Health Equity

Dr. Paula Braveman, a leader in the study of health equity defines it as:

“Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.” – Braveman (2017)

Sir Michael Marmot and colleagues at the Institute of Health Equity provide this definition:

“Health Equity means fair opportunity to live a long, healthy life. Inequities in health are not inevitable or necessary; they are unjust and are the product of unfair social, economic and political arrangements.” – Marmot (2010)

Dr. Camara Jones explains that health equity is a process and defines it as:

“Health equity is assurance of the conditions for optimal health for all people. Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need. Health disparities will be eliminated when health equity is achieved.” – Jones (2014)

The creators of this tool acknowledge that health equity is relational and recognize the historical and ongoing injustices of colonialism, racism, sexism, and other processes of discrimination and the imbalance of power and resources between groups that have been structurally privileged and those that have been marginalized and oppressed. Health equity needs to be understood and assessed not just at the level of individuals with respect to their access to prevention and care services and their experience with social determining factors such as income, housing, and health systems. Understanding the influence of the socioeconomic and political context on health including governing structures, social and public policies, and societal norms and values, allows for a broader view of structural factors driving inequity and opportunities for intervention.

Initiatives, programs and policies aimed at improving health equity often focus on certain dimensions – such as addressing health care disparities within a given setting or facilitating equitable participation involving community and academic partners – but do not address all elements of health equity. In applied case examples of how different D&I TMFs are used, we highlight the specific dimensions that are emphasized in each case in order to be clear about their contribution to the pursuit of health equity and at the same time recognize that there are many dimensions that are not being addressed within a specific application.

Health equity dimensions that are not currently reflected or are underrepresented in D&I Science that are common in the broader equity field are:

• Distributive justice
• Resource allocation
• Power and autonomy
• Proportionate universalism
• Intersectionality
• Structural determinants of health

[1] https://www.nimhd.nih.gov/about/strategic-plan/nih-strategic-plan-definitions-and-parameters.html

[2] Institute of Medicine 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/10260.

[3] Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006 Dec;96(12):2113-21. doi: 10.2105/AJPH.2005.077628.

[4] International Collaboration for Participatory Health Research (ICPHR) (2013) Position Paper 1: What is Participatory Health Research? Version: Mai 2013. Berlin: International Collaboration for Participatory Health Research. (Online) http://www.icphr.org/uploads/2/0/3/9/20399575/ichpr_position_paper_1_defintion_-_version_may_2013.pdf

[5] Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health. 2010 Apr 1;100 Suppl 1(Suppl 1):S40-6. doi: 10.2105/AJPH.2009.184036.

[6] International Association for Public Participation (IAP2). (2018). IAP2 public participation spectrum. (Online): https://iap2.org.au/wp-content/uploads/2020/01/2018_IAP2_Spectrum.pdf

[7] https://nccdh.ca/images/uploads/comments/NCCDH-Health-equity-and-the-built-environment-EN.pdf

[8] Governance for health equity in the WHO European Region: taking forward the equity values and goals of Health 2020 in the WHO European Region. https://www.euro.who.int/__data/assets/pdf_file/0020/235712/e96954.pdf

[9] National Collaborating Centre for Determinants of Health. https://nccdh.ca/glossary/entry/marginalized-populations

[10] Hall, J. M., Stevens, P. E., & Meleis, A. I. (1994). Marginalization: A guiding concept for valuing diversity in nursing knowledge development. Advances in Nursing Science, 16(4), 23–41; Baah FO, Teitelman AM, Riegel B. Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review. Nurs Inq. 2019 Jan;26(1):e12268. doi: 10.1111/nin.12268.

[11] Jones CP. Systems of power, axes of inequity: parallels, intersections, braiding the strands. Med Care. 2014 Oct;52(10 Suppl 3):S71-5. doi: 10.1097/MLR.0000000000000216.

• There is a call in D&I Science to increase the emphasis on health equity.
• Ten action steps have been proposed to increase equity in D&I Science:“(1) link social determinants with health outcomes, (2) build equity into all policies, (3) use equity-relevant metrics, (4) study what is already happening, (5) integrate equity into implementation models, (6) design and tailor implementation strategies, (7) connect to systems and sectors outside of health, (8) engage organizations in internal and external equity efforts, (9) build capacity for equity in implementation science, and (10) focus on equity in dissemination efforts.”[1]
• D&I Science has an opportunity to learn from the many disciplines that have contributions to advancing the pursuit of health equity with theories such as: postcolonial theory, reflexivity, Intersectionality, structural violence, and syndemics.[2]
• Community based participatory research has influenced many D&I studies and frameworks. Equitable participation is more prominent in D&I science than other health equity dimensions.

