Charting A Path Forward Toward Integrating Macrolevel Phenomena, Marginalization, and Health Equity Principles In into Dissemination and Implementation Science

Abstract

Dissemination and implementation (D&I) science is ascendant within public health in the United States, but D&I scientists have long voiced concern at their field’s capacity to fulfill two essential and intertwined public health responsibilities: analyzing and intervening in macrosocial determinants and achieving health equity.

To help break this impasse, we explore D&I’s theoretical roots by critically reviewing three historical eras, eras that D&I’s origin story has identified as foundational to D&I’s development:

1890–1903: Tarde’s Laws of Imitation

1920–1960: Rural Sociology

1960–1980: Knowledge Utilization Research.

Our racism-conscious disciplinary self-critique reveals that, as elsewhere in public health, D&I became ascendant in part by developing an “epistemology of ignorance” that has acted in service to racial capitalism - that is, D&I has developed a structured way of (not) knowing that systematically suppresses evidence about racial capitalism and its consequences. Each of D&I’s foundational eras was characterized by marked transitions in racial capitalism, in which macrosocial phenomena produced novel forms of marginalization that in turn engendered mass resistance (e.g., industrialization and imperialism; farming crises). In response, D&I’s forebears crafted explanatory frameworks (e.g., Diffusion of Innovation) that obscured these transformational macrosocial phenomena, reinforced the marginalizations that they produced, and diverted attention toward atomistic individual-level phenomena. These frameworks have helped foster an epistemology of ignorance within D&I about macrosocial phenomena, marginalization, and health inequities that persists to this day.

We propose that D&I has an opportunity to forge another era now in which it partners with critical social scientists, practitioners, activists, and people with lived experience to bring macrosocial phenomena, marginalization, and health inequities more firmly into its orbit. We close with principles to guide the development of this era that are rooted in learnings from D&I’s history and Public Health Critical Race Praxis.

Introduction

Dissemination and implementation (D&I) science is ascendant within public health in the United States (US), but US D&I scientists have repeatedly voiced concern at their field’s capacity to fulfill two essential and intertwined public health responsibilities: analyzing and intervening in macrosocial determinants, and achieving health equity.^1–11 D&I emerged in the late 1990s to resolve a challenge:¹² though the US had spent billions to develop effective public health interventions, far too few had been implemented in “real world” settings.^3,13 The roots of this challenge lie, in part, in intervention research’s historical neglect of the contextual complexities of intervention implementation.^1–4 Designed as a paradigm shift that responded to this challenge, D&I seeks to place “context at its center” by advancing “the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies” in community and clinical contexts.^{5, p. 134}

At its essence, then, D&I exists to help the public survive and thrive by ensuring that scientific discoveries reach communities to transform lives. To date, D&I has documented patterns of reach, adoption, implementation, and sustainment of evidence-based interventions (EBIs) (Table 1 defines underlined terms), and investigated their determinants.^1,7,14–18 D&I categorizes these determinants into barriers and facilitators that lie in the intervention, implementing individuals, the implementing organization, and the broader environment in which the organization is embedded. D&I scientists then develop and test strategies to overcome barriers and enhance facilitators to equitable implementation. Over the last decade, US public health agencies, scientists, and practitioners have embraced D&I’s potential: National Institutes of Health institutes have embedded D&I into their strategic plans,¹⁹ and D&I publications have soared.²⁰ Investments are substantial: one institute (National Cancer Institute) invested $93 million in D&I in 2000–2012 alone.²¹

Table 1. Definitions of Select Dissemination & Implementation Science Terms (verbatim from⁶⁹).

Term	Definition
Evidence-based intervention (EBI)	Interventions that have been proven effective
Implementation	“intervention agents’ fidelity to the various elements of an intervention’s protocols”
Adoption	“The absolute number, proportion, and representativeness of: a) settings; and b) intervention agents (people who deliver the program) who are willing to initiate a program”
Reach	“The absolute number, proportion, and representativeness of individuals who are willing to participate in a given initiative, intervention, or program”
Sustainment	“The extent to which: a) behavior is sustained 6 months or more after treatment or intervention; and b) a program or policy becomes institutionalized or part of the routine organizational practices and policies.”

For years, however, D&I scientists have expressed concern that their paradigm shift toward context has faltered at the organizational threshold, poorly engaging the universe operating outside organizational walls.^{2–4,6,8–10} In particular, D&I has engaged poorly with “macrosocial phenomena” – defined here as macrolevel policies, systems, and processes, and place characteristics that may shape health but are not overtly designed to do so (e.g., racial capitalism, heteropatriarchy, class exploitation). When engaging with context at all, D&I research has maintained a persistently narrow focus on organizational phenomena (e.g., staff champions) and on health policies that are intentionally designed to shape health and healthcare infrastructure (e.g., Medicaid Expansion).⁴

D&I’s limited engagement with macrosocial phenomena is inextricably intertwined with its elision of health inequities in EBI reach, adoption, implementation, and sustainment.^6–8,10,11 Per the Intersectionality framework, macrosocial phenomena are essential to the process of producing dominance and marginalization, because they unjustly distribute hazards and resources across and within populations.^22,23 Unjust distributions of hazards and resources, in turn, create health inequities. Because dominance and marginalization are intersectional – that is, gender, race, class, citizenship and other dimensions of social position are mutually co-constructing – the health inequities dominance creates are as well.^22,23 D&I cannot help eliminate health inequities without first reckoning with the macrosocial phenomena – essential dimensions of context – that produce them.

