Table 1 Definitions, illustrative examples, and sample measures of the Health Equity Implementation Framework
Domain and determinants | Definition | Illustrative example(s) | Sample measuresa |
|---|---|---|---|
Characteristics of the innovation [31]: • Underlying knowledge sources • Clarity • Degree of fit with existing practice/values • Usability • Relative advantage • Trialability • Observable results • Evidence for the innovation [64] • Research • Clinical experiences • Patient experiences | An innovation is a treatment, intervention, or practice with unique characteristics that determine how such innovations will be applied in a particular setting. Innovations fall into one of the “7 Ps”: programs, practices, principles, procedures, products, pills, or policies [30]. The innovation should be tailored with minor changes or adapted with major changes to the setting’s needs and practices for successful implementation [31, 65]. | A study examined the uptake of the Healthy Heart Kit (innovation), a risk management and patient education resource for the prevention of cardiovascular disease, in a primary care setting. They found that relative advantage (innovation was the most comprehensive tool for cardiovascular health) and observable results (evidence-based practice supports innovation) were more influential to the uptake of Healthy Heart Kit than other characteristics [66]. | Quantitative: • Decision-Maker Information Needs and Preferences Survey • Electronic Health Record Nurse Satisfaction Survey [67] • Reports assessing the current status of implementing the innovation, completed by one clinic point of contact or champion [68] Qualitative: • Barriers and facilitators assessment instrument • General practitioners’ perceptions of the route of evidence-based medicine • Knowledge, attitudes, and expectations of web-assisted tobacco interventions [67] |
*Clinical encounter (patient-provider interaction) | This is the nature of the interaction between patient and provider. This domain is centered on how the patient and provider choose, adapt, and coordinate the conversation to achieve their shared and personal goals concerning health-related matters [40]. The interaction could be influenced by: • Predisposition features which are individual differences that influence communication that may be objective (e.g., age) and subjective (e.g., self-concept). • Cognitive/affective influences that 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 [40]. | In studying recordings of HIV patient-provider encounters, there was less psychosocial talk in patient-provider encounters with Hispanic compared to non-Hispanic white patients [39]. In a study on predictors and consequences of negative patient-provider interactions among a sample of African American sexual minority women, authors found racial discrimination was most frequently mentioned, and gender and sexual orientation discrimination were also related to negative patient experiences [50]. | Quantitative: • Patient and provider questionnaires about relevant demographics to assess concordance/match between patient and provider • Patient rating about the encounter: Interpersonal Processes of Care Survey [39] • Experiences of Discrimination Scale [69] Qualitative: • Patient qualitative interviews about their experience of care [70, 71] Clinical encounters coded using audiotapes, analyzed using the Roter Interaction Analysis System [39] |
Recipients [31]: • Motivations • Values and beliefs • Goals • Skills • Knowledge • Time, resources, support • Local opinion leaders • Collaboration/ teamwork • Existing networks • Learning environment • Power and authority • Presence of boundaries | Recipients are individuals who influence implementation processes and those who are affected by implementation outcomes, both at the individual and collective team levels. Recipients can facilitate uptake of an innovation or resist its implementation [31]. | See below | See below |
*Recipients: providers and staff: Culturally relevant factors include [35]: • Demographics (e.g., neighborhood immigrant status) • Unconscious/implicit bias • Knowledge and attitudes • Skillsets | In a healthcare setting, providers and staff are the people who administer the innovation. A providers’ objectives and beliefs about a patient affect how they behave during the patient-provider interaction [72]. Providers, especially in busy healthcare settings, may be vulnerable to subconscious bias and stereotypes [73]. | Physicians who consider themselves “liberal” spent more time giving more information to patients than those who consider themselves “conservative” [40]. Providers may engage in more detailed conversations about the health status of educated patients, yet provide basic explanations for less-educated patients [40]. During a post-angiogram encounter, physicians perceived patients of lower socioeconomic status as having more negative personality characteristics that include lack of self-control and more negative behavioral tendencies [38]. | Quantitative: • Implicit Association Test to assess implicit bias [48] • Surveys of relevant practice, knowledge, attitudes, or skills [74, 75] • Colorblind Racism Scale [76] Qualitative: • Analysis of taped conversation between provider and patient [39, 48] • Participant observation [77] • One-on-one interviews [78] |
