A fundamental goal of implementation science is to integrate research and practice experience in ways that improve the outcomes of those being served (see Estabrooke and colleagues). For this to happen, implementation scientists must work with all communities and embrace the diverse experiences that both drive and shape implementation efforts. This requires an explicit commitment to equity.
Equitable implementation occurs when strong equity components (including explicit attention to the culture, history, values, and needs of the community) are integrated into the principles and tools of implementation science to facilitate quality implementation of effective programs for a specific community or group of communities.
A group of leading implementation researchers, practitioners, and funders gathered at AcademyHealth’s recent dissemination and implementation conference to grapple with how implementation science can support equitable implementation and outcomes. With support from the National Implementation Research Network, the Annie E. Casey Foundation, and the William T. Grant Foundation, participants centered on five themes for taking action:
Shift Implementation Science’s Terminology to Place Different Perspectives on Equal Footing
Participants pushed for implementation research methods to place organizations and community members on equal footing with researchers. As a first step, the group recommended revisiting the terminology of implementation science, which shapes the ideas, measures, and relationships that undergird the work. Participants discussed biases implicit in some of implementation science’s key terms, which then point to a focus for the work. For example, currently “readiness” refers to communities’ readiness to implement but does not consider the researchers’ or developers’ readiness to support implementation or to engage community members and their culture, values or history. Readiness is gauged by a singular perspective, representing a power differential between researchers and communities, and, in turn, has implications for how change efforts unfold.
Employ Strategies and Build Structures that Elevate Equity Concerns
Facilitation and research-practice partnerships are two approaches for bringing equity concerns to the surface, and both can be used to address power dynamics in research-practice relationships. Participants encouraged the use of specific facilitation techniques, team processes, and trainings that effectively promote equitable implementation and enhance equity in outcomes. They were also eager to identify and extend curricula, syllabi, training, and professional development to build the competency of the implementation workforce to use facilitation techniques that support equity and inclusion, as has been done in other areas such as patient-centered outcomes research.
Participants raised the inherent power imbalance toward researchers in current research-practice partnerships, despite the theoretical appeal of the approach. The group encouraged studies that would yield information on factors that contribute to equitable partnerships and recommended using a framework that utilizes equity as a lens. Studies could assess the extent to which partners experienced a sense of fairness and transparency in their work and received and contributed in ways that were expected.
Cultivate Relationships and Trust
There was agreement that social relationships are at the heart of implementation. Participants called for more studies to inform researchers’ understanding of how to cultivate trust; how historic relationships, power dynamics, trauma, and system processes inform those interactions; and what organizational policies and practices build relationships that facilitate equitable outcomes.
Participants also discussed the need for reliable and valid tools to assess trust. They recommended borrowing both theory and assessments from clinical psychology, such as alliance measures, cognitive behavioral theory and psychodynamics. They also highlighted the need for tools to measure the processes that affect relationships and trust at the institutional level. Finally, participants noted that trust is gained slowly, through frequent and sustained interactions. They underscored the importance of funding that allows for the time needed to build the relationships that provide the foundation for the work.
Shift Funding Incentives to Value Practice Expertise and Questions
Participants acknowledged that funding incentive structures favor research and academic expertise. This, in turn, has implications for the types of questions included in requests for proposals, the allocation and distribution of funds and the criteria used to score proposals. These biases are reinforced by what is rewarded in the academy. To move toward more equitable outcomes, institutions need to issue guidelines that reflect equal valuing of different kinds of expertise. For example, it would be useful to compensate community advisors at the same pay rates as research advisors and to provide funds for a process observer or documentarian to provide real-time feedback on the quality of the interactions during the planning and research process. This may increase the likelihood that questions and strategies from the community are represented in the research agenda, measures and interpretation, and integration of findings. Shifting funding incentives for implementation research recognizes and values implementation as inherently a collaborative act and will, therefore, produce knowledge and evidence that is more implementable as described by Rycroft Malone and colleagues.
Promote Exchanges Between Researchers and Community Members
Too often, research and implementation are done to practice and for a community without adequate respect to either. Implementation researchers’ immersion is a key strategy to enhance an understanding of both the context and potential equity issues as part of conducting implementation research. Examples included community-based participatory research and rapid ethnography, which involve field work methods (e.g., observations and interviews) conducted in shorter periods of time given resource and time constraints. Participants explored strategies for students to embed in communities during their education and called for funding opportunities that would allow more established researchers to immerse in practice settings. Key to this immersion is the skill of researchers to collaboratively engage community members in setting joint priorities for research. They noted the need to implement existing knowledge to co-create the research agenda, research process, relationships, and implementation to achieve more equitable outcomes. Participants also noted that, given the spectrum of engagement strategies, it is important to take the lead from those engaging in participatory research and examine under what conditions specific engagement methods are most effective in contributing to equitable outcomes. NIRN and the Annie E. Casey and William T. Grant Foundations are eager to continue the conversation. To learn more, read a Casey Foundation blog post on equitable implementation to improve outcomes for kids, families, and communities.
These five action areas represent a call to action for the implementation science community to expand its role in implementation research and practice as contributors to equitable health outcomes. Execution of the activities described in these five areas would shape what implementation researchers study and how implementation practitioners work with communities, leading to more equitable implementation of effective programs and practices for specific communities.