Here, we seek to help fully realize D&I’s promise by charting paths toward more comprehensively integrating macrosocial phenomena, marginalization, and health inequities into D&I’s orbit. We focus on D&I’s theories of the determinants of implementation outcomes (“determinants theories”) because D&I has placed theory at its center. Theories are powerful. Derived from the Proto-Indo-European root for “perceive” (wer-), each theory, regardless of discipline, is designed to direct attention toward select constructs and their inter-relationships that it deems meaningful, and cast all others into shadow.

Given the content of D&I’s omissions (macrosocial phenomena, marginalization, and health inequities) and ongoing frustration within D&I about slow progress toward remedying them, we propose that they exemplify an epistemology of ignorance.²⁴ True to its etymology (i.e., in=not, and gno=know), an epistemology of ignorance is a structured way of “not knowing” that obscures a particular form of marginalization and its consequences.²⁴ Dominant classes develop and champion these epistemologies to maintain their dominance by concealing its reality and toll.^24,25 Here, we propose that this epistemology of ignorance is one of many in public health that supports racial capitalism in the US. Racial capitalism is a political economic system that generates and sustains marginalization to channel economic, social, and political power toward disproportionately White owners of wealth, through expropriation and exploitation.²⁶ Expropriation refers to the (unremunerated) confiscation of labor, land, personhood, knowledge, and other resources from marginalized populations (e.g., occupation of tribal lands, enslavement, women’s unpaid domestic labor).²⁷ Exploitation refers to waged labor of putatively free people who receive subsistence wages while surplus value is siphoned off to accumulate wealth.²⁷ We argue that D&I’s suboptimal engagement with these processes and their impacts is a form of epistemic ignorance. Mills’ concept of “the racial contract” challenges us to deepen this argument: he posited that dominant groups preserve this ignorance in exchange for conserving the systems that support them/us. Notably, racialized processes of capital accumulation, particularly in the knowledge economy and market of health services, are inextricably intertwined with the construction of gender and other dimensions of social position; the racial contract likewise extends beyond race to encompass these other dimensions as well.

We trace the arc of this epistemic ignorance – an arc that upholds the racial contract - across D&I’s origin story. Origin stories are essential to identity formation for emerging fields: fields recite origin stories to communicate unspoken assumptions that undergird their present-day theories, methods, and substance.²⁸ D&I articles invoke three eras in their origin story:

• 1890–1903: Tarde and the Laws of Imitation;

• 1920–1960: Rural Sociology and Diffusion of Innovation; and

• 1960–1980: The Great Society and Knowledge Utilization Research.¹³

Critical review of these three eras reveals that each was roiled by macrosocial phenomena that created new forms of exploitation and expropriation, which marginalized populations mobilized to challenge. In each era, D&I’s forebears upheld the racial contract: they acted in service to these emerging forms of racial capitalism, by creating epistemologies of ignorance that obscured the attendant macrosocial phenomena and reinforced the marginalizations they created.

We propose that our current decade – characterized as it is by intensifying racial capitalism, surging marginalization, and soaring health inequities – has the potential to become another era in D&I’s origin story, an era that is dedicated to breaking the racial contract through an “epistemics of resistance,” that is, committed to ways of knowing that “interrogate, disrupt, [and] counter hegemonic…assumptions.”⁷ In this 4^th era, D&I could acknowledge and repair these past patterns by altering its determinants theories and other key components to far more effectively reckon with macrosocial phenomena and health inequities. We close with principles to guide the development of this era, rooted in Public Health Critical Race Praxis.

Epistemologies of Ignorance: Macrosocial Phenomena and Equity

Almost since its inception, D&I scientists have voiced alarm at their field’s neglect of macrosocial phenomena. In 2008, Raghavan and colleagues argued that D&I must evolve to encompass the entire “implementation ecology,”^{2, p. 2} including societal stigma and social policies, to be effective.² Glasgow and colleagues echoed this critique four years later:

Many of the current approaches to D&I…[underemphasize] the value of context…We know that … 80% [of the variation in health outcomes ] is determined by factors outside the [healthcare] system, including social and environmental influences.^{3, p. 1278}

Seven years later, Nilsen and Bernhardsson’s review of whether and how D&I determinants theories encompassed “context” revealed ongoing neglect of macrosocial phenomena.⁴ This review identified 17 determinants frameworks, which collectively conceptualized 12 “contextual” domains. Most “contextual domains” pertained to organizational phenomena.⁴ Only one – the “wider environment” domain – explicitly and exclusively pertained to macrosocial phenomena.⁴ Most constructs within this “wider environment” domain, in turn, were intentionally designed to shape healthcare systems and health; this domain thus ignored the universe of macrosocial phenomena that might shape implementation outcomes but were not designed to do so (e.g., residential segregation). This problem persists. A 2023 review by Escoffery et al of all D&I theories found that just 54% included even one contextual construct.⁹

In recent years, D&I scientists have observed that their field suffers a second systematic flaw: weak engagement with marginalization and health inequities, a weakness that extends to evidence, methods, and measures.^1,5,14–18 While several existing determinants theories have been revised recently to better encompass context and equity (e.g., CFIR/CFIR 2.0, REAIM/PRISM) these updates may not enhance evidence. A recent review of EPIS (Exploration, Preparation, Implementation and Sustainment), a framework offering a more comprehensive conceptualization of context than most, indicates that macrosocial applications remain suboptimal.²⁹