*Recipients: patients: Culturally relevant factors include [34, 35, 45, 79,80,81]: • Medical mistrust • Health literacy and numeracy • Demographics (e.g., neighborhood, immigrant status) • Socioeconomic status, including household income, net wealth, health insurance status, education level • Expectations about therapeutic relationships • Beliefs and preferences | In a healthcare setting, patients are the people (individuals, families, caregivers) who will actually receive the innovation. Culturally relevant factors are associated with health and healthcare disparities and can include demographic factors, beliefs, information, and biological or genetic conditions related to equitable implementation. | Asian American patients in Hawaii participated less in their medical visits than mainland Americans [82]. Patients with more formal educations are more expressive and tend to want to play a role in the decision-making process than less educated patients [40]. Many patients are unsure about their role in the encounter and the appropriateness of their participation [83]. | Quantitative [34]: • Telephone survey of a random sample of residents • Medical Mistrust Index [84] • Measures of underutilization of health services • Health literacy question [85] • Health numeracy question [86] • Appropriated Racial Oppression Scale [87] Qualitative: • Interview about expectations for treatment or the patient-provider-interaction [39, 88] • Interviews about experience seeking care [89] |
Inner context (local) [26]: • Formal and informal leadership support • Culture • Previous experience of innovation or change • Change mechanisms for embedding innovation • Evaluation and feedback processes | The immediate local setting of implementation. Examples include: • Ward • Unit • Clinic • Hospital department | Among 303 providers working in 49 publicly funded health programs for youths, providers’ perception of certain leadership styles was associated with stronger provider willingness to adopt evidence-based treatments [90]. Pisando Fuerte is a fall prevention program linguistically and culturally tailored for Latino individuals at risk for falls. It is adapted from “Stepping On,” an evidence-based fall prevention program. Fidelity to Pisando Fuerte was subpar; when comparing fidelity between the two sites, fidelity was lower in the site that did not give additional time to implement the program (poor leadership support) and had no experience in organizing programs like Pisando Fuerte (no previous experience of innovation) [91]. | Quantitative: • Perceptions of Supervisory Support Scale [92] • Organizational commitment [93] • Readiness for Organizational Change measure [94] • Validated inner setting measures [95] Qualitative [96]: • Site visit • Key informant interviews about inclusivity • Stakeholder meetings or focus groups with providers about their understanding of equitable care • Public forums and listening sessions • Provider and staff interviews to determine actual practice and processes [97] |
Inner context (organizational) [26]: • Organizational priorities • Senior leadership and management support • Culture • Structure and systems • History of innovation and change • Absorptive capacity • Learning networks | The organizational atmosphere in which the unit or team is embedded. | Hospitals’ adoption of the Culturally and Linguistically Appropriate Services standards focused on retaining translators and adapting culturally and linguistically appropriate materials. However, this adoption did not often include engagement in broader organizational change [98]. Researchers studied a disparity-reduction program in Israel across 26 clinics and 109 clinical teams. After 3 years, they found different inner context configurations of factors predicting disparity reduction. One example of a successful configuration was clinics with a large disparity gap to minimize, high clinic density, high perceived team effectiveness, and focused efforts on tailoring services to their enrollee patients [99]. | Quantitative: • Measures of organizational readiness for change [100] • Cultural Competency Assessment Tool for Hospitals [98] Qualitative [101]: • Key informant interviews assessing knowledge/action of policies about equity • Key informant interviews assessing beliefs organization holds about marginalized people • Stakeholder meetings about the importance of equitable care • Public forums and listening sessions [102] • Focus groups |
Outer context (healthcare system) [26]: • Policy drivers and priorities • Incentives and mandates • Regulatory frameworks or external accreditation systems • Inter-organizational networks and relationships | This is the broader context defined in terms of resources, culture, leadership, and orientation to evaluation and learning. There is an increasing amount of research that shows that inequities in obtaining preventative care among racial and ethnic minorities compared with non-Hispanic whites are due to “organizational characteristics, including location, resources, and complexity of a clinic or practice” [35]. | Researchers examined predisposing, enabling, and need factors as predictors of changes in healthcare utilization and found that patients’ experiences differed by group within the healthcare system and impacted their beliefs and attitudes about receiving healthcare, ultimately affecting the extent to which healthcare services were utilized [50]. | Qualitative: • Archival analysis, reading and documenting policies, program manuals, or procedural protocols [103, 104] • Interviews with leadership [99] Quantitative: • 15 core measures of healthcare qualit y[105] • Population surveys • Social network analysis of 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] |