[1] Brownson, R.C., Kumanyika, S.K., Kreuter, M.W. et al. Implementation science should give higher priority to health equity. Implementation Sci 16, 28 (2021). https://doi.org/10.1186/s13012-021-01097-0

[2] Snell-Rood et al. 2021. Advancing health equity through a theoretically critical implementation science. TBM. doi: 10.1093/tbm/ibab008.

The following strategies and considerations can be taken into account when selecting health equity-relevant TMFs:

• Much like when selecting a TMF in general, considerations include key constructs in the TMF and levels of the socio-ecological framework considered.
• Explore examples of the TMF uses in D&I work to identify dimensions incorporated in those studies, settings, and topics to which the TMF may have been applied previously.
• Examine the literature to identify gaps relevant to health equity found in previous work, and how health equity-relevant TMFs may help fill these gaps. This likely requires looking beyond the D&I literature.

The following strategies and considerations can be taken into account when combining TMFs to incorporate health equity:

• Consider similar reasons for combining TMFs described in D&I more broadly. In particular, combining a health equity-relevant TMF with a D&I TMF can support intentionality and enhance conceptualization of health equity in a D&I study.
• Combining a D&I TMF with a health equity-relevant TMF may support selection of methodologies and study designs conducive to supporting equity-focused studies and impact on outcomes that more intentionally integrate health equity.
• One example of a TMF that was designed to be combined with D&I TMFs is the Health Equity Implementation Framework.

The following strategies and considerations can be taken into account when adapting D&I TMFs to incorporate health equity more explicitly:

• To enhance the focus of a study on health equity and integrate this focus throughout a study, it may be possible, for example, to adapt a D&I TMF by including relevant constructs, expanding the way existing constructs are operationalized to explicitly address equity, or modifying the organization of constructs in a process TMF to better reflect an equity focused implementation approach.
• Examples where authors have intentionally adapted a D&I TMF to enhance the focus on health equity can be found here and here.
• It may also be possible to adapt a TMF from a field outside D&I, which already has a focus on health equity to expand its relevance to D&I.

The following strategies and considerations can be taken into account when using health equity-relevant TMFs in D&I:

• To support health equity as an intentional focus throughout a study, incorporating a health equity-relevant TMF is important from designing the study through interpreting and reporting the results.
• Using TMFs goes beyond naming and describing a TMF in the background and/or discussion of a manuscript or proposal. Conceptual guidance from TMFs should be clear in the study aims or research questions, the study design and approach, selection of constructs, variables, or outcomes of interest and measurement of these, framing the study results, and guiding how the findings are translated.
• As constructs in many TMFs (D&I TMFs and health equity-relevant TMFs) are broadly defined, a first step is likely to specify the definition in the construct of the study, then using these specifications to drive all aspects of the study.
• Examples of how researchers have operationalized and applied TMFs with a focus on health equity can be found here.

The following strategies and considerations can be taken into account when assessing equity-related TMFs

• As in D&I more broadly, clearly identifying and defining the construct or variable from an equity-related TMF is necessary for successful assessment. Locate construct definitions from the literature describing the TMF and examples of how equity-related constructs have been assessed in previous studies.
• Use health equity-related TMFs to operationalize construct definitions and assessment targets, and to critically appraise previous assessment approaches for gaps that may inhibit finding answers to equity-related questions.