What is at stake if D&I continues to stumble at the organizational threshold and grapple ineffectively with inequities? Not only will D&I fail to fulfill its core public health mission of eliminating inequities, D&I projects will actively widen them. Inequitable social systems – such as White supremacy and heteropatriarchal systems – are potent macrosocial phenomena within racial capitalism that profoundly shape whether organizations serving marginalized populations are able to implement, adapt, and sustain EBIs, and whether EBIs actually reach people in need. Ignoring these phenomena perpetuates their pernicious influence on inequities. Moreover, these inequities deepen with each effective D&I intervention that disproportionately supports dominant groups and the organizations that serve them. Eliminating health inequities is predicated, in part, on bringing macrosocial phenomena more firmly into D&I’s orbit.^1,5,14–18

Origin Stories, Epistemologies of Ignorance, and Racial Capitalism

We next trace the origins of these present-day omissions across three eras that figure prominently in D&I’s origin story:

1890–1903: Tarde and the Laws of Imitation,

1920–1960: Rural Sociology and Diffusion of Innovation, and

1960–1980: The Great Society and Knowledge Utilization Research.¹³

We describe the manifestations of racial capitalism and related mobilizations in each era, to lend weight to the possibility that D&I’s forebears had opportunities to engage deeply with both but instead collectively forged an epistemology of ignorance in D&I that exists in service to racial capitalism. (NB: this section does not discuss health inequities because this work did not encompass health).

1890–1903: Tarde and the Laws of Imitation

Gabriel Tarde (1843–1904) is widely recognized as the father of D&I.^13,30 Published in 1890, his Laws of Imitation model posited that innovation and imitation – two eventual pillars of D&I – were the foundations of social life.^13,31 Tarde viewed societies as aggregations of individuals, and conceptualized innovation and imitation as essential processes that linked individuals to one another in these atomized societies. He posited a top-down model of innovation development and diffusion: innovations – so essential to the formation of societies – were developed by “people with original ideas (intellectuals, artists, creators)”and then spread to individuals in “less-educated classes (proletariats, farmers)” via imitation, defined as “the influence of one brain upon another brain.”^{32, p. 491 31} Tarde developed this model to explain crimes committed by crowds, and dedicated much of his career to explaining the behavior of crowds or “foules” (mobs). He viewed them pejoratively, positing that individuals in crowds regressed toward animalistic, highly emotional states, and describing them using dehumanizing language (e.g., “savage”).³³

His contemporary, Emile Durkheim, fiercely contested Tarde’s proposition that societies were mere agglomerations of individuals.^31,34 Durkheim argued instead that each society is an entity independent of its constituent individuals, possessing a distinct biography and set of “social facts” – many of which we might call “macrosocial phenomena” – that powerfully shaped the course of individual lives. Durkheim dedicated a chapter of his book Suicide to refuting Tarde’s model,³⁴ developing and comparing multiple maps of suicides and of various macrosocial “social facts” (e.g., anomie, religious composition), and ultimately concluding from these geographic analyses that his “social facts” model out-performed Tarde’s atomistic “brain-to-brain” model.^31,34

Essential arguments were, however, notably absent from Durkheim’s critiques. Perhaps most significantly, Tarde’s model suppressed the true purpose of the very crowds it was designed to explain. During Tarde’s lifetime, crowds mobilized globally to contest emerging forms of capitalist exploitation and expropriation – macrosocial innovations in and of themselves – that were emerging in France, and their attendant marginalizations. French industrialization reignited empire, and by 1850 France had colonized 110 million people in western Africa and Southeast Asia;³⁵ France enslaved more than one million people in its African colonies during these years,³⁶ and also altered the meaning of gender in these colonies by enforcing rigid gendered hierarchies where previously gender roles had been complementary.³⁷ French arts, science, and politics mobilized to uphold the racial contract, justifying empire by saturating the public with dehumanizing White supremacist images of its newly colonized subjects as “savages” and “beasts.”³⁵ Millions of racialized, colonized, and gendered people mobilized for sovereignty and survival against the innovations of colonialism and White supremacy, and forced France to wage – and sometimes lose - wars on fronts as far-flung as Tahiti, Senegal, Vietnam, and Algiers.³⁵

These colonies generated the raw materials to fuel France’s domestic industrialization, and this escalating industrialization catapulted France’s White workers into an emerging economy of starvation wages and lethal labor conditions. In response, crowds of White working-class protesters seized Paris in 1871 and built a social democratic government – an innovation in and of itself worthy of study – that suspended rent, abolished child labor, and transferred ownership of abandoned factories to workers.^{38 39} White working-class women fought for equal wages and political and social rights, when factory jobs introduced gender inequalities in pay.^40,41

Tarde’s contemporaries and immediate predecessors – including W.E.B. du Bois and Karl Marx^42,43– analyzed these mobilizations as globally transformative uprisings designed to overthrow the innovations of industrialization and colonization and their consequent marginalizations. Though Tarde’s legacy is complex,⁴⁴ for D&I Tarde inaugurated a particular interplay of epistemic and political power that would persist through the next two eras of this field’s origin story: (1) obscure macrosocial phenomena that support novel forms of racial capitalism and create marginalization – here, by ignoring the very existence of the “social facts” inciting the crowds Tarde sought to explain; (2) replace macrosocial phenomena with atomistic explanations – here, by denying that society exists beyond “brain-to-brain” flows of innovation and imitation; and (3) reinforce marginalization – here, by producing a theory that bolstered racial capitalism by framing innovations as produced by elites and framing protesting crowds as “savages” driven by bestial emotion, rather than as communities astutely analyzing emergent macrosocial phenomena that marginalized them and mobilizing to end that marginalization.