• Economies • Physical structures • Sociopolitical forces • Up-, mid-, or downstream social determinants of health [44] | Forces outside the healthcare system that influence all other domains and determinants of implementation may include but be broader than social determinants of health, may focus on the presence of stigma and discrimination such as racism, classism, or transphobia (as examples) and the institutionalization of such discrimination in every determinant of implementation.b,c | See below | See below |
*Economies [53]: • Traditional • Command • Market • Mixed | The structure of the city, state, or country related to the wealth and resources of people and what is exchanged for healthcare delivery (e.g., insurance). This can be divided into human resources (i.e., labor, management) and non-human resources (i.e., land, capital goods, financial resources, and technology) [55]. | In a study assessing longitudinal effects of health insurance and poverty, researchers reported low-income, middle-aged adults in the U.S. with no insurance, unstable coverage, or changes in insurance have higher out-of-pocket expenditures and financial burdens than public insurance holders [107]. In a case study, the presence of chronic kidney disease indicators in the pay-for-performance system in primary care created an incentive for improvement [26]. | Quantitative: • Insurance claims data • Gross domestic product [108] • Gross national product [109] • Minimum wage [110] • Population and total employment [111] • Annual average wage level of the primary, secondary, and tertiary industries [112] • Tax revenue as a percentage of total revenue [113] • Interest rate on saving deposits and inflation rate [114] Qualitative [115]: • Key informant interviews about goods and services exchanged [116] • Analysis of comparative economic structure [115] |
*Physical structures: • Location • Availability of public transportation • Actual environment of the point-to-care • Language spoken and/or signage • Available structures in one’s neighborhood to use innovation • Grocery stores • Healthcare facilities • Local businesses • Physical infrastructure | The physical environment, structure, location of services, and recipients, also known as the built environment as it relates to equitable implementation [55]. | One study compared Black and White Americans who were exposed to the same set of socioeconomic, social, and environmental conditions in an area of one U.S. city. Although there is robust research documenting disparities in hypertension, diabetes, obesity, and use of health services by race among national samples, within the racially integrated city in the study, disparities in these health conditions were either absent or significantly smaller. Thus, the place where people lived had an impact on their health conditions, beyond race [117]. In a qualitative study of transgender individuals’ experiences in residential addiction treatment, researchers observed that residential facilities that split the milieu and housing based on the gender binary may be stigmatizing people who identify as transgender or gender non-conforming [118]. | Quantitative: • Indices of segregation [119]b • Public data such as hospitals per capita, public transportation trips per capita, car ownership, revenue dedicated to parks and recreation, transportation, other infrastructure needs, and grocery stores per capita • Center on Budget and Policy Priorities data • State Departments of Finance and Administration [55] Qualitative: • Windshield and walking surveys include assessing infrastructure; surveyors are on foot and take note of the neighborhood related to the physical or built environment [120]. |
*Sociopolitical forces [41, 43, 57]: • Policy climate • Political support • Laws • Local culture • Social movements or structures such as racism, classism, heterosexism, transphobiac | Policies and procedures, formal or informal, in national and local governments that systemically inhibit or promote equitable health. | In a U.S. study on the adoption of behavioral health evidence-based treatment by states, the following were some factors that played a role: state characteristics, state fiscal supports to promote innovation adoption, and state policy that supports to promote evidence-based treatment adoption [57]. | Quantitative: • Select measures of determinants of policy implementation, such as visibility of policy actors or policy implementation climate [121] • The State-Level Racism Index [122]b Qualitative: • INCLENS equity lens: examines whether clinical guidelines address health needs and inequities experienced by marginalized groups [123] • Interview questions with recipients about laws, policies, or social movements relevant to the innovation |