        and delineate steps to incorporate health equity do-
mentation disparities. If implementation researchers and          mains in an implementation determinant framework,
practitioners could meaningfully and practically assess and       with sample measures and data collection tools for each
understand the determinants of implementation dispar-             domain.
ities, this would allow them to adapt the innovation and
implementation strategies for marginalized populations
and detect health equity determinants as potential moder-         Health Equity Implementation Framework
ators for implementation success/failure [21]. Unfortu-           In the Health Equity Implementation Framework, we
nately, most implementation determinant frameworks                proposed determinants believed to predict successful
have yet to be explicitly adapted for or tested within health     and equitable implementation, seen in Fig. 1 [23]. These
equity efforts and any that do appear too vague to be used        determinants are grouped under domains. We define do-
meaningfully [24].                                                mains as broad constructs relevant to implementation
   Our prior work documented and piloted adaptations              and health equity success. Within each domain are sev-
of one existing implementation determinant framework              eral determinants or specific factors that are measurable
with three health equity domains to create the Health             and, together in constellation with other determinants,
Equity Implementation Framework [23]. One may also                clarify barriers, facilitators, moderators, or mediators to
use the Health Equity Implementation Framework in its             implementation and health equity success. This frame-
entirety as an implementation determinant framework               work was developed for healthcare and clinical practice
or use the three health equity domains as additions to            settings [25]. In the Health Equity Implementation
another implementation determinant framework. Many                Framework, we added three health equity domains to
researchers and practitioners have requested clarification        the Integrated Promoting Action on Research in Imple-
of the Health Equity Implementation Framework do-                 mentation in Health Services (i-PARIHS) framework
mains for practical use. Damschroder argued that imple-           [26], which also proposes a process—facilitation—by
mentation frameworks must describe how domains are                which change in each domain would occur [25, 26]. The
well-grounded in existing literature, provide clear defini-       focus of this manuscript is on the three health equity do-
tions, and offer suggested validated implementation               mains, rather than facilitation, as science is still emer-
strategies [22]. Therefore, we review definitions of the do-      ging on how implementation processes should be
main of the Health Equity Implementation Framework in             tailored or adapted to promote equity.

 Fig. 1 Health Equity Implementation Framework
Woodward et al. Implementation Science Communications   (2021) 2:61                                                     Page 4 of 16

Domains typical in implementation determinant                     Domains known to affect health equity
frameworks                                                        The Health Equity Implementation Framework incorpo-
Broad domains typical in implementation determinant               rates these domains known to affect health disparities
frameworks focus on factors spanning multiple levels,             and thus, equity: (1) culturally relevant factors, such as
including the individual (e.g., personal characteristics,         medical mistrust, demographics, or biases of recipients
actors of implementation, individuals receiving an                [34–37]; (2) clinical encounter or patient-provider inter-
innovation), organization (e.g., clinical service, school,        action [38–40]; and (3) societal context including phys-
department, factory), community (e.g., local government,          ical structures, economies, and social and political forces
neighborhood), system (e.g., school district, hospital sys-       [41–43]. We added these three health equity domains,
tem), and policy (e.g., state government, broader laws)           described below, from existing research that have clear,
[27]. These domains can be further specified, such as             strong associations with disparities in health status, ac-
inner setting or outer setting within an organization             cess to, quality of, or outcomes of healthcare, [44] or
[28]. Domains from i-PARIHS are the basis of the                  there is enough evidence to suggest determinants within
Health Equity Implementation Framework and include                these domains should be considered (e.g., [45]).
those typical in most implementation determinant
frameworks [27]. Determinants within each domain act                  1. Culturally relevant factors of recipients. Recipients
to enable or constrain implementation and each domain                    in the implementation process are individuals who
is briefly defined below.                                                will be asked to offer or receive an innovation (e.g.,
                                                                         patients, providers) [26]. Culturally relevant factors
Innovation                                                               of recipients are characteristics unique to a group
Innovation refers to the treatment, intervention, practice,              of people in the implementation effort (e.g.,
or new “thing” to be implemented, adopted by providers                   patients, staff, providers) based on their lived
and staff, and delivered to patients [29]. The innovation                experience. Some examples of recipient factors that
may be a program, practice, principle, procedure, prod-                  may be culturally relevant are implicit bias,
uct, pill, or policy [30].                                               socioeconomic status, race and/or ethnicity,
                                                                         immigrant acculturation, language, health literacy,
Recipients                                                               health beliefs, or trust in the clinical staff or patient
Recipients are individuals who influence implementation                  group [36, 37]. Demographic characteristics, such
and those who are affected by its outcomes, both at the                  as socioeconomic status or race, are not inherently
individual and collective team levels [26]. In healthcare,               descriptive of one’s culture. Rather, the important
recipients are typically grouped into providers and other                takeaway is how living in the world with these
staff, and patients and caregivers.                                      factors shapes one’s culture and experience (e.g.,
                                                                         living in impoverished neighborhoods, experiencing
Context                                                                  racism). We do not feel strongly that any
Context includes different micro, meso, or macro levels                  demographic factor be categorized as a culturally
that correspond to inner and outer contexts [26]. Con-                   relevant factor—the most important thing, from our
text can include factors such as resources, culture, lead-               view, is that implementation practitioners and
ership, and orientation to evaluation and learning. In                   scientists acknowledge these demographics among
this framework, the micro-level includes the local inner                 their recipient groups and consider how
context (e.g., specific ward or clinic), whereas the meso                implementation may need to be adapted based on the
includes the organization (e.g., hospital or medical cen-                lived experience of recipient groups. For instance,
ter). The macro-level of outer context includes the wider                implementation practitioners and scientists should
healthcare system and effect this has on the other do-                   consider how implementation would need to change
mains (e.g., United Kingdom National Health Service)                     for those who have little formal education, are people
[28].                                                                    of color, or are underinsured. Factors from patients
                                                                         and providers might attend to differences between,
Facilitation or process                                                  for example, age, pre-existing stereotypes, or lack of
There are processes by which barriers in implementation                  trust that could hinder the interaction [40]. Culturally
domains are solved or overcome, and strengths are har-                   relevant factors will vary by group, local context, and
nessed to promote the use of an innovation in routine                    individuals. It is crucial that culturally relevant factors
practice [28]. In i-PARIHS, facilitation is the “active in-              of recipients are considered as determinants or
gredient” or process [31]. Facilitation involves imple-                  potential moderators in implementation success/failure
mentation strategies that result in implementation                       when patients belong to a group experiencing a health
coming to fruition [32, 33].                                             or healthcare disparity.