1920–1960: Rural Sociology and Diffusion of Innovation

The next chapter in D&I’s origin story, and in its developing epistemology of ignorance, lies in the mid-century US (1920s-1960s), when the US Department of Agriculture (USDA)’s Farm Bureau funded rural sociologists to explain the diffusion of farming innovations.^45–47 These rural sociologists were primarily located within agricultural economics departments in Land-Grant universities, and thus isolated from Durkheim, Du Bois and Marx’s descendants in sociology departments.^45–47 In this setting, they revived Tarde to develop the Diffusion of Innovation (DOI) model. DOI conceptualized diffusion of agricultural innovations as a multiphase process that starts when an individual becomes aware of an innovation, develops an interest in it, evaluates it and experiments with it, and integrates it into continued use.^48,49 While there was some recognition that macrosocial phenomena – including community values, expectations, and leadership structure – were salient, few studies explored them.^48,49 Individual-level factors dominated rural diffusion work: as originally posited by Tarde, DOI envisioned innovations as essentially traveling “brain to brain.”

DOI’s critics emerged in the 1970s, when a new generation of rural sociologists harshly judged their forebears^45–47,50 for approaching DOI:

“…via the social psychology of individual innovators. [And for failing to]…consider the structural inhibition on innovation…”^{47, p. 72}

They denounced their predecessors’ refusal to study the ways in which emergent forms of agricultural exploitation and expropriation – macrosocial innovations worthy of study in and of themselves – decimated rural areas by consolidating family farms into agribusinesses controlled by corporations and displacing rural workers.^46,47 They condemned their predecessors’ neglect of the ways that New Deal policies reinforced White supremacy, by forcing Black sharecroppers from their homes and disproportionately funneling resources to White farmers.^46,47 The 1920s-1960s also witnessed the persistent interplay of White supremacy, citizenship, and land ownership in rural areas, as the federal government continued to expropriate land from Indigenous Americans living on reservations, and from Japanese-American farmers interned during World War II, often deeding it to White people.^51–53 Farming communities mobilized to counter their decimation (e.g., the Farm Holiday movement, marches).⁵¹

As a result, rural sociologists from the 1970s onward derided their predecessors’ research as, at best, negligible: the President of the Rural Sociological Association reported in 1972 that if the field’s prior research “were to have somehow disappeared, the world would have noticed little loss.”^{46, p. 521} At worst, some viewed it as complicit in the destruction of rural communities: one observed that by elevating the “social psychology of individual innovators… [our field] abetted the widespread deterioration of the social conditions of a significant sector of the rural population.”^{47, p. 72}

These critics themselves, however, missed institutional pressures within Land-Grant universities and the USDA – rural sociologists’ academic homes and funders, respectively – that conspired to support racial capitalism. Both were developed, in part, to strengthen the 1862 Homestead Act, which accelerated US colonization of North America by deeding tribal land to White men who occupied and cultivated it.⁵⁴ Passed shortly after the Homestead Act, the Morrill Act established at least one “Land-Grant” university in each state that was dedicated to training future generations of farmers in agricultural and mechanical sciences to cultivate newly occupied tribal lands and other territories for years to come.^54,55 Beneficiaries were White: founded in the midst of a Civil War that would transform millions of enslaved rural Black farmers into freemen and freewomen, most Land-Grant universities nonetheless restricted admissions to White people until the mid-1900s.⁵⁵ The USDA was established shortly thereafter to provide these White farmers with needed agricultural equipment and technical skills.⁵⁴ The agency evolved to support the ongoing expropriation of land from tribal nations and Black farmers.⁵⁴ By the 1920s, the USDA Farm Bureau prohibited its grantees, including rural sociologists, from examining macrosocial phenomena that supported racial capitalism, including structural racism and the transformational impact of agribusiness on family farms.^{46,47,50,56,57} Investigators who broke the racial contract were punished: to illustrate, the USDA burnt all printed copies of a USDA-funded study by a rural sociologist that highlighted racism targeting Black farmers, and derailed the career of a rural sociologist who insisted on documenting the lives of marginalized farmers.^46,47,50,57

Primarily housed within Land-Grant universities and funded by the USDA, rural sociologists of the 1920s-1960s thus faced strong institutional pressures to perpetuate Tarde’s epistemology of ignorance. Their work (1) obscured macrosocial phenomena that undergird transitions in racial capitalism – here, refusing to engage with agribusiness, racist New Deal policies, and land seizures from racialized citizens; (2) centered atomistic explanations instead – here, individual awareness of and interest in innovations; and (3) reinforced White supremacy and other forms of marginalization – here, by shrouding the exploitation, expropriation, and suffering endured by marginalized rural populations, and their mobilizations, in silence. Despite these limitations, and despite its condemnation within its field of origin, intentionally or not Everett Rogers – widely hailed as another father of D&I – explicitly used DOI as a foundation for present-day D&I.⁵⁸

1960–1980: The Great Society and Knowledge Utilization Research

Knowledge Utilization Research forms the final era of D&I’s origin story. D&I draws methods to study organizational processes and characteristics from this field.¹³ It emerged, however, to quash mid-20^th century social movements mobilizing to end White supremacy and other forms of marginalization, and neutralize Great Society initiatives.⁵⁹ These movements sought to innovate a new society by transforming discriminatory policies against Black, Chicano, and American Indian communities, and by liberating cisgender women; lesbian, gay, bisexual, and transgender (LGBT) people; people with disabilities; and other marginalized groups. Catalyzed by these movements, the Great Society sought to soften the ravages of centuries of racial capitalism, by advancing racial equality (e.g., the Voting Rights Act), mitigating poverty (e.g., Supplemental Nutrition Assistance Program), and strengthening education (e.g., Head Start) and healthcare (e.g., Medicaid).⁵¹