A more comprehensive listing curated by the Consortium for Cancer Implementation Science Context and Equity in Implementation Science group: Advancing Health Equity through Implementation Science: Bibliography and Resources

Woodward, E. N., Singh, R. S., Ndebele-Ngwenya, P., Melgar Castillo, A., Dickson, K. S., & Kirchner, J. E. (2021). A more practical guide to incorporating health equity domains in implementation determinant frameworks. Implementation science communications, 2(1), 61. https://doi.org/10.1186/s43058-021-00146-5

1. Describes the steps, definitions, examples, and suggests sample quantitative and qualitative measures to incorporate a health equity lens into an implementation determinant framework
2. Recommends incorporating three health equity domains (culturally relevant factors of recipients, clinical encounter or patient-provider interaction, and societal context) within the Integrated Promoting Action on Research in Implementation Health Services (I-PARIHS) framework
3. Describes steps researchers and practitioners could use to integrate health equity domains into implementation determinant frameworks (I.e., select a suitable framework or domains for an implementation disparity problem; Determine implementation determinants; Use domains to develop an implementation mechanistic process model or logic model; use framework determinants to conduct and tailor implementation; & Writing implementation reports or findings)

Brownson, R. C., Kumanyika, S. K., Kreuter, M. W., & Haire-Joshu, D. (2021). Implementation science should give higher priority to health equity. Implementation science: IS, 16(1), 28. https://doi.org/10.1186/s13012-021-01097-0

1. Propose a vision and set of steps for making health equity more prominent and central aim of implementation science to elicit a more equity-focused approach to research and practice
2. Key challenges for health equity implementation science include: 1) limitations of the evidence base; 2) underdeveloped measures and methods; 3) Inadequate attention to context
3. Recommendations to the challenges include: 1) Linking social determinants with health outcomes; 2) Build equity into all policies; 3) Use equity-relevant metrics; 4) Study what is already happening for more practice-based evidence; 5) Integrate equity into implementation models; 6) Design and tailor implementation strategies; 7) Connect to systems and sectors outside of health; 8) Engage organizations in internal and external equity efforts; 9) Build capacity for equity in implementation science; 10) Focus on equity in dissemination efforts

Kerkhoff, A.D., Farrand, E., Marquez, C. et al. Addressing health disparities through implementation science—a need to integrate an equity lens from the outset. Implementation Sci 17, 13 (2022). https://doi.org/10.1186/s13012-022-01189-5

1. Proposes four pre-implementation planning steps and associated guiding questions that have been adapted from the early phases of the Knowledge-to-Action Framework that could elevate health equity throughout all processes represented by implementation science activities and complement the recommendation from Brownson and colleagues (refer to citation above)
2. Proposed four pre-implementation planning steps: 1) Identify important partners related to equity and establish roles for partners throughout the entire implementation process- strong attention to involving individuals from and representing vulnerable populations; 2) Include equity-related considerations when deciding which intervention(s) to implement and de-implement- the strength of the evidence for effectiveness should be considered; 3) Evaluate the performance gap related to the intervention or program of interest in vulnerable populations- the performance gap (I.e., the difference between current and ideal update of an intervention) and outcome gap (I.e., the expected improvement in outcomes including health disparities) should be assessed among vulnerable populations to help determine how much potential there is to reduce health disparities related to quality outcomes; 4) Identify and prioritize barriers faced by vulnerable populations including structural racism and power dynamics- crucial to conduct formative research involving those with relevant lived experiences in conjunction with community partners and other partners to identify barriers to intervention access
3. These steps may help in selecting interventions and associated implementation strategies to best reach and be more effective among vulnerable populations

Snell-Rood, C., Jaramillo, E. T., Hamilton, A. B., Raskin, S. E., Nicosia, F. M., & Willging, C. (2021). Advancing health equity through a theoretically critical implementation science. Translational behavioral medicine, 11(8), 1617–1625. https://doi.org/10.1093/tbm/ibab008

1. Proposes three domains of critical theory relevant to implementation research on health equity that can add nuance and rigor to implementation science
2. Proposed three domains of critical theory: 1) Theories of postcoloniality and reflexivity force attention to the role of power in the production of knowledge, as well as how researchers and interventionists may inadvertently perpetuate inequalities by drawing on biased evidence; 2) Structural violence and intersectionality theory can help in understanding of the unequal burden of health disparities; 3) Theories of policy and governance encourages us to examine the social-political forces of the outer context determining implementation and sustainability
3. The proposed theories give opportunities to rethink the evidence base, help decide which interventions are most worthy of implementation support, and expand understanding of implementation strategies in include structural change

Shelton, R. C., Adsul, P., & Oh, A. (2021). Recommendations for Addressing Structural Racism in Implementation Science: A Call to the Field. Ethnicity & disease, 31(Suppl 1), 357–364. https://doi.org/10.18865/ed.31.S1.357