Woodward et al. Implementation Science Communications   (2021) 2:61                                                Page 5 of 16

  2. Clinical encounter (patient-provider interaction).           factor is exclusively an economy, physical structure, so-
     This domain describes the transaction that occurs            cial norm, or all three; rather, it is important these soci-
     between patients and providers in healthcare                 etal determinants are detected and addressed to ensure
     appointments, where decisions concerning                     strategies address key drivers of societal inequities. Soci-
     diagnoses and treatment are made, and providers              etal context may not be assessed comprehensively in one
     administer care [46]. The clinical encounter is              study or initiative, due to feasibility constraints, but they
     important to assess because there is a myriad of             should be documented in formative evaluations/initial
     behaviors and perceptions during the clinical                diagnostic assessments of the implementation problem.
     encounter that affect whether an innovation is
     offered by a provider and whether it is accepted by          Economies
     a patient. Behaviors will vary by innovation,                There are four typical structures of economies including a
     context, and recipients and may be especially                traditional economy (i.e., mostly agricultural), market
     important for patients who experience health or              economy (i.e., firms and private interests control capital),
     healthcare disparities due to unequal power                  command economy (i.e., government controls capital),
     between them and providers. Factors to measure               and a mixed economy (combination of command and
     might be how recipients maneuver the conversation            market) [53]. It is helpful to consider how economic struc-
     accordingly to achieve their individual and shared           ture affects access to resources for implementation. Mar-
     goals [40, 47]. It would also be important to capture        ket forces can be used to change demand for products
     unconscious or implicit bias from either recipient           deemed healthy or unhealthy, therefore driving policy im-
     about the other recipient’s characteristics, such as         plementation. Examples of market forces include taxes on
     race, weight, or perceived sexual orientation [48–           tobacco, unhealthy food, and soft drinks, or food subsidy
     50]. These unconscious biases may manifest in                programs for women with low incomes [41].
     unhelpful behaviors during the encounter, such as
     dismissing someone’s concerns, interrupting the              Physical structures
     other person, or not smiling, touching, or making            Equity can be affected by how physical spaces, or “built
     eye contact. Clinical encounters predict patient             environments,” are arranged and how transition between
     satisfaction, trust, and health outcomes; thus, it is        those spaces occurs for healthcare [41]. Physical struc-
     crucial to assess and address what occurs during             tures include any factors where people have to physically
     the clinical encounter, especially with regard to            go to get healthcare and what environmental elements
     implementation disparities [47, 50–52].                      people may be exposed to (e.g., privacy or lack thereof,
  3. Societal context: economies, physical structures,            what they see, what is emitted in the air and into their
     and sociopolitical forces. This domain is similar to         bodies). One example in healthcare settings is the type
     social determinants of health, yet also incorporates         and quality of language translations of information dis-
     more upstream determinants (e.g., governance) that           played (e.g., flyers, waiting rooms)—whether it matches
     have been investigated less relative to mid- or              the language of patients served [54]. The location of the
     downstream determinants (e.g., neighborhoods)                healthcare setting in a town or city is important in rela-
     [44]. Societal context includes three specific               tion to where patients reside [54, 55], e.g., is it difficult
     determinants: (1) economics, (2) physical structures,        for patients to get to the point of care? Another example
     and (3) sociopolitical forces. In piloting the Health        is the implementation of one U.S. state’s naloxone stand-
     Equity Implementation Framework, societal context            ing order in which pharmacies could distribute naloxone
     affected receipt of antiviral hepatitis C virus              without a prescription: 61.7% of retail pharmacies had
     medicine for Black patients in the U.S. Veterans             naloxone available without a prescription [56]. However,
     Health Administration [23].                                  naloxone availability was lower in neighborhoods with
                                                                  higher percentages of residents with public health insur-
  Societal context may include historical or current dis-         ance—a physical structure problem (lower availability of
crimination against marginalized groups, such as racism,          naloxone in some neighborhoods) interacting with an
classism, or transphobia that may be formally or infor-           economic factor (public health insurance). This finding
mally institutionalized within any organizational or local        was particularly problematic due to an increased cost of
context. These factors usually occur in the broadest              naloxone for people on public health insurance as a re-
levels of the environment (e.g., province, nation), affect-       sult of the statewide mandate.
ing the healthcare system, clinics, and recipients down-
stream. Many societal context determinants are                    Sociopolitical forces
interrelated, such as a policy affecting a physical struc-        The third societal context describes social norms or pol-
ture. It is not as important to distinguish whether a             itical forces, which can include but are not limited to
Woodward et al. Implementation Science Communications   (2021) 2:61                                                Page 6 of 16

political support, laws, and social structures in which           framework guided subsequent integration of qualitative
linkages between institutions perpetuate oppression,              and quantitative data, including the use of qualitative
such as racism, misogyny, classism, or heterosexism [43,          themes to complement and expand quantitative findings.