It its initial years, the federal Community Action Program (CAP) was a Great Society initiative that embodied these movements’ transformative vision. The federal government channeled unprecedented funds directly to communities to eliminate poverty via CAP, which required “maximum feasible participation” by low-income local residents and viewed community-rooted programs as essential elements of social change.⁵⁹ CAP conceptualized programs (e.g., the Black Panthers Free Breakfast for School Children) as concretizations and engines of social movements that could transform communities.⁵⁹

The magnitude of the transformations promised by the Great Society Initiatives, CAP, and the social movements that catalyzed them, however, concerned moderate Democrats, Republicans, and major foundations. As the Vice President of the Ford Foundation observed, transformations were moving “too far, too fast.”^{59, p. 232}

Knowledge Utilization Research emerged to counter CAP, help neutralize the Great Society’s transformative potential, and preserve the racial contract.⁵⁹ Funded through Nixon’s Office of Economic Opportunity’s Research, Planning, Policy, and Evaluation (RPP&E) office and major foundations (e.g., the Ford Foundation), Knowledge Utilization researchers developed metrics of success for Great Society initiatives that shifted its targets from its promised macrosocial transformations to individual-level and programmatic traits, behaviors, and failings.⁵⁹ Rather than measuring federal, state, and local investments in schools, they exclusively measured individual educational attainment; rather than assessing deindustrialization, they solely assessed individual employment status; and rather than analyzing the implications of macrolevel racial/ethnic discrimination for occupational segregation, they only analyzed Black individuals’ incomes.⁵⁹ While individual-level processes matter, the elision of macrosocial phenomena from success metrics helped stymy promised social transformation by shifting accountability from governments to individuals. The enfeebling of social movements into these quantifiable individual-level metrics was an opening salvo of Moynihan’s “culture of poverty” and, later, neoliberalism.⁵⁹ Both attributed individual and communal marginalization to bad behavior (often Black women’s bad behavior) rather than to discriminatory policies and other macrosocial phenomena, and both shifted accountability from powerful government agencies to blameworthy civilians.

Knowledge Utilization Research thus follows the pattern set by Tarde and rural sociologists of the 1920s-1960s,⁶⁰ (1) obscuring macrosocial phenomena that created marginalization, and (2) replacing them with atomistic explanations by reducing discriminatory policies, and the potentially transformative social movements that contested them, to quantifiable programmatic- and individual-level characteristics. It also (3) reinforced marginalization – by shifting the onus of responsibility for poverty and other forms of marginalization to individuals.

Reflections on D&I Origin Stories and Epistemologies of Ignorance

This review suggests that the persistent challenges D&I has had integrating macrosocial phenomena, marginalization, and health inequities collectively form an epistemology of ignorance that has elided racial capitalism’s existence and consequences. Each era that D&I’s origin story proposes as central to its formation witnessed largescale transitions in racial capitalism. During these tumultuous years, D&I’s forebears consistently developed theories that obscured potent and highly salient macrosocial phenomena, and instead narrowly focused on individual-level phenomena. This origin story reveals why D&I scientists remain frustrated with their field’s progress: D&I became ascendant, in part, by rendering invisible the very macrosocial phenomena that the field now seeks to illuminate, and by supporting the marginalization of populations suffering health inequities today.

Institutions catalyzed this distorted epistemology. In the 1920s-1960s and 1960s-1980s, US agencies tied to rural sociology and Knowledge Utilization Research actively suppressed the generation of critical evidence and action about the evolving sector of racial capitalism for which they were responsible (e.g., USDA), and ensured that D&I’s forebears supported this suppression. RPP&E’s individual-level metrics were designed to crush the transformative promise of CAP. Rural sociologists were embedded within two institutions – Land-Grant universities and the USDA – that were established at least in part to support US expropriation and exploitation, and experienced repercussions when they broke the racial contract.

Knowledge generation is situated not just within institutions; individual scientists’ social position profoundly shapes the questions we ask and ignore, and how we set about answering them.²⁴ D&I’s most prominent predecessors in each era were affluent White men. Tarde was White and affluent by profession if not by birth. Faculty at rural land-grant universities earn middle-to-upper-class salaries and are overwhelmingly White even in this century.⁶¹ RRP&E leaders (e.g., Shriver) were White men, and D&I scientists remain predominately White to this day.¹¹ The very nature of innovation itself excluded others: both Tarde’s Laws of Imitation and DOI viewed innovations as originating among elites. This model persists in contemporary D&I, when academics create EBIs with the goal of disseminating them to practitioners.⁶² It continues in the potent role of overwhelmingly White scientists in framing problems and potential solutions, and in the Whiteness of D&I study participants. Notably, most of the individuals who developed frameworks critical of racial capitalism during these three eras were Black Indigenous, or Other People of Color (e.g., Du Bois, Robinson, the Combahee River Collective⁶³).

The racial/ethnic and class compositions of authors of this present manuscript broadly follow that of D&I’s forebears: all are affluent by profession, if not by birth, and most are White (six White women; three Black/African-American women; one Asian-American woman; one White man, one Central-Asian man). We White middle/upper class authors have felt our limitations acutely. White authors, for example, faced discomfort when we confronted our own ignorance about D&I’s role in supporting racialized capitalism, because our personal racial/ethnic position allows us to feel unquestioningly at home within dominant discourses, and because this paper’s analyses demanded that we acknowledge the suffering that we have sustained through epistemic ignorance. BIPOC coauthors routinely navigate marginalization, including epistemic injustice that questions our work on racism and White supremacy; nevertheless, as academic researchers we also enjoy certain class privileges. Collectively, the experiences of writing this manuscript poignantly illustrate the limitations that Whiteness and affluence bring to D&I, and the possibility of more just approaches.