1. Proposes recommendations for the field of IS to include structural racism as a more explicit focus of work and to consider it as a determinant of equitable implementation of EBIs and implementation strategies
2. Recommendations: 1) Include structural racism in IS frameworks, models, and related measures for research focused on racial/ethnic health disparities and health equity; 2) Use a multi-level approach for selecting, developing, adapting, and implementing EBIs and implementation strategies to address structural racism and impact health inequities; 3) Apply transdisciplinary and intersectional collaborations and engagement as essential IS methods to address structural racism and promote health equity
3. These recommendations should be considered in future research and recommendations expanded on while also addressing structural racism (and its relationship to other forms of racism) to combat the threat it poses on health equity

McNulty, M., Smith, J. D., Villamar, J., Burnett-Zeigler, I., Vermeer, W., Benbow, N., Gallo, C., Wilensky, U., Hjorth, A., Mustanski, B., Schneider, J., & Brown, C. H. (2019). Implementation Research Methodologies for Achieving Scientific Equity and Health Equity. Ethnicity & disease, 29(Suppl 1), 83–92. https://doi.org/10.18865/ed.29.S1.83

1. Examines several methodological approaches for conducting implementation research to advance equity both in our understanding of what historically disadvantaged populations would need (scientific equity) and how this knowledge can be applied to address health equity
2. Methodological framework to approach health disparities for implementation science: 1) Using existing data- make efficient use of existing data by applying epidemiologic and simulation modeling to understand what drives disparities and how they can be overcome (e.g., Agent-based modeling); 2) Including populations with health inequities in new implementation research- implementation researcher would ideally design studies that contain a large proportion of the target disadvantaged populations; 3) Implementation research focused exclusively on populations experiencing inequities- delivering EBIs to populations experiencing high levels of health disparities and allowing for adaptation of the EBIs to new populations and/or healthcare systems for highest public health impact need to consider specific factors of the target group in order to reach those populations
3. Endorses the need for the scientific field to acknowledge the need for equity, so that trainees and established researchers are continually encouraged to address disparities among different communities

Helfrich, C. D., Hartmann, C. W., Parikh, T. J., & Au, D. H. (2019). Promoting Health Equity through De-Implementation Research. Ethnicity & disease, 29(Suppl 1), 93–96. https://doi.org/10.18865/ed.29.S1.93

1. De-implementation is critical for advancing equity: 1) sometimes healthcare overuse adds additional harms from underuse; 2) healthcare overuse is greater by Whites among insured populations and this overuse is subsidized by minority members; 3) experiences of overuse differ by patient subgroups, which requires researchers to approach studying and communicating about overuse different than how we approach underuse
2. Actions to close research gaps: 1) Subgroup analyses-in studies of overuse, include subgroup analyses to understand the association with racial, ethnic or socio-economic subgroups; 2) Specifying and measuring potential mechanisms- under what conditions and why do the double –jeopardy model (patients from racial and ethnic minorities are at higher risk of underuse and overuse of healthcare) and thermostat model (racial and ethnic minorities and other vulnerable subgroups of patients receive less appropriate care and inappropriate care) prevail over another; 3) Testing de-implementing strategies that may mitigate bias- assess whether the interventions themselves have associated disparities and seek ways to address them; 4) Partnerships to successfully promote health equity through de-implementation
3. Moving forward, it would be beneficial for researchers to produce findings that help illustrate and address healthcare overuse-especially about the intersection of de-implementation and health equity

Galaviz, K. I., Breland, J. Y., Sanders, M., Breathett, K., Cerezo, A., Gil, O., Hollier, J. M., Marshall, C., Wilson, J. D., & Essien, U. R. (2020). Implementation Science to Address Health Disparities During the Coronavirus Pandemic. Health equity, 4(1), 463–467. https://doi.org/10.1089/heq.2020.0044

1. Implementation science can help address disparities through guiding equitable development and deployment of preventive interventions, testing, and eventually, treatment and vaccines
2. Implementation science can inform these efforts by: 1) Quantifying and understanding disparities- using implementation frameworks (I.e., understanding historical context, values, culture, and needs of minority populations), behavioral approaches (I.e., designing interventions to improve mask wearing, sheltering in place, and social distancing among minority populations), and metric assessments (I.e., assessing gaps in reach and adoption of interventions in the minority communities) to improve the understanding of the factors driving health disparities; 2) Designing equitable interventions- utilizing tools to guide the design of interventions based on individual, community, and health system-level characteristics to enhance the intervention’s relevance and potential impact; 3) Test, refine, and retest- interventions should be designed for, or (continuously) tested in, racial and ethnic minorities
3. This approach could help tackle health disparities across several conditions in order to ensure that the most vulnerable, but also all individuals have access to, and benefit from, quality healthcare and public health services