57]. For instance, public health policies (e.g., fiscal, regu-    Preliminary findings indicate a significant impact of
lation, education, preventative treatment, and screening)         outer and inner context on inequities, including fit be-
demonstrate positive and negative effects on health dis-          tween patient recipient characteristics, culturally relevant
parities that occur across health domains (e.g., tobacco,         factors, and characteristics of available innovations. Add-
food and nutrition, reproductive health services) [41]. As        itional outer context factors, including sociopolitical fac-
another example, a study examined U.S. state legislators’         tors and physical structures such as location (urban
behavioral health research-seeking practices and dissem-          versus rural) also impact service utilization, including in-
ination preferences and found significant variation be-           teractions with provider factors and innovation
tween Democrats and Republicans, suggesting                       characteristics.
dissemination materials be tailored to different social
norms for different groups [58].
   Next, we showcase two examples of how implementa-              Conducting a process evaluation to categorize ongoing
tion teams have used culturally relevant factors of recipi-       barriers/facilitators
ents, patient-provider clinical encounter, and societal           In Toronto, Canada, legally sanctioned supervised con-
context as health equity domains in formative and                 sumption services (the innovation) are integrated within
process evaluations. Each example comes from different            health centers; implementation has occurred and is on-
health service sectors and describes efforts focused on           going. Supervised consumption services are for people
implementation disparities.                                       who inject drugs to receive sterile injection equipment
                                                                  and inject under staff supervision. Staff educate on safer
Conducting a formative needs assessment prior to                  injecting, provide referrals to services, and can respond
implementation                                                    to overdoses, reducing transmission of infectious dis-
The Health Equity Implementation Framework has been               eases (e.g., HIV) and overdose deaths. Researchers used
applied to guide a needs assessment for an implementa-            ethnographic observation and individual semi-structured
tion project aiming to reduce inequities in the provision         interviews with 24 patients who injected drugs in super-
and receipt of publicly funded services for individuals           vised consumption services at two community health
with developmental disabilities in the U.S. (Rieth SR,            centers, half of who were people of color or Indigenous
Dickson KS, Plotkin R, Corsello C, Ko J, Cook-Clark T,            to Canada [59]. After coding, researchers interpreted
et al: An in-depth analysis of expenditures for Latinx in-        findings within domains of the Health Equity Implemen-
dividuals with developmental disabilities: Following the          tation Framework.
money and perspectives from the front line, in prepar-              Integrating legally sanctioned supervised consumption
ation). In 2016, the State of California Department of            services within health centers (sociopolitical force) pro-
Developmental Services made funds available to address            vided clients access to other health services, including
significant inequities in service expenditures for Latinx         dentistry and medical assistance that eliminated the need
clients. In response, the San Diego Regional Center, the          for a provider visit (characteristics of the innovation,
local agency coordinating and funding publicly-funded             organizational context). Patients appreciated having
developmental disability services, initiated a partnership        everything in one physical place (physical structure).
with local services and implementation researchers to             One participant said the services allowed them to avoid
identify inequity reduction targets and develop and im-           meeting providers who were prejudice against drug use
plement an inequity reduction model. A mixed methods              (sociopolitical force, provider culturally relevant factor).
needs assessment was conducted to inform model devel-               Yet, there were barriers to implementation. Patients
opment and implementation activities. Quantitative data           were uncomfortable being seen by peers using the center
included administrative data from the previous year.              due to stigma about drug use (sociopolitical force).
Qualitative data were gathered from focus groups with             Spatial limitations at the center made it difficult to have
regional center case managers to identify key determi-            privacy while injecting (physical structure). Patients pre-
nants of inequities from their perspectives.                      ferred the center to be open all the time (organizational
   The Health Equity Implementation Framework guided              context), but there were not enough staff for that flexi-
the identification of implementation determinants and             bility (healthcare system context). Ethnographic observa-
the selection of data coding and analyses. Specifically,          tion suggested standalone supervised consumption
the framework informed the development of the qualita-            services were consistently busier than integrated ser-
tive codebook, including coding domains and definitions           vices, potentially because some people felt uncomfort-
that were iteratively refined for this project. The               able in a healthcare setting (patient factor).
