Advancing healthcare equity through dissemination and implementation science

Objective

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

Data Sources and Study Setting

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

Study Design

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

Data Collection/Extraction Methods

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

Principal Findings

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

Conclusions

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.     

Nutrition and Chronic Disease Prevention: Priorities for US Minority Groups

Persistent disparities affecting US racial/ethnic minorities present a continuing challenge within the larger picture of chronic disease prevention, in part because of the socio-political disadvantages that affect minority populations. Many of these disparities are nutrition related. Complementary approaches to identifying priorities for nutrition assessment and intervention in minority populations include: 1) a dietary perspective that considers eating patterns in relation to current dietary guidelines, and 2) a chronic disease perspective that considers dietary implications of population risk profiles. Integrating these perspectives requires additional considerations of feasibility and relative priority for the population in question.     

“Live, Learn and Play”: Building strategic alliances between professional sports and public health

Public–private partnerships allow communities and corporate entities to pool resources to address a mission of relevance to their common constituency or consumer base. Collaborations between public health and professional sports may present unique opportunities to improve health outcomes related to physical activity since athletes are fitness icons, both for adults and children. There are many “win–win” opportunities, as sports venues regularly host huge numbers of spectators, offering food and entertainment, providing hours of exposure, and introducing new ideas for engaging fans in order to remain a competitive draw. In 2008, the San Diego Padres embarked on a communitywide fitness initiative, FriarFit, including incorporating 10-minute Instant Recess™ breaks during their Sunday homestand pre-game shows. Many lessons have been learned that may be useful to others mounting such initiatives, such as: there is more at stake in cost-benefit and risk-benefit assessment for sports executives, requiring greater caution and circumspection than is typical for public health projects; the core business of the corporate entity must be accommodated without undermining the health objectives; and health aims must be addressed in a way that is financially viable and delivers tangible value for profit-making concerns, in terms of marketing, revenues or brand enhancement.     

Effects of Integrated Risk Counseling for Cancer and Cardiovascular Disease in African Americans

ObjectiveWe evaluated a risk counseling intervention designed to enhance understanding about risk factors for cancer and cardiovascular disease, to improve self-efficacy for diet and physical activity, and to increase intentions to eat healthier and be physically active.MethodsWe conducted a quasi-experimental study developed by academic investigators and community stakeholders to evaluate the effects of integrated risk counseling in a community-based sample of African American adults (n = 101). The intervention provided education about the overlap in risk factors for cancer and cardiovascular disease and included components from motivational interviewing.ResultsChanges in behavioral intentions were not statistically significant (p > .05). Participants reported significantly greater levels of self-efficacy for diet (f = 2.25, p = .03) and physical activity (f = 2.55, p = .01), and significantly increased perceived risks of developing colon cancer (x² = 3.86, p = .05) and having a heart attack (x² = 4.50, p = .03).ConclusionsIntegrated risk counseling may have some benefits among African Americans.     

Healthy people: a 2020 vision for the social determinants approach

For the past three decades, the Healthy People initiative has represented an ambitious yet achievable health promotion and disease prevention agenda for the nation. The recently released fourth version-Healthy People 2020-builds on the foundations of prior iterations while newly embracing and elevating a comprehensive "social determinants" perspective. By clearly articulating a new overarching goal to "create social and physical environments that promote good health for all" and a new topic area dedicated to defining the social determinants of health approach, it breaks new ground. Specifically, the 2020 plan emphasizes the need to consider factors such as poverty, education, and numerous aspects of the social structure that not only influence the health of populations but also limit the ability of many to achieve health equity. Improving health is too multifaceted to be left to those working in the health sector alone. Using a social determinants approach can reframe the way the public, policy makers, and the private sector think about achieving and sustaining health. This article describes why such a social determinants approach can enhance our collective efforts to improve population health. This is achieved by defining the context for this new perspective, the process by which the Healthy People 2020 goals and objectives were developed, and the challenges and opportunities ahead. Adding this broad, social determinants perspective and vision for shared societal responsibility for change leaves Healthy People 2020 poised to promote a stronger legacy for a healthier nation and reaffirm a unity of purpose for the future.     

