Implementation Science & Equity

When building the Framework for Effective and Equitable Implementation in Aotearoa (FrEEIA) tools there were a number of key concepts that we considered. These are outlined below, along with links to material to help people get a deeper understanding of equity and implementtion science.

1. What is equity and why is it important?

‘Equity is the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (e.g. sex, gender, ethnicity, disability, or sexual orientation)’ (World Health Organisation)

‘In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage may require different approaches and resources to get equitable outcomes’ (Ministry of Health/Manatū Hauora, 2018)

Two important components of these and other definitions are that (Braveman & Gruskin, 2003):

Equity is an ethical concept as it refers to fairness, or social justice. There are health disparities that are not unfair or unjust (for example people assigned male at birth have greater morbidity and mortality from prostate problems than people assigned female at birth because people assigned female at birth do not have prostate glands). These are health inequalities. Health inequities, on the other hand, result in people who already experience social disadvantages being subjected to further disadvantage with respect to their health, and ultimately their wellbeing.

Equity is consistent with human rights principles, and hence the right to ‘the highest attainable standard of health’ (World Health Organisation, 1946). Practically this can be benchmarked by looking at the standard of health achieved by the most socially advantaged groups in society. In Aotearoa New Zealand, the right of Māori to this standard of health is protected under te Tiriti o Waitangi (Ministry of Health/Manatū Hauora, 2018) and can be operationalised by a focus on equity. Consequently, equity is one of the Treaty principles identified by the Waitangi Tribunal for the primary health care system (Waitangi Tribunal, 2023).

Health equity occurs when health systems, programmes or services are designed to meet the needs of the entire population, which includes underrepresented groups. Conversely, inequities in health are created over time when these same health systems, programmes or services are not designed to respond to the diverse needs of the population. Services that are not designed to meet everyone’s health needs (both physical and mental), circumstances and preferences (including kaupapa Māori and whānau centred services) result in inequitable access to care/services and/or inequitable health outcomes (Ministry of Health/Manatū Hauora, 2023).

2. What is equitable implementation?

Equitable implementation of health services and interventions needs to be planned. Not everyone has the same resources or opportunities for attaining good health, therefore the implementation of health interventions needs to account for social disadvantage and injustice. This should be reflected in the allocation of resources and the design of policies and programmes (Braveman & Gruskin, 2003; Brownson et al., 2021). For equitable implementation to be more likely to succeed, individuals, teams and organisations need to be ready to implement change, and this means being both willing and able (Weiner, 2009)

3. What is equity readiness?

The concept of equity readiness has come from the field of organisational readiness and refers to the conditions necessary for an intervention to achieve equity. Equity readiness has dynamic components: motivation, intervention-specific capacity, and organisational capacity (Scaccia et al., 2015). Looking at each of these components (and identified sub-components) separately can help to identify motivation- or capacity-building strategies that will enhance equitable implementation. Equity readiness can vary between different levels of analysis (individuals, groups of individuals, the organisation as a whole) and can change over time (Scaccia et al., 2015; Weiner, 2009). It should therefore be monitored throughout the implementation life cycle.

4. What is implementation science and why are implementation barriers and facilitators important?

Implementation science considers a ‘thing’ – what we refer to in this User Guide as an intervention. While effectiveness research concerns itself with whether ‘the thing’ works, implementation science looks at how best to do ‘the thing’. Therefore implementation science outcome measures relate to the quality and extent of implementation rather than clinical (or other types of) outcomes of ‘the thing’, or intervention, itself (Curran, 2020).

Barriers and facilitators refer to the various factors influencing implementation in the real world context (Fernandez et al., 2022). Identifying these factors is closely associated with the concept of organisational readiness and allows individuals, teams and organisations to consider potential solutions, or implementation strategies. Implementation strategies are therefore actions we might take to improve delivery of ‘the thing’ (Curran, 2020). This is important because if there are inequities in the delivery of a health intervention, then this can worsen already existing health inequities. In implementation science, theories, models and frameworks are used to help understand and/or explain barriers and facilitators, to look at implementation processes, and to guide the selection of implementation strategies, amongst other functions (Nilsen & Bernhardsson, 2019).

Resource list

Measuring organisational health equity readiness

LoCurto, J., Lange, B.C.L., Iverson, M.G. et al. A Systematic Review of Organizational Assessments Related to Racism and Equity. J. Racial and Ethnic Health Disparities (2023) [CLICK to access]

Marcus, R., Monga Nakra, N., & Pollack Porter, K. M. (2023). Characterizing Organizational Health Equity Capacity Assessments for Public Health Organizations: A Scoping Review. Public Health Reports, 139(1), 26-38. [CLICK to access]

Health Equity

Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of epidemiology and community health (1979), 57(4), 254-258. [CLICK to access]

Braveman, P., Arkin, E., Orleans, T., Proctor, D., Acker, J., & Plough, A. (2018). What is Health Equity? Behavioral Science & Policy, 4(1), 1-14. [CLICK to access]

Ministry of Health/Manatū Hauora. (2018). Achieving Equity in Health Outcomes: Highlights of important national and international papers. [CLICK to access]

World Health Organisation. Health Equity: Overview. [CLICK to access]

Implementation Science

Brownson, R. C., Kumanyika, S. K., Kreuter, M. W., & Haire-Joshu, D. (2021). Implementation science should give higher priority to health equity. Implementation Science, 16(1), 28.[CLICK to access]

Curran, G. M. (2020). Implementation science made too simple: a teaching tool. Implementation Science Communications, 1(1), 27. [CLICK to access]

Gustafson, P., Abdul Aziz, Y., Lambert, M. et al. A scoping review of equity-focused implementation theories, models and frameworks in healthcare and their application in addressing ethnicity-related health inequities. [CLICK to access]

Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science, 10(1), 53. [CLICK to access]

Organisational Readiness

Miake-Lye, I. M., Delevan, D. M., Ganz, D. A., Mittman, B. S., & Finley, E. P. (2020). Unpacking organizational readiness for change: an updated systematic review and content analysis of assessments. BMC Health Services Research, 20(1), 106. [CLICK to access]

Scaccia, J. P., Cook, B. S., Lamont, A., Wandersman, A., Castellow, J., Katz, J., & Beidas, R. S. (2015). A practical implementation science heuristic for organizational readiness: R = MC2. Journal of Community Psychology, 43(4), 484-501. [CLICK to access]