Woodward et al. Implementation Science Communications   (2021) 2:61                                                Page 7 of 16

Methods                                                           Determine implementation determinants
We completed a consensus process to clarify steps for             Assess which determinants are present in an implemen-
incorporating a health equity lens into an implementa-            tation disparity and whether each determinant is a bar-
tion determinant framework, situated within the existing          rier (challenge) to improving equitable implementation
literature. We reviewed Moullin and colleagues’ ten sug-          or a facilitator (strength). Through formative evaluation
gested steps for incorporating frameworks into an imple-          to assess barriers and facilitators in each domain [62, 63]
mentation effort [60] and selected the five steps                 align qualitative interview guides, quantitative measures,
applicable to an implementation determinant framework             and other assessment methods (e.g., participant observa-
(vs. evaluation or process frameworks). The first author          tion, policy review) to the framework’s determinants. For
(ENW) expanded those five steps from Moullin and col-             qualitative and quantitative assessments of determinants,
leagues [60] with steps on how to incorporate health              we present in Table 1 a variety of assessment methods
equity domains and determinants. These steps were vet-            and measures one might use to assess determinants
ted with the authorship team through a process of oral            within the Health Equity Implementation Framework.
discussions, reviewing written documents, and refining            An illustrative example is given to showcase how others
steps until all agreed. Next, our team created or aligned         have assessed various determinants incorporated in the
a table, tool, or example for more practical guidance on          framework. Although Table 1 is not exhaustive, it is a
how each step could be executed.                                  robust reference and guide to consider certain measures,
                                                                  tools, or data sources for formative evaluation.
Results                                                              If one is using qualitative methods to determine some
Applying health equity domains across an                          or all of the equitable implementation determinants, we
implementation effort                                             provide examples of questions from qualitative interview
Below are suggested steps on how to use frameworks in             guides we piloted that are aligned to domains of the
an implementation effort [60] with a focus from our               Health Equity Implementation Framework (see Add-
authorship team specifically on health equity in an im-           itional file 1). If this approach is used, the framework do-
plementation determinant framework.                               mains are then helpful for designing qualitative
                                                                  codebooks or templates for analysis. We provide a code-
Select a suitable framework or domains for an                     book for analysis we piloted that is aligned to the three
implementation disparity problem                                  health equity domains (see Additional file 2). The code-
If an implementation effort will focus on a health condi-         book for the health equity domains can be combined
tion or marginalized population with documented health            with codebooks of other determinant frameworks, such
or healthcare disparities, we strongly suggest incorporat-        as Consolidated Framework for Implementation Re-
ing determinants from the three health equity domains             search [126].
into one’s preferred implementation framework or use
the Health Equity Implementation Framework. If we do              Use domains to develop an implementation mechanistic
not assess or consider domains that promote or inhibit            process model or logic model
disparities, then we cannot expect to address them in a           Determinants in the Health Equity Implementation
meaningful way, and we cannot build our scientific inte-          Framework may directly influence the success and equity
gration of health equity and implementation science to            of an implementation effort or they may indirectly affect
generalize across implementation efforts. To find an im-          outcomes as mechanisms through which success or
plementation determinant framework other than the                 equity are enhanced. Using the three health equity do-
Health Equity Implementation Framework that can be                mains added to an implementation determinant frame-
adapted for implementation disparities, pick a frame-             work, one may develop theoretically driven hypotheses
work using an online webtool showcasing many imple-               about which domains, or determinants within them,
mentation determinant frameworks (https://                        must change to lead to improved equity and implemen-
dissemination-implementation.org/) [61].                          tation success [127]. These determinants are mecha-
   The Health Equity Implementation Framework can be              nisms. When working on an implementation disparity
adapted to any population or country where implemen-              problem, this will ensure some mechanisms related to
tation disparities occur. The framework proposes deter-           equity and implementation are investigated.
minants of inequitable implementation and a process                 To understand the concept of mechanisms of imple-
(facilitation) by which to address determinants. The              mentation disparities, we consider a hypothetical ex-
framework has not been used as a process or evaluation            ample of an implementation disparity at one hospital
framework; thus, we cannot speak to the value of focus-           where an evidence-based innovation is received mostly
ing on these domains in implementation processes or to            by White people with moderate or high incomes. In this
these domains as evaluation outcomes.                             example, the implementation disparity between patients
Woodward et al. Implementation Science Communications                 (2021) 2:61                                                                Page 8 of 16

Table 1 Definitions, illustrative examples, and sample measures of the Health Equity Implementation Framework
Domain and                     Definition                                  Illustrative example(s)                   Sample measuresa
Characteristics of the         An innovation is a treatment,               A study examined the uptake of the        Quantitative:
innovation [31]:               intervention, or practice with unique       Healthy Heart Kit (innovation), a risk    • Decision-Maker Information Needs
 • Underlying knowledge        characteristics that determine how          management and patient education            and Preferences Survey
sources                        such innovations will be applied in a       resource for the prevention of            • Electronic Health Record Nurse
 • Clarity                     particular setting. Innovations fall into   cardiovascular disease, in a primary        Satisfaction Survey [67]
 • Degree of fit with          one of the “7 Ps”: programs, practices,     care setting. They found that relative    • Reports assessing the current status
existing practice/values       principles, procedures, products, pills,    advantage (innovation was the most          of implementing the innovation,
 • Usability                   or policies [30].                           comprehensive tool for cardiovascular       completed by one clinic point of
 • Relative advantage          The innovation should be tailored           health) and observable results              contact or champion [68]
 • Trialability                with minor changes or adapted with          (evidence-based practice supports         Qualitative:
 • Observable results          major changes to the setting’s needs        innovation) were more influential to      • Barriers and facilitators assessment
 • Evidence for the            and practices for successful                the uptake of Healthy Heart Kit than        instrument
innovation [64]                implementation [31, 65].                    other characteristics [66].               • General practitioners’ perceptions of
 • Research                                                                                                            the route of evidence-based
 • Clinical experiences                                                                                                medicine
 • Patient experiences                                                                                               • Knowledge, attitudes, and
                                                                                                                       expectations of web-assisted tobacco
                                                                                                                       interventions [67]
*Clinical encounter            This is the nature of the interaction       In studying recordings of HIV patient-    Quantitative:
(patient-provider              between patient and provider. This          provider encounters, there was less       • Patient and provider questionnaires
interaction)                   domain is centered on how the               psychosocial talk in patient-provider       about relevant demographics to
                               patient and provider choose, adapt,         encounters with Hispanic compared to        assess concordance/match between
                               and coordinate the conversation to          non-Hispanic white patients [39].           patient and provider
                               achieve their shared and personal           In a study on predictors and              • Patient rating about the encounter:
                               goals concerning health-related mat-        consequences of negative patient-           Interpersonal Processes of Care
                               ters [40].                                  provider interactions among a sample        Survey [39]
                               The interaction could be influenced         of African American sexual minority       • Experiences of Discrimination Scale
                               by:                                         women, authors found racial discrimin-      [69]
                               • Predisposition features which are         ation was most frequently mentioned,      Qualitative:
                                 individual differences that influence     and gender and sexual orientation dis-    • Patient qualitative interviews about
                                 communication that may be                 crimination were also related to nega-      their experience of care [70, 71]
                                 objective (e.g., age) and subjective      tive patient experiences [50].            Clinical encounters coded using
                                 (e.g., self-concept).                                                               audiotapes, analyzed using the Roter
                               • Cognitive/affective influences that                                                 Interaction Analysis System [39]
                                 show how communication is related
                                 to strategy (e.g., goals), attributions
                                 (e.g., stereotypical), and trust.
