Table 1 PROSPECTIVE APPLICATION (planning, designing, and delivery of healthcare interventions)
From: How to leverage implementation research for equity in global health
Guidance* | How to apply | Example of relevant methods |
|---|---|---|
Implementation contexts | ||
1. Define health problems by differences among groups defined by ‘equity variables’ (use equity variables e.g., ‘PROGRESS’ – place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status, social capital and disability status [52,53,54] – to define groups and categorize their health and/or implementation problems with the evidence-supported intervention (ESI) of interest). Define groups that are socially disadvantaged based on the definition of health problems by different equity variables. | a. Determine how the burden of a health problem (e.g. incidence or prevalence of a vaccine-preventable disease) compares for groups categorized by relevant equity variables (e.g. race, socioeconomic status, gender, disability status). b. Determine how the implementation problem with the ESI (e.g. vaccine) differ for groups categorized by relevant equity variables. The implementation problem can be indicated by measures of access and quality (e.g. measures of effective coverage [55] related to the ESI comparing different groups. c. Determine if differences in social determinants of health (e.g. income and social protection, job/employment, affordable health services, good housing, and transportation) [56] for the relevant groups contribute to any disparity in health and implementation problems. d. Based on a-c, determine which groups are socially disadvantaged with respect to health and implementation problems linked to differences in their social determinants of health. | • Secondary data analysis of available quantitative data (including population-based survey, surveillance, administrative, burden of disease data, and health management information system records) • Literature review • Qualitative interviews |
2. Identify and work with relevant stakeholders (give special attention to the perspectives of socially disadvantaged groups) in defining the problems of interest, solutions, and implementation arrangements. | a. Identify representatives of socially disadvantaged groups defined from step 1 above – and consult with them to systematically characterize the underlying causes of any disparity in health and implementation problems (i.e., find out from their perspective why the health/implementation problems occur) – and identify possible solutions. b. Systematically characterize the underlying causes of any disparity in health and implementation problems with other relevant actors (e.g. ESI implementers, other health services providers, decision-makers around the ESI at different levels) – and identify possible solutions. c. Compare perspectives (causes, causal pathways, and solutions) of different actors prioritizing instances where they agree, and the perspective of socially disadvantaged groups where there is no agreement. | • Stakeholder meetings and analyses [57] • Theory of change workshop and group modeling to capture a variety of causes, pathways, and potential solutions [58] • Root cause analysis techniques (e.g. ‘5 whys’ [59]) with specific groups for problems with limited number of causes and pathways • Other participatory methods [60] • Literature review |
3. Unpack the social contexts and causal chain that may have contributed to health inequities (i.e., identify how specific structural and systemic determinants of health may have contributed to the health problems for socially disadvantaged groups), and propose mechanisms for health inequities (e.g. specify the type of social injustices and/or human rights violations). | a. Define the inner and outer context of implementation for the ESI. The inner context encompasses the characteristics of the beneficiaries of the ESI, implementers, implementing organizations (e.g. structure, climate), and implementation level (e.g. households, communities, health facilities). The outer context encompasses the sociopolitical, economic, and policy environment that are external to the inner context. [61, 62] b. Explicate any power differentials between actors within the inner context of implementation and arrangements for health services delivery (e.g. beneficiaries of ESI vs. implementers of ESI, researchers vs. research subjects, communities vs. implementing organization, health services providers vs. clients). c. Identify any specific social injustices and/or human rights violations within the inner context of implementation and arrangements for health services delivery (e.g. discrimination, oppression, exclusion from services based on group membership). d. Consider how historical antecedents (e.g., colonization, slavery, group supremacy) may have shaped advantages and disadvantages within the health system that governs the inner context of implementation and delivery of other health services. Consider how historical antecedents may have shaped other systems and structures (e.g. labor, housing, and transportation systems) that govern any pertinent social determinants of health identified from step 1. e. Identify how specific systemic and structural determinants of health [49] may have contributed to the disparity in health and implementation problems affecting socially disadvantaged groups (e.g. what role within relevant systems do institutionalized racism, [47] gender-based discrimination, classism [63] and ableism [64] contribute to the disparity in health and implementation problems affecting the socially disadvantaged groups?) | • Literature review • Qualitative interviews with all actors, including implementers and members of socially disadvantaged groups • Direct observations during stakeholder meetings • Participatory methods [60] |
