Opportunities to Advance Health Equity through Implementation Science

Never before has public health become such a part of our daily discourse. Living in a global pandemic, with every infection we are reminded of how interconnected we are as a community, nation, and world. It is also in this pandemic where we are witnessing stark inequalities that have been magnified by differences in access to resources and racial injustices which have been shaped and enforced by physical, historical, and social structures in our daily lives.

In response to these inequalities, there has been an urgency in prioritization of health equity from the broader public and from our own research and practice community. As an implementation science (IS) community, this new year is an opportunity to actively engage in how we tackle this as a field in cancer prevention and control.

As we do so, here are a few questions I would like to pose for us to consider in the new year.

1. How can we incorporate social determinants of health (SDoH) into implementation science studies?

   Social determinants of health (SDoH) are the conditions in which people are born, grow, live, work, and age, including the health system, and these conditions are shaped by historical and contemporary policies, law, governance, investments, culture, and norms. These determinants shape health inequalities. Patterns of social disadvantage such as adverse working and living conditions are associated with unhealthy lifestyle behaviors and poor health outcomes in cancer prevention and control. In IS there is an opportunity to build on this evidence by incorporating structural, community, and health system determinants in the development and testing of implementation strategies that may drive population health goals for achieving equitable implementation of EBIs. Several models in IS have emphasized this need to examine SDoH and multilevel approaches to advance health equity through IS (Woodward et al 2019, Baumann et al 2020, Shelton et al 2020, Eslava-Schmalback et al 2019). As we move forward, learning more about application of these models will help to build an evidence base around this work. At NCI, multilevel approaches and interventions have been a priority in epidemiologic, surveillance, and behavioral research (Warnecke et al 2008, Srinivasan et al 2014, Hall et al 2018). This emphasis is highlighted in multiple funding opportunity announcements including reference to examination of individual, family, health care, community, and policy-level factors and relationships across levels. NCI colleagues leading these efforts can work with investigators interested in these funding opportunities. Training opportunities are also offered in conducting multilevel intervention research, led by the NCI Healthcare Delivery Research Program through the Multilevel Intervention Training Institute.

2. What goals can we set as a community of scientists to promote meaningful community participation and engagement in implementation of evidence-based interventions for cancer prevention and control?

   The voice of the community as an equal partner in research is a tool for advancing equity. Some have even called community engagement a key ingredient in an ethical approach to science. But not all engagement is created equal or consistently defined, and trusted relationships can take time and investment to cultivate and sustain. There are various approaches by which researchers have engaged with community in public health and in implementation science. Several networks have been exploring this further in the intersection of cancer control and implementation science. The Implementation Science Consortium in Cancer’s workgroup on Community Engagement is a great forum for identifying tools, approaches, and exchange practices for advancing community engagement in implementation science. This is an open membership consortium hosted by NCI. Another resource is the CDC’s Cancer Prevention and Control Research Network. This network has a history of creating trusted relationships with community partners to conduct, promote, share, and translate equity-oriented knowledge and practices; open-access resources and tools are freely available on their website.

3. What are the opportunities to leverage multisectoral collaboration?

   Leveraging effective multisectoral collaboration and development of complementary implementation strategies across sectors presents an opportunity for sustained population health impact and broader stakeholder engagement. The ongoing NCI IS policy webinar series has highlighted this, including opportunities to contribute to building the science on policy implementation. In the Division of Cancer Control and Population Sciences (DCCPS) we have emphasized many other non-traditional partners in addressing health disparities and interventions within social and physical structures that shape health. For example the NCI Tobacco Control Research Branch’s portfolio in tobacco-free housing and smoke-free policies, the related health equity PAR, and the DCCPS work in geospatial research, highlighting the role of place-based factors on health, have all encouraged and identified research opportunities outside of usual health care settings.

4. How are we examining power in science?

   In many definitions of equity, power is an important construct and phenomena. The discourse on power in science has been ongoing in behavioral and social science research, and this work can inform how we think about engagement, translation, and equity. A consideration for all the roles in the research process (e.g., who holds the power and who doesn’t) can impact achievement of goals for equitable implementation and efforts to not exacerbate disparities. While there is more evaluative work to be done, it may be important to consider the implications of reframing power as an essential element in understanding and conducting health equity research. By explicitly defining power at the intersection of identity and context, we may be better able to investigate decision making, behavior, and other implementation processes and how work is disseminated.

5. What are ways we can learn across contexts and settings?

   Collecting and sharing data across the portfolio of research on context, implementation outcomes, and testing of programs will advance our opportunities to learn more rapidly across settings and populations about adoption, adaptation, and sustainability. NIH’s call for data sharing and the NCI Cancer Moonshot’s data sharing policy are unique opportunities for investigators and partners to give data back to the patients and communities and to learn from each other. These efforts are enhanced when the field can exchange innovations in measurement and analytics and identify common data elements across studies.

6. What is our role in equitable communication of information and knowledge translation?

   Health communication science is essential in transdisciplinary approaches to addressing health equity in IS. It is our responsibility to communicate and disseminate our research findings with our communities, patients, and other stakeholders. Are we guilty of only talking to ourselves and sharing our knowledge within our own echo chambers? Does the language of equity open partnerships? What are the barriers to effective communication? Approaches such as user-centered design or community engagement to develop messages will be important for relevance to our audiences in ways that speak to goals and values, culture, language, and literacy, and are consistent with message goals. The NCI Health Communication and Informatics Research Branch has been a leader in articulating opportunities and an agenda for this work, including development of research priorities and identifying ways to consider health communication in development and dissemination of implementation strategies.