Adsul, P., Chambers, D., Brandt, H. M., Fernandez, M. E., Ramanadhan, S., Torres, E., Leeman, J., Baquero, B., Fleischer, L., Escoffery, C., Emmons, K., Soler, M., Oh, A., Korn, A. R., Wheeler, S., & Shelton, R. C. (2022). Grounding implementation science in health equity for cancer prevention and control. Implementation science communications, 3(1), 56. https://doi.org/10.1186/s43058-022-00311-4

1. A greater focus is needed in Implementation science on actively promoting health equity through explicit considerations of social and structural injustices
2. Opportunities for cross-disciplinary, bi-directional, and collaborative learning between the fields of IS and health equity scholarship: 1) Articulating an explicit focus on health equity for conducting and reviewing implementation science; 2) Promote an explicit focus on health equity in theories, models, and frameworks guiding implementation science; 3) Identify methods for understanding and documenting influences on the context of implementation that incorporates on the context of implementation that incorporate a focus on equity
3. Recommendations to ensure progress in bi-directional learning and synergies between the fields of implementation science: 1) Build capacity among researchers and research institutions for health equity-focused and community-engaged; 2) Incorporate health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); 3) Continuing a focus on cross-disciplinary opportunities in health equity and implementation science

Shelton, R. C., Adsul, P., Oh, A., Moise, N., & Griffith, D. M. (2021). Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity. Implementation Research and Practice, 2. https://doi.org/10.1177/26334895211049482

1. Racism is a fundamental driver of racial health inequities, and it is important for implementation science researchers to apply an antiracism lens in implementation research
2. Core elements to applying an antiracism lens in implementation research: 1) Research partner engagement- Applying an antiracism lens in implementation research necessitates early and ongoing inclusion and engagement of communities; 2) Conceptual frameworks and models- an antiracism lens considers racism as a determinant and key aspect of context in implementation frameworks, theories, and models; 3) Implementation of evidence-based interventions: Applying an antiracism lens in implementation research requires the development, selection, and/or adaptation of multi-level and structural interventions that include a focus on health equity and addressing racism; 4) Evaluation approaches- an antiracism lens explicitly includes measures and study designs to assess racism and health equity; 5) Implementation strategies- applying an antiracism lens in implementation research requires application and testing of implementation strategies to advance spread and scale of antiracist, equity-focused solutions
3. Encourage implementation researchers to adopt and integrate antiracism approaches in their research to bring an antiracism lens to several core elements in implementation research and to prioritize and reflect on the impact to health equity

Xiong, S., Abdi, H., & Pratt, R. (2021). 51727 A Systematic Review of Implementation Science Frameworks Used in Cancer Prevention Interventions. Journal of Clinical and Translational Science, 5(Suppl 1), 134–135. https://doi.org/10.1017/cts.2021.744

1. Systematic review of consolidated literature on how implementation science frameworks have been used in cancer prevention services to reduce health disparities
2. The systematic review showed that: 1) us-based studies were disproportionate to non-us based studies indicating a need for cross-fertilization and collaboration with the global research community; 2) Most research was conducted during the pre-implementation or the post-implementation phase resulting in a lack of studies assessing, measuring, and reporting implementation outcomes and a lack of empirical findings on whether the applications of the implementation science frameworks could influence the outcome; 3) There was a limited number of studies that used implementation science frameworks (CFIR being the most common)- indicated that current implementation science frameworks may be limited in their applicability to dynamic and cyclical types of implementations, and the need for implementation researchers and practitioners to integrate implementation science frameworks across the implementation process; 4) Increase the awareness and application of implementation framework decision tools to help researchers and practitioners incorporate an implementation framework into their implementation
3. Implementation research is a growing field and incorporating a health equity component in to the implementation frameworks could help innovations being implemented be more equitable in order to reduce health disparities- specifically cancer disparities