Health disparities and health equity: the issue is justice

Eliminating health disparities is a Healthy People goal. Given the diverse and sometimes broad definitions of health disparities commonly used, a subcommittee convened by the Secretary's Advisory Committee for Healthy People 2020 proposed an operational definition for use in developing objectives and targets, determining resource allocation priorities, and assessing progress. Based on that subcommittee's work, we propose that health disparities are systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups; they may reflect social disadvantage, but causality need not be established. This definition, grounded in ethical and human rights principles, focuses on the subset of health differences reflecting social injustice, distinguishing health disparities from other health differences also warranting concerted attention, and from health differences in general. We explain the definition, its underlying concepts, the challenges it addresses, and the rationale for applying it to United States public health policy.     

Using a mixed-methods approach to identify health concerns in an African American community

Objectives. We used qualitative and quantitative data collection methods to identify the health concerns of African American residents in an urban community and analyzed the extent to which there were consistencies across methods in the concerns identified.Methods. We completed 9 focus groups with 51 residents, 27 key informant interviews, and 201 community health surveys with a random sample of community residents to identify the health issues participants considered of greatest importance. We then compared the issues identified through these methods.Results. Focus group participants and key informants gave priority to cancer and cardiovascular diseases, but most respondents in the community health survey indicated that sexually transmitted diseases, substance abuse, and obesity were conditions in need of intervention. How respondents ranked their concerns varied in the qualitative versus the quantitative methods.Conclusions. Using qualitative and quantitative approaches simultaneously is useful in determining community health concerns. Although quantitative approaches yield concrete evidence of community needs, qualitative approaches provide a context for how these issues can be addressed. Researchers should develop creative ways to address multiple issues that arise when using a mixed-methods approach.Community-based participatory research is a collaborative process in which academic and community investigators work together to develop, implement, and evaluate interventions to improve the health of community residents.^1–4 As part of these partnerships, formative research that includes focus groups and key informant interviews may be conducted to identify the health priorities and concerns of community residents and to obtain guidance from stakeholders on how these issues should be addressed and how to develop interventions.^5,6 Although this information is critical to the implementation of intervention strategies, the generalizability of data obtained from these methods may be limited because individuals may self-select for participation in focus groups, and key informants are often identified using nonrandom methods. Thus, it may be important to use quantitative methods such as population-based random surveys along with qualitative approaches to ensure that the health priorities and concerns identified during the formative phase of academic–community partnerships are most representative of the community. However, limited empirical data exist on the congruence of data obtained using different methods.In 2005, members of 4 community-based organizations in Philadelphia, Pennsylvania, and researchers and staff at the University of Pennsylvania ( Figure 1) established the West Philadelphia Consortium to Address Disparities with funding from the National Center on Minority Health and Health Disparities.⁷ The purpose of our academic–community partnership is to conduct collaborative research to address disparities in chronic diseases that disproportionately affect African Americans in terms of morbidity and mortality using a community-based participatory framework. In keeping with the principles of community-based participatory research, the leaders of each community partner are listed as coinvestigators (R. R., V. B., E. D., J. P.) in the research alongside the academic-based coinvestigators. Moreover, each community partner receives its share of the funding directly. The organizations involved have all worked with academic investigators previously and realized that they share similar interests and could work together in a mutually beneficial way.Open in a separate windowFIGURE 1Overview of mixed-methods approach: West Philadelphia Consortium to Address Disparities, Philadelphia, PA, 2006–2007.Note. COCCDC = Christ of Calvary Community Development Corporation; HPC = Health Promotion Council of Southeastern Pennsylvania; NBLIC = National Black Leadership Initiative on Cancer; Penn = University of Pennsylvania; SWAC = Southwest Action Coalition.We used a mixed-methods⁸ approach that consisted of focus groups, key informant interviews, and a fixed choice community health survey (CHS) with a random sample of residents to identify the health concerns of African American residents in the West Philadelphia community to determine the focus for pilot interventions that the partnership would develop and implement. We describe analyses that were undertaken to determine the extent to which there was consistency in the concerns residents identified using qualitative and quantitative methods, and we offer suggestions for managing inconsistencies that may arise when using a mixed-methods approach.