                               • Communication influences refer to
                                 how the patient and the provider
                                 tailor their responses to create a
                                 coherent and effective exchange
Recipients [31]:               Recipients are individuals who              See below                                 See below
 • Motivations                 influence implementation processes
 • Values and beliefs          and those who are affected by
 • Goals                       implementation outcomes, both at
 • Skills                      the individual and collective team
 • Knowledge                   levels. Recipients can facilitate uptake
 • Time, resources, support    of an innovation or resist its
 • Local opinion leaders       implementation [31].
 • Collaboration/ teamwork
 • Existing networks
 • Learning environment
 • Power and authority
 • Presence of boundaries
*Recipients: providers         In a healthcare setting, providers and      Physicians who consider themselves        Quantitative:
and staff:                     staff are the people who administer         “liberal” spent more time giving more     • Implicit Association Test to assess
Culturally relevant factors    the innovation.                             information to patients than those          implicit bias [48]
include [35]:                  A providers’ objectives and beliefs         who consider themselves                   • Surveys of relevant practice,
 • Demographics (e.g.,         about a patient affect how they             “conservative” [40].                        knowledge, attitudes, or skills [74, 75]
neighborhood immigrant         behave during the patient-provider          Providers may engage in more              • Colorblind Racism Scale [76]
status)                        interaction [72].                           detailed conversations about the          Qualitative:
 • Unconscious/implicit bias   Providers, especially in busy healthcare    health status of educated patients, yet   • Analysis of taped conversation
 • Knowledge and attitudes     settings, may be vulnerable to              provide basic explanations for less-        between provider and patient [39,
 • Skillsets                   subconscious bias and stereotypes           educated patients [40].                     48]
                               [73].                                       During a post-angiogram encounter,        • Participant observation [77]
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Table 1 Definitions, illustrative examples, and sample measures of the Health Equity Implementation Framework (Continued)
Domain and                     Definition                               Illustrative example(s)                       Sample measuresa
                                                                        physicians perceived patients of lower        • One-on-one interviews [78]
                                                                        socioeconomic status as having more
                                                                        negative personality characteristics
                                                                        that include lack of self-control and
                                                                        more negative behavioral tendencies
*Recipients: patients:         In a healthcare setting, patients are    Asian American patients in Hawaii             Quantitative [34]:
Culturally relevant factors    the people (individuals, families,       participated less in their medical visits     • Telephone survey of a random
include [34, 35, 45, 79–81]:   caregivers) who will actually receive    than mainland Americans [82].                   sample of residents
 • Medical mistrust            the innovation. Culturally relevant      Patients with more formal educations          • Medical Mistrust Index [84]
 • Health literacy and         factors are associated with health and   are more expressive and tend to want          • Measures of underutilization of
numeracy                       healthcare disparities and can include   to play a role in the decision-making           health services
 • Demographics (e.g.,         demographic factors, beliefs,            process than less educated patients           • Health literacy question [85]
neighborhood, immigrant        information, and biological or genetic   [40].                                         • Health numeracy question [86]
status)                        conditions related to equitable          Many patients are unsure about their          • Appropriated Racial Oppression Scale
 • Socioeconomic status,       implementation.                          role in the encounter and the                   [87]
including household                                                     appropriateness of their participation        Qualitative:
income, net wealth, health                                              [83].                                         • Interview about expectations for
insurance status, education                                                                                             treatment or the patient-provider-
level                                                                                                                   interaction [39, 88]
 • Expectations about                                                                                                 • Interviews about experience seeking
therapeutic relationships                                                                                               care [89]
 • Beliefs and preferences
Inner context (local) [26]:    The immediate local setting of           Among 303 providers working in 49             Quantitative:
 • Formal and informal         implementation. Examples include:        publicly funded health programs for           • Perceptions of Supervisory Support
leadership support             • Ward                                   youths, providers’ perception of                Scale [92]
 • Culture                     • Unit                                   certain leadership styles was                 • Organizational commitment [93]
 • Previous experience of      • Clinic                                 associated with stronger provider             • Readiness for Organizational Change
innovation or change           • Hospital department                    willingness to adopt evidence-based             measure [94]
 • Change mechanisms for                                                treatments [90].                              • Validated inner setting measures [95]
embedding innovation                                                    Pisando Fuerte is a fall prevention           Qualitative [96]:
 • Evaluation and feedback                                              program linguistically and culturally         • Site visit
processes                                                               tailored for Latino individuals at risk for   • Key informant interviews about
                                                                        falls. It is adapted from “Stepping On,”        inclusivity
                                                                        an evidence-based fall prevention pro-        • Stakeholder meetings or focus
                                                                        gram. Fidelity to Pisando Fuerte was            groups with providers about their
                                                                        subpar; when comparing fidelity be-             understanding of equitable care
                                                                        tween the two sites, fidelity was lower       • Public forums and listening sessions
                                                                        in the site that did not give additional      • Provider and staff interviews to
                                                                        time to implement the program (poor             determine actual practice and
                                                                        leadership support) and had no ex-              processes [97]
                                                                        perience in organizing programs like
                                                                        Pisando Fuerte (no previous experi-
                                                                        ence of innovation) [91].