Can we form a new era in D&I’s origin story that is dedicated to bringing macrosocial phenomena, marginalization, and health inequities more firmly into its orbit? The stage is set: as with all prior eras in D&I’s origin story, the past 20 years have been characterized by significant gains by racial capitalism. In the US, globalization, neoliberal policies, and de-unionization have created unprecedented income inequalities that are widening and racialized. War on Drugs and immigration policies have generated mass incarceration of BIPOC individuals and state-sponsored violence. Systemic failures to respond to the COVID-19 pandemic generated catastrophic mortality and staggering inequities in these deaths. As during prior formative D&I eras, largescale uprisings – including Occupy Wall Street, Black Lives Matter, and Standing Rock Sioux Tribe mobilization – have mobilized, as have more local, grassroots oppositions. We are just weeks into the Trump administration as we write this, and that administration is intensifying racial capitalism; violently ending DEI initiatives designed to curtail discrimination; openly attacking trans people, immigrants, and protesters; enacting tax and entitlement policies that further consolidate oligarchal wealth; and slashing entitlements that buffered the worst ravages of racial capitalism. Resistance is still forming. Will D&I form a new era that engages deeply with these and other pressing macrosocial issues, or continue to generate evidence and action that perpetuate marginalization and inequities by obscuring racial capitalism?

Creating a new D&I Era: Epistemics of Resistance and Public Health Critical Race Praxis

Creating this new era will require committing to an “epistemic of resistance” –a commitment toward ways of knowing that “align not only with one’s scientific training but also against it.”⁷ We propose integrating Ford and Airhihenbuwa’s Public Health Critical Race Praxis (PHCRP) to realize this commitment. PHCRP is well-positioned for this work: it (1) centers macrosocial processes and inequities; (2) offers clear, actionable steps; and (3) explicitly requires engagement with past disciplinary distortions in service to racial capitalism. Rooted in Critical Race Theory, PHCRP creates an iterative process to analyze and end racializing processes that generate health inequities, in part by illuminating disciplinary approaches (including discourse, methods, and practice) that reinforce hierarches of dominance and oppression. It consists of Four Focus areas (Contemporary Racial Relations, Knowledge Production, Conceptualizing and Measuring, and Action) and 10 principles (italicized below).

Here, we describe ways to apply these Focus areas and principles to generate a new D&I era. Supplement 1 provides a detailed, concrete application of this process using Bozinoff et al’s 2024 Lancet review of D&I articles analyzing determinants of buprenorphine prescribing in Emergency Departments (EDs). Buprenorphine is an effective medication to treat opioid use disorder.

Focus 1: Contemporary Racial Relations

PHCRP calls us to open each project by identifying the macrosocial processes driving racialization that are salient to its time, place, and population of interest, and to remain attentive to this salience throughout the project’s lifecycle. This call stems from three PHCRP principles. PHCRP’s primacy principle recognizes that racializing processes are the bases for ordering US capitalist society. The US is racialized at the root (“race” derives from the Arabic word for beginning [“ra’s”]). Because contemporary inequities flow from this origin, identifying these racializing processes must be each project’s starting point. PHCRP’s principle of structural determinism posits that macrosocial factors shape population-level distributions of health and disease. This principle thus hones this starting point to focus specifically on the subset of racializing processes that are macrosocial. PHCRP’s intersectionality principle guides us to explore how these racializing macrosocial processes interlock with gendered social systems, class, and other hierarchies of power to create variations in individual and collective experiences of social position.

Given that D&I’s epistemologies of ignorance have consistently enshrouded macrosocial processes – racializing and otherwise – in silence, deliberately opening D&I projects with an exploration of these questions is a form of epistemic resistance that breaks its longstanding racial contract. Focus 1 might unfold in two Stages for D&I projects:

Stage 1: Building the Team:

PHCRP and the history of D&I teach us that D&I teams will stumble in Focus 1 unless we first attend to the intertwined PHCRP principles of voice and the social construction of knowledge – that is, unless we fundamentally alter the compositions of D&I teams developing evidence. Several strategies could expand voice:

1. Transforming the Social Composition of Scientific Teams: D&I leaders have expressed concern that too many contemporary D&I scientists are White.¹¹ D&I’s history, the racial contract, and PHCRP caution that White people are prone to systematically ignoring macrosocial racializing processes, as are scientists in or dependent on historically White institutions. PHCRP further teaches that structurally marginalized scientists may have developed an “oppositional gaze” to survive these processes, a gaze that allows them to critically evaluate them. The power of this oppositional gaze is well-documented: more diverse teams are more innovative and productive.⁶⁴

   A key step, then, is to continue to ensure that structurally marginalized scientists, scholar-activists, and other research partners hold meaningful leadership positions on D&I teams. These groups still wield the capacity to make these changes despite the termination of federal anti-discrimination initiatives. White scientists, for example, could intentionally loosen their/our grip on the field by shortening their/our leadership terms; refusing to serve without meaningful BIPOC co-leadership; and foregoing these roles altogether to clear paths for their BIPOC peers. Relatedly, PHCRP’s race consciousness principle implies that all team members can continue the work of dismantling our own personal entrenchments in racial capitalism by deeply engaging with how interlocking dimensions of our personal social position shape what questions we pose, how we answer them, and our subsequent actions.