4. Adapt ESI and the inner context of implementation (implementing organization; implementation level e.g., households, communities, health facilities; implementers’ and beneficiaries' characteristics) to address implementation problems for socially disadvantaged groups. | a. Use a systematic approach involving relevant actors to make modifications to the ESI and inner context of implementation to address implementation problems (e.g. improve quality and access to the ESI) for the socially disadvantaged groups (e.g. change time and venue of vaccine delivery to when and where is convenient for members of the socially disadvantaged groups). The modifications could be guided by various implementation research (IR) adaptation frameworks and models. [65, 66] b. Specify strategies to address power differentials among actors within the inner context of the implementation (e.g. establish a social accountability mechanism [67] such as client feedback or community scorecard where implementers are held accountable to members of the socially disadvantaged groups). The strategy specification here (and subsequently) could be guided by various IR strategy frameworks. [68, 69] c. Test adaptations and strategies with members of the socially disadvantaged groups and make further modifications as necessary (e.g. conduct an initial pilot or qualitative assessment of the adaptations with members of the socially disadvantaged groups). | • Literature review • Participatory methods [60] • Focus groups and qualitative interviews • Theory-based analyses (application of IR theory, models, and frameworks) [70] |
Implementation strategies** | ||
1. Include implementation strategies that target mechanisms of health inequities (e.g., addressing specific and relevant social injustices and human rights violations) within the inner context of implementation. | a. Consider and specify strategies for addressing social injustices and human rights violations within the inner context of implementation (e.g., establishing anti-discriminatory policies and safe procedures for reporting anti-discriminatory and oppressive practices, [71] enforcing existing antidiscrimination policies, [49] incentivizing and promoting practices that uphold rights of members of socially disadvantaged groups, and institutionalizing social accountability strategies). [67] | • Theory-based analyses (application of IR theory, models, and frameworks). [70] |
2. Include implementation strategies that target structural and systemic determinants of health inequities within the inner context of implementation (and the outer context as much as feasible). | a. Consider and specify strategies for addressing pertinent social determinants of health relevant to the inner context of implementation, and the outer context as much as feasible (e.g. provision of subsidized or free access to good quality health services, income supplements such as conditional cash transfer, subsidized and good quality housing, transportation vouchers to socially disadvantaged groups). [72] b. Consider and specify strategies for addressing negative historical antecedents and pertinent structural and systemic determinants of health relevant to the inner context of implementation, and outer context as much as feasible (e.g. training and deploying tools for addressing unconscious bias and discrimination within health systems, [73] setting livable minimum wages and maternity leave with benefits within labor systems, affirmative actions and reparations throughout all systems. [49, 74] | • Theory-based analyses (application of IR theory, models, and frameworks) [70] |
Implementation outcomes | ||
1. Prioritize implementation outcomes for the socially disadvantaged groups. | a. Operationally define and measure relevant implementation outcomes (IO) [75, 76] e.g., acceptability and fidelity linked to the adapted ESI and any specified implementation strategies from the perspectives of socially disadvantaged groups, i.e. primary IO. Consider taking measurements of these IO at more than one time point. b. Operationally define and measure other relevant IO (e.g. uptake and sustainment of the ESI) for all groups (encompassing both socially and disadvantaged and advantaged groups), i.e. secondary IO – and compare measures for socially disadvantaged groups vs. advantaged groups. Consider taking measurements at more than one time point. c. Link any differences in the secondary IO (e.g. uptake) comparing disadvantaged groups vs. advantaged groups to changes in the primary IO (e.g. acceptability) for disadvantaged groups. | • Theory-based analyses (application of IR theory, models, and frameworks) [70] • Psychometric approaches to develop and adapt tools for quantitative assessment • Mixed [77] and multi-methods [78] (combining various methods as needed along the research process – and not necessarily combining quantitative and qualitative methods for a single set of hypotheses as observed in mixed methods) |
IR design | ||
1. Use pragmatic research designs to generate evidence for implementation (impact of design features on implementation outcomes and overall health outcomes for all population and the socially disadvantaged groups). | Consider the following research objectives: a. Include a research objective to estimate changes in implementation outcomes (IO) for all populations and the socially disadvantaged groups. b. Include a research objective to estimate changes in the overall health outcomes (e.g. morbidity and mortality) for all populations and socially disadvantaged groups. c. Examine time varying changes in implementation outcomes linked to changes in overall health outcomes for all populations and socially disadvantaged groups. d. Examine time varying changes in implementation outcomes comparing socially disadvantaged vs. advantaged groups linked to time varying changes in overall health outcomes comparing socially disadvantaged vs. advantaged groups. | • Quantitative IR study design [79, 80] • Qualitative IR study design [81] • Mixed [77] and multi-methods [78] (combining various methods as needed along the research process – and not necessarily combining quantitative and qualitative methods for a single set of hypotheses as observed in mixed methods) • System science methods [82] |