Inner context                The organizational atmosphere in           Hospitals’ adoption of the Culturally         Quantitative:
(organizational) [26]:       which the unit or team is embedded.        and Linguistically Appropriate Services       • Measures of organizational readiness
 • Organizational priorities                                            standards focused on retaining                  for change [100]
 • Senior leadership and                                                translators and adapting culturally and       • Cultural Competency Assessment
management support                                                      linguistically appropriate materials.           Tool for Hospitals [98]
 • Culture                                                              However, this adoption did not often          Qualitative [101]:
 • Structure and systems                                                include engagement in broader                 • Key informant interviews assessing
 • History of innovation and                                            organizational change [98].                     knowledge/action of policies about
change                                                                  Researchers studied a disparity-                equity
 • Absorptive capacity                                                  reduction program in Israel across 26         • Key informant interviews assessing
 • Learning networks                                                    clinics and 109 clinical teams. After 3         beliefs organization holds about
                                                                        years, they found different inner con-          marginalized people
                                                                        text configurations of factors predict-       • Stakeholder meetings about the
                                                                        ing disparity reduction. One example            importance of equitable care
                                                                        of a successful configuration was             • Public forums and listening sessions
                                                                        clinics with a large disparity gap to           [102]
                                                                        minimize, high clinic density, high per-      • Focus groups
                                                                        ceived team effectiveness, and focused
                                                                        efforts on tailoring services to their en-
                                                                        rollee patients [99].
Outer context                  This is the broader context defined in   Researchers examined predisposing,            Qualitative:
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Table 1 Definitions, illustrative examples, and sample measures of the Health Equity Implementation Framework (Continued)
Domain and                     Definition                                   Illustrative example(s)                     Sample measuresa
(healthcare system) [26]:      terms of resources, culture, leadership,     enabling, and need factors as               • Archival analysis, reading and
 • Policy drivers and          and orientation to evaluation and            predictors of changes in healthcare           documenting policies, program
priorities                     learning.                                    utilization and found that patients’          manuals, or procedural protocols
 • Incentives and mandates     There is an increasing amount of             experiences differed by group within          [103, 104]
 • Regulatory frameworks       research that shows that inequities in       the healthcare system and impacted          • Interviews with leadership [99]
or external accreditation      obtaining preventative care among            their beliefs and attitudes about           Quantitative:
systems                        racial and ethnic minorities compared        receiving healthcare, ultimately            • 15 core measures of healthcare
 • Inter-organizational net-   with non-Hispanic whites are due to          affecting the extent to which                 qualit y[105]
works and relationships        “organizational characteristics, includ-     healthcare services were utilized [50].     • Population surveys
                               ing location, resources, and complexity                                                  • Social network analysis of
                               of a clinic or practice” [35].                                                             relationships between relevant
                                                                                                                          leadership and/or teams [99]
                                                                                                                        • Existing reports hospital-wide scores
                                                                                                                          on assessments of care and equity,
                                                                                                                          e.g., National Quality Forum or
                                                                                                                          Healthcare Equality Index [106]
*Societal context [41, 42]:    Forces outside the healthcare system See below                                           See below
 • Economies                   that influence all other domains and
 • Physical structures         determinants of implementation may
 • Sociopolitical forces       include but be broader than social
 • Up-, mid-, or               determinants of health, may focus on
downstream social              the presence of stigma and
determinants of health [44]    discrimination such as racism, classism,
                               or transphobia (as examples) and the
                               institutionalization of such
                               discrimination in every determinant of
*Economies [53]:               The structure of the city, state, or         In a study assessing longitudinal           Quantitative:
 • Traditional                 country related to the wealth and            effects of health insurance and             • Insurance claims data
 • Command                     resources of people and what is              poverty, researchers reported low-          • Gross domestic product [108]
 • Market                      exchanged for healthcare delivery            income, middle-aged adults in the U.S.      • Gross national product [109]
 • Mixed                       (e.g., insurance). This can be divided       with no insurance, unstable coverage,       • Minimum wage [110]
                               into human resources (i.e., labor,           or changes in insurance have higher         • Population and total employment
                               management) and non-human re-                out-of-pocket expenditures and finan-         [111]
                               sources (i.e., land, capital goods, finan-   cial burdens than public insurance          • Annual average wage level of the
                               cial resources, and technology) [55].        holders [107].                                primary, secondary, and tertiary
                                                                            In a case study, the presence of              industries [112]
                                                                            chronic kidney disease indicators in        • Tax revenue as a percentage of total
                                                                            the pay-for-performance system in pri-        revenue [113]
                                                                            mary care created an incentive for im-      • Interest rate on saving deposits and
                                                                            provement [26].                               inflation rate [114]
                                                                                                                        Qualitative [115]:
                                                                                                                        • Key informant interviews about