2. Recognizing Expertise Among People with Lived Experience, Advocates, and Practitioners: PHCRP warns that elevating “objective” narrowly defined scientific expertise is an insidious myth that reifies dominant perspectives. For decades, this myth has limited the role of people with lived experience in research to that of subjects, and sidelined advocates and practitioners. People with lived experience are, however, best positioned to shape research into their own lives. Some advocates are exquisitely positioned to identify salient racializing macrosocial processes, because that is their daily experience. Practitioners have developed deep understandings of community context, and of prior and existing efforts to improve health in specific contexts. Identifying salient racializing macrosocial factors is contingent on prioritizing people with lived/living experience, advocates, and practitioners, with a focus on BIPOC individuals, in various team roles (e.g., equitably paid leadership). This strategy builds on an emerging strength within D&I: multiple projects now use human-centered design elements and/or employ community-based participatory approaches.

3. Interdisciplinary Teams: Investigating the multilayered pathways through which racializing macrosocial processes impact implementation outcomes and health equity will be contingent on knitting disciplines together. D&I justifiably prides itself on interdisciplinary Team Science approaches, but the disciplines included on these teams typically have been limited to behavioral health, psychology, and education, and thus have been focused on individual and organizational processes.⁶⁵ D&I can build on this strength by integrating scientists and practitioners from other social science disciplines that have strong histories of critical macrosocial and racial justice analyses (e.g., Black feminist sociology, Cultural Black studies).

Stage 2: Answering Guiding Questions:

Once assembled, the team could turn to answering the following guiding questions in the context of a specific D&I project:

1. What are the current macrosocial racializing processes that shape salient individual and collective experiences within this patient population and this organization in this time and place?

2. What macrosocial processes create interlocking variations in these experiences, as defined by gender, class, and other hierarchies of power?

The team might convene to generate a roster of macrosocial phenomena that were particularly salient to structurally marginalized patients/clients and to the organizations that served them (examples in Supplement 1).⁷ Discussions could rank nominated phenomena, based on (1) impact on the population(s) and institutions(s) of interest; (2) exposure prevalence for these populations and institutions; and (3) potential for change (e.g., perhaps findings could inform local advocacy efforts).⁷ While macrosocial processes that intentionally target healthcare settings could be included in the roster, they should not dominate, and should be scrutinized first and foremost for their racializing influences (e.g., Medicaid policies governing reimbursement should be scrutinized for possible stipulations that disproportionately exclude BIPOC people and the institutions that serve them). Dedicated time should be set aside for discussion of macrosocial phenomena that are not designed to shape healthcare settings, given D&I’s history.

Focus 2: Knowledge production

Focus 2 is, in part, a reckoning with the past. It delves into whether and how racializing processes have distorted existing evidence and generated actions that brought us away from equity. For D&I applications, guiding questions might be:

1. Which of the macrosocial racializing processes identified in Focus 1 have been studied as determinants, however distal, of the implementation outcome of interest? What other macrosocial processes interlock with them?

2. What other macrosocial processes – not identified in Focus 1 – have been empirically studied as determinants?

3. How have these processes been theorized, conceptualized, and measured in prior work?

4. How have findings shaped interventions and other actions to end inequities?

5. How was the EBI itself developed? What evidence exists that it would be effective for marginalized communities?

6. What a priori assumptions or biases does each member of the research team hold about this project and how might they influence the work?

The process of answering Questions 1–4 might draw on D&I’s strong history of conducting rigorous scoping reviews. Turning to Questions 1–3, and consistent with previously described limitations of contemporary D&I research, we would expect that this scoping review might find little evidence pertaining to macrosocial processes (from Focus 1 or otherwise), and that the theories guiding the analyses would rarely encompass these processes, racializing or otherwise, above and beyond laws designed to shape healthcare settings. Consistent with Knowledge Utilization Research, this review might also reveal a systematic flattening of macrosocial constructs, ascribing them to programs and individuals. The buprenorphine example starkly reveals this pattern. Bozinoff et al’s review identified 361 D&I papers about prescribing buprenorphine in EDs. Collectively, these papers studied >70 determinants of buprenorphine uptake that operated beyond ED walls. Only one of these >70 determinants captured any macrosocial racializing process whatsoever, despite documented inequities in these prescriptions. The review further revealed D&I’s tendency to flatten macrosocial phenomena: the authors observe systematic diminishment of macrosocial phenomena toward individual-level and programmatic measures (e.g., stigma).

Turning to Question 4, this review may further reveal that these findings generated EBIs that exacerbated inequities, because they failed to address barriers that are particularly relevant for BIPOC people, particularly those experiencing intersecting forms of structural marginalization. Each EBI-generated improvement experienced disproportionately by White people and predominately White-serving institutions will exacerbate inequities.

Question 5 centers the very selection of EBIs in the first place. Were affected communities engaged in its creation? Is the EBI rooted in what Green called “practice-based evidence” – that is, is it a practice rooted in evidence developed by and for affected communities? Likewise, to what extent have members of affected communities – particularly those who are structurally marginalized – been engaged in deciding if the EBI is indeed effective for them?

Question 5 provides an opportunity to start to chart a new path, by recognizing that everyone who produces knowledge also helps construct it and has an opportunity, through race consciousness, to help build an epistemic of resistance that breaks the racial contract. Ford et al provide an example for how to realize this opportunity, through critical reflexivity that is documented as a part of the research process. In an HIV-related study, Ford et al. iteratively self-administered surveys querying a priori assumptions about salient dimensions of the research, and critically and collectively reflected on survey results in team meetings before proceeding with each next phase of the research process.⁶⁶

Focus 3: Conceptualizing and Measuring

After reckoning with the past in Focus 2, Focus 3 builds a bridge toward the future. PHCRP dedicates Focus 3 to conceptualizing and measuring the processes through which racializing macrosocial processes shape inequities. In Focus 3, D&I can draw on a major strength: it has consistently valued theory. This history, however, also raises a caution. D&I has traditionally developed new theories by scanning past D&I research (e.g., CFIR 2.0, PRISM). Given the field’s intertwinement with racialized capitalism, this approach to theory development entrenches existing epistemologies of ignorance.⁶⁷

