The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment

Abstract

Background: Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies.

Methods: We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA.

Results: The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality.

Conclusion: The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.

Keywords: Health disparities; Health equity; Healthcare disparities; Implementation framework; Implementation research; Implementation science.

Fig. 1

The Health Equity Implementation Framework explains factors relevant to implementation and disparities in healthcare. In this framework, the innovation is delivered in the clinical encounter. We posit that the clinical encounter is an interaction between recipients (e.g., patient and provider) and the innovation itself (e.g., HIV prevention medication), although the interaction could occur in other settings (e.g., between patient and peer navigator). The Health Equity Implementation Framework identified healthcare system factors, broadly, which most closely aligned with the outer context in i-PARIHS. i-PARIHS specified two other levels within context: inner (local—clinic or unit or ward) and inner (organizational—hospital or network). In the Health Equity Implementation Framework, we highlight that societal influence is especially important to consider when assessing all other factors because of the impact society can have on healthcare disparities. Implementation facilitation, or facilitation, is an essential active process to ignite change to any of the elements or factors