                                                                                                                          goods and services exchanged [116]
                                                                                                                        • Analysis of comparative economic
                                                                                                                          structure [115]
*Physical structures:          The physical environment, structure,         One study compared Black and White          Quantitative:
 • Location                    location of services, and recipients,        Americans who were exposed to the           • Indices of segregation [119]b
 • Availability of public      also known as the built environment          same set of socioeconomic, social, and      • Public data such as hospitals per
transportation                 as it relates to equitable                   environmental conditions in an area of        capita, public transportation trips per
 • Actual environment of       implementation [55].                         one U.S. city. Although there is robust       capita, car ownership, revenue
the point-to-care                                                           research documenting disparities in           dedicated to parks and recreation,
 • Language spoken and/or                                                   hypertension, diabetes, obesity, and          transportation, other infrastructure
signage                                                                     use of health services by race among          needs, and grocery stores per capita
 • Available structures in                                                  national samples, within the racially       • Center on Budget and Policy
one’s neighborhood to use                                                   integrated city in the study, disparities     Priorities data
innovation                                                                  in these health conditions were either      • State Departments of Finance and
 • Grocery stores                                                           absent or significantly smaller. Thus,        Administration [55]
 • Healthcare facilities                                                    the place where people lived had an         Qualitative:
 • Local businesses                                                         impact on their health conditions,          • Windshield and walking surveys
 • Physical infrastructure                                                  beyond race [117].                            include assessing infrastructure;
                                                                            In a qualitative study of transgender         surveyors are on foot and take note
                                                                            individuals’ experiences in residential       of the neighborhood related to the
                                                                            addiction treatment, researchers              physical or built environment [120].
                                                                            observed that residential facilities that
                                                                            split the milieu and housing based on
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Table 1 Definitions, illustrative examples, and sample measures of the Health Equity Implementation Framework (Continued)
Domain and                      Definition                                   Illustrative example(s)                      Sample measuresa
                                                                             the gender binary may be
                                                                             stigmatizing people who identify as
                                                                             transgender or gender non-
                                                                             conforming [118].
*Sociopolitical forces [41,     Policies and procedures, formal or           In a U.S. study on the adoption of           Quantitative:
43, 57]:                        informal, in national and local              behavioral health evidence-based             • Select measures of determinants of
 • Policy climate               governments that systemically inhibit        treatment by states, the following             policy implementation, such as
 • Political support            or promote equitable health.                 were some factors that played a role:          visibility of policy actors or policy
 • Laws                                                                      state characteristics, state fiscal sup-       implementation climate [121]
 • Local culture                                                             ports to promote innovation adoption,        • The State-Level Racism Index [122]b
 • Social movements or                                                       and state policy that supports to pro-       Qualitative:
structures such as racism,                                                   mote evidence-based treatment adop-          • INCLENS equity lens: examines
classism, heterosexism,                                                      tion [57].                                     whether clinical guidelines address
transphobiac                                                                                                                health needs and inequities
                                                                                                                            experienced by marginalized groups
                                                                                                                          • Interview questions with recipients
                                                                                                                            about laws, policies, or social
                                                                                                                            movements relevant to the
                                                                                                                          • Archival analysis of policy documents
                                                                                                                            [103, 104]
*Health equity domains adapted to i-PARIHS
  Measures or data collection methods are examples from literature; for a repository of implementation science measures, see the Society for Implementation
Research Collaboration’s Instrument Review Project [124]
  For a repository of measures specific to racism, see Appendix B of Racism: Science & Tools for the Public Health Professional [125]
 Implementation scientists should review existing measurement tools specific to health disparities in your area of interest or study to further integrate health
equity into implementation

of different races and incomes may be due to (1) the                                 and equitable delivery of healthcare. Consider these
innovation was developed and tested in samples of                                    health equity determinants in developing a logic
mostly White people such that it is not acceptable to or                             model to explain the implementation process, includ-
effective for Black people (characteristic of the                                    ing its mechanisms of change.
innovation), (2) providers do not offer the innovation as
often to Black patients as they do to White patients                                 Use framework determinants to conduct and tailor
(clinical encounter), (3) there may not be many Black or                             implementation
lower-income people served at the hospital (outer con-                               After formative evaluation or initial diagnosis of the im-
text), or (4) the hospital is not readily accessible via pub-                        plementation disparity is complete, the areas for change
lic transportation to people with lower incomes who do                               will become clear and implementation strategies will
not have motor vehicles (physical structure). There may                              need to be selected and tailored to local context and re-
be some known or unknown determinant within any do-                                  cipients with careful attention to equity and justice.