We propose that D&I instead engage social scientists from critical disciplines (already team members, per Focus 1) as well as members of the impacted communities, advocates, and practitioners to integrate a mid-range social science theory with an existing D&I theory. Rodrigues et al developed a process to integrate intersectionality into D&I that is instructive here, and we adapt it as follows:

Step 1: Selecting the Two Theories:

To support the identification of the D&I determinants theory, teams could turn to the T-CaST tool, which systematically identifies suitable D&I theories for a specific project.⁶⁸ No parallel tool exists to select social science theories, but the selected theory should (1) be designed to explain the impacts of racializing macrosocial processes; and (2) be multilayered, including a mesolevel that describes organizational phenomena as key sites of racialization. Candidate theories might be Intersectionality, Critical Race Theory, and the Intersectional Risk Environment Model.

Step 2: Theorizing an Integrated Causal Diagram:

The goal of this step is to develop a conceptual diagram that conceptually and visually integrates the two theories (from Step 1) to richly describe causal pathways linking macrosocial racializing exposures to the D&I outcome. Social science disciplines are dedicated to understanding the universe outside the organization, and so the selected social science theory will likely richly populate the currently under-theorized macrolevel/outermost domain in D&I. These theories, however, often under-conceptualize organizational processes, a complementary D&I strength, and so we expect that the D&I theory would richly populate the domain where organizational processes lie (e.g., the mesolevel).

Rodrigues et al developed a process to identify and potentially transform salient constructs within the D&I theory. The team – here, developed in Focus 1 – would review the D&I constructs in light of evidence (generated by the Focus 2 scoping review) and experience (lived and professional), and then conduct a nomination and ranking process to identify those that are most salient to the influence of macrosocial racializing processes on the selected outcome. Once those constructs have been identified, the tasks shift to adapting these constructs to better reflect their roles in racializing processes. Supplement 1 concretizes this process.

Step 3: Develop the Putative Causal Pathways:

In Step 3, the team would trace possible causal pathways that link the macrosocial racializing processes to the outcome. This process might be guided by (1) systematically considering assumptions from both theories about how constructs relate to one another; (2) past evidence about these inter-relationships; and (3) lived and professional experience. This process may require particular creativity when tracing pathways that link macrolevel constructs with institutional constructs, because they may cross disciplinary boundaries. To support this creativity, the process of building the causal diagram might be bidirectional, brainstorming possible pathways “down” from focal macrosocial phenomena, and also “up” from determinants identified during the scoping review. People with lived and professional experience may be particularly important at this point, because their lives – like all of ours – cross boundaries created by disciplines at each moment.

The resulting conceptual diagram may be quite comprehensive, and a single study might be incapable of engaging all the hypotheses it proposes. The team could select a subsection of the causal diagram to investigate. This subsection would have to link a macrosocial racializing process to an implementation outcome. Additional criteria might be (1) the subsection must be believed to account for substantial outcome variance; (2) high exposure prevalence for the macrosocial racializing process; and (3) potential for resulting evidence to enrich existing advocacy. Notably, remaining sections of the diagram would not be discarded, but returned to later or investigated by other teams.

New theories require novel measures, and as noted D&I research has rarely operationalized macrosocial constructs even when their theories highlight their salience. Warner et al’s database of county-level macrosocial measures might be a useful resource, as might archives of macrosocial measures culled by social epidemiology, and the guidance of the social scientists and advocates on the research team.¹⁰

Focus 4: Action

PHCRP’s Focus 4 is dedicated to actions that disrupt one or more causes of inequities. PHCRP proposes that Foci 1–3 are all important actions in and of themselves, because they disrupt D&I’s racial contract and develop novel theories that move the field toward justice. In addition, studies grounded in Focus 3 will generate evidence that can open new arenas for multilayered, justice-oriented actions that extend beyond D&I’s traditional organizationally oriented interventions. For example, if investigations rooted in Focus 3 identify a particular law as a racializing process that creates inequities in a specific implementation outcome, advocates on the team and their allies could use this evidence as fodder for advocacy to change the law itself or its enforcement, with the expectation (to be tested) that changing the law or its implementation will have beneficial downstream effects on organizational practices and thus on implementation equity. Practitioners and people with lived experience might leverage findings about organizational-level mediators to break causal pathways linking macrosocial racializing processes to inequitable implementation outcomes, or to amplify moderators that shield patients from harm.

PHCRP reminds us that storytelling itself is action. While the etymologies of “narrative” and “science” are different (“gna-” vs. “scire”), both mean “to know.” Narratives are significant ways people come to know the world, and remedy i/gnorance, epistemologic or otherwise. Science is a systematic way of knowing, though the narratives we produce are often rigidly formulaic (i.e., articles). We close this particular story by concluding that a new chapter in D&I’s origin story is both necessary and possible. It must be a story of resistance that is told by different people, literally different because new people will come to the fore with different social positions, lived experiences, and disciplines, and different through transformative race consciousness work. It must be a chapter that explicitly grapples with 130 years in which D&I’s forebears upheld the racial contract, and that deliberately resists this history by melding current D&I theories and measures with those from critical social sciences and measures in order to, finally, center and develop actions to help end racializing macrosocial processes and inequities. .

Highlights.

• D&I science struggles to advance equity and engage with macrosocial features.

• Using a racial capitalist framework, we examine this struggle’s historical roots.

• We find that D&I science evolved to reify racial capitalism across time.

• New partnerships are needed with critical social scientists & advocates.