main of the Health Equity Implementation Framework                                   There are many existing ways to use information from
contributing to implementation disparities; perhaps pro-                             formative evaluation to select and tailor implementation
viders have unconscious biases toward Black people (a                                strategies [128–130]. To address implementation dispar-
factor within the cultural recipients domain) that lead to                           ities, explicitly include determinants of inequity in
them offering the innovation less frequently to Black pa-                            selecting and tailoring strategies, as well as unique bar-
tients than to White (clinical encounter). The key factor                            riers that may prevent organizations from addressing
to change would be unconscious bias to affect provider                               these inequities. For example, there may be a need to
behavior and alter the clinical encounter. To the extent                             use community- or patient-informed strategies to repair
possible, one can hypothesize which factor is the lever                              harm and build trust among patient recipients who have
for more equitable implementation—which of these                                     been and are marginalized in healthcare systems, im-
factors, if changed, would result in the innovation be-                              prove cultural and structural competence at all levels of
ing received by more people with lower incomes and                                   an organization, or continuously monitor reach between
more Black people at that hospital? These levers are                                 patient subgroups to detect change in disparities. Al-
mechanisms of implementation disparities (areas to                                   though some are focusing on equity more in using im-
change with implementation strategies) for more just                                 plementation strategies [33, 91, 99, 131], there is
Woodward et al. Implementation Science Communications   (2021) 2:61                                              Page 12 of 16

considerably more work to be done on this, and careful            levels in implementation science and practice will eluci-
attention to equity elements is needed to tailor                  date drivers of health inequities such as structural ra-
implementation.                                                   cism, heterosexism, and patriarchy. Thus, the discovery
  As implementation progresses, an implementation                 of these drivers of health inequities should necessitate
plan will need to be adapted as determinants change.              implementation strategies to overcome or resolve such
The Health Equity Implementation Framework can be                 complex and oppressive structures. Future research
useful for determining areas to assess repeatedly and             should focus on implementation strategies (or other pro-
thus, intervene on, throughout implementation. Doing              cesses) used to address health equity determinants of
so ensures an equity lens is applied throughout imple-            unjust health inequities in our healthcare systems and
mentation and that implementation processes, such as              societies.
planning, strategy use, and goal setting, are thoughtfully           We have only piloted the three health equity domains
executed according to dynamic needs. Repeated assess-             within the context of a determinant framework; however,
ments can be done informally through observations,                they may be suitable as process or evaluation variables. As
consultations with recipients and leadership, or more             this framework evolves through implementation research
formally through mixed methods, including ones men-               and we have more data to inform its application, future
tioned in Table 1 and used previously in formative                considerations could include that some of these domains
evaluation [63].                                                  for determinants should also be outcomes of implementa-
                                                                  tion disparity reduction efforts. For an implementation
Writing implementation reports or findings                        process framework that incorporates an equity lens, see
For documenting the results of an implementation ef-              frameworks proposed by Nápoles and Stewart [132] and
fort, clarify how the Health Equity Implementation                Eslava-Schmalbach and colleagues [133]. For an imple-
Framework or its three health equity domains were in-             mentation evaluation framework that incorporates an
corporated. For example, barriers and facilitators from           equity lens, see preliminary equity-focused implementa-
formative evaluation may be presented by framework                tion outcomes [133] and the proposed extension of the
domains. As implementation progresses, a team may                 RE-AIM framework [134].
want to document key changes within domains from the                 There are limitations to our framework and practical
Health Equity Implementation Framework, similar to                guidance presented here. We have piloted test many, but
how ongoing implementation barriers and facilitators              not all, the feasibility and acceptability of the steps we
were recorded for the study that examined the imple-              described using three health equity domains and mea-
mentation of legally sanctioned supervised consumption            sures in Table 1. However, we suggest these as starting
services in Canada [59]. The mixed method approaches              places, and with confidence, as they all have entire bod-
suggested earlier will provide key information to be re-          ies of science showcasing their relevance to health
ported, making clear why implementation was successful            equity. We limited the application of this framework to
or not, and how certain strategies affected whether dis-          healthcare settings, although it could be adapted to com-
parities in receipt, use, access to, or quality of an             munity or school settings. Although health equity can be
innovation were reduced [6].                                      incorporated across several determinant frameworks, we
                                                                  provided a detailed application of health equity domains
Discussion                                                        tied to i-PARIHS. They have the potential for broader
Disparities in healthcare occur in implementation out-            applications to other implementation science frame-
comes and patient health outcomes. Implementation dis-            works. This has not been piloted yet to our knowledge.
parities are rooted in social injustice, exacerbated by
multiple inputs, such as societal context, patient mis-           Conclusion
trust, provider bias, and poor patient-provider interac-          Implementation researchers and practitioners must
tions. The three health equity domains presented in               adopt a health equity lens as foundational to any
more depth here are key adaptations for implementation            research-practice gap where inequity exists. Researchers
researchers and suggested to adapt one’s preferred im-            might collect data on the feasibility, acceptability, and
plementation framework (e.g., EPIS) to incorporate an             predictive utility of health equity determinants in this
equity lens and account for inputs contributing to imple-         burgeoning area of implementation science. The Health
mentation disparities. Three health equity domains from           Equity Implementation Framework is an implementation
the Health Equity Implementation Framework can be                 determinant frameworks to capture and understand bar-
studied as determinants of implementation, as show-               riers and facilitators to health inequities [23, 135]. The
cased in the application to services for developmental            applications, steps, and tools in the manuscript are one
disabilities in California. We propose that an increased          step toward systematic integration of health equity and
focus on health equity explicitly at multiple ecological          implementation science in frameworks.
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