The Role of Implementation Science in Reducing Sexual and Gender Minority Mental Health Disparities

Abstract

Owing to multiple and multilevel ecological factors, sexual and gender minority (SGM) populations exhibit persistent mental health disparities. SGM populations are also at increased risk for never being reached by evidence-based mental health care in real-world settings, which is essential for reducing these disparities. To be maximally effective in reducing these disparities, we must strive to bring our research findings into routine clinical care quickly. Implementation science can help SGM health researchers achieve this goal. This perspective outlines how researchers can use implementation science theories and methods to reduce SGM mental health disparities more efficiently and more durably.

Introduction

Sexual and gender minority (SGM) populations (i.e., lesbian, gay, bisexual, and other nonheterosexual populations, and transgender and other gender nonbinary populations) exhibit well-documented and stark mental health disparities, including higher prevalence of depression, anxiety, suicidality, and substance abuse.¹ These disparities are often highest and most sobering among racial and ethnic minority SGM populations.¹ Considerable research efforts have examined the many factors that drive these disparities (e.g., discrimination,^1,2 internalized and structural stigma,^1,2 more limited health care access¹ and health insurance coverage,¹ and limited provider training in SGM population health¹), and the field has worked to elucidate interventions that can address them.³ However, relatively less research has specifically investigated how these disparities can be effectively addressed in SGM populations in real-world clinical settings, which is one critical step in achieving widespread and sustained reductions in SGM mental health disparities. This is the primary goal of implementation science, which is the “scientific study of methods to promote the systematic uptake of research findings into routine practice.”^4,5

Implementation science as a field offers conceptual frameworks, research designs, and methods to help support the important work of bringing evidence-based mental health treatments to SGM populations. Indeed, research efforts^6,7 and research centers (e.g., the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University) have begun using implementation science to address SGM health disparities, for example, within HIV⁶ and in school settings.⁷ Efforts seem slower, however, in bringing evidence-based mental health treatments to SGM populations. This perspective outlines why the gap between science and practice within mental health is of particular concern for SGM populations, how implementation science can help researchers bridge that gap, and ways for SGM health researchers to bring implementation science into their own work on SGM mental health disparities.

Potential Delays in Evidence-Based Mental Health Care Reaching SGM Populations

For many fields, there is a lengthy delay before scientific discoveries are adopted into clinical practice, if at all, which leads to a significant research-practice gap.⁸ Important research findings about minority populations, including SGM populations, may have an even slower uptake into community practice. Specific to SGM populations, one factor that might exacerbate this delay is that the efficacy (i.e., evidence from carefully controlled randomized trials) of many mental health treatments is unknown for SGM populations.⁹ This is, in part, because many mental health clinical trials do not collect sexual orientation and gender identity data from participants nor are they statistically powered to test for differences in efficacy by sexual orientation or gender identity.⁹

Within routine clinical care, the majority of health care systems also do not collect sexual orientation and gender identity data,¹⁰ even within health care systems that have prioritized the care of SGM individuals (e.g., the Veterans Health Administration).¹¹ Thus, the reach and effectiveness of routine mental health care for SGM populations are also not well established. These issues suggest that, beyond mental health interventions needing to be efficacious for SGM populations, they must also be able to reach these populations in the real world, be integrated into routine care, and be sustainable to have a reliable positive impact on SGM mental health disparities.

Using Implementation Science to Reduce SGM Mental Health Disparities

SGM health researchers can most efficiently reduce SGM health disparities by directly evaluating the process of implementing interventions in the real world through rigorous implementation science. Implementation science is concerned with the use of evidence-based practices and the processes that lead organizations to use them (or not). An important place for SGM health researchers to begin to incorporate implementation science into their work is to orient their research question to the correct stage of implementation. Researchers can then determine what the implementation-related goal of the project is and the necessary steps for achieving it. A guiding framework for this purpose is the Quality Enhancement Research Initiative Implementation Roadmap,¹² which lays out implementation in three stages. The Roadmap describes preimplementation, where the goal is to identify the health problem and determine appropriate evidence-based treatment; implementation, where the focus is on strategies to successfully apply the evidence-based practice; and sustainment, where the focus is on building the business case to promote ongoing maintenance of an evidence-based practice.

Researchers will also want to select an implementation science theory or framework (e.g., the integrated Promoting Action on Research Implementation in Health Services model,^13,14 the Consolidated Framework for Implementation Research,¹⁵ or Proctor's implementation outcomes framework¹⁶) that can incorporate theoretical drivers of SGM health disparities, as these may also affect successful implementation of an evidence-based intervention. Although we highlight only some of the models used in implementation science,¹⁷ many are applicable to SGM health research.

One example of applying the Roadmap¹² and implementation science theory to evidence-based treatment for mental health among SGM populations comes from our own ongoing research. Exposure to violence is a pressing public health concern among all SGM populations and they are at greater risk of post-traumatic stress disorder (PTSD).¹ Our group's planned project aims to evaluate the potential for telehealth delivery to increase access to and retention in evidence-based PTSD psychotherapy for SGM populations. To do so, the project will first use qualitative interviews to understand perceptions of the telehealth modality for PTSD treatment from SGM patients, mental health providers, and insurers. We will next meet repeatedly with a stakeholder advisory board of key decision makers to understand fitting the intervention and delivery modality into the local setting. Finally, we will pilot implementation of the modality and use mixed methods to assess implementation and effectiveness outcomes, guided by Proctor's framework.¹⁶ This project builds from the preimplementation stage (i.e., qualitative formative evaluation) to the implementation stage (i.e., examining strategies in an implementation pilot) of the Roadmap. This is just one example of using rigorous implementation science methods, which we discuss in the next section, to bring an evidence-based mental health intervention to SGM populations in an ideally more effective and durable manner.

Methodological Tools from Implementation Science for SGM Health Researchers

SGM health researchers will also want to know which implementation science tools they might use to conduct their work. Hereunder, we raise several methodological considerations for researchers interested in applying these methods to studying the implementation of evidence-based mental health treatments for SGM populations. These include involvement of stakeholders, qualitative methods, and measurement of implementation outcomes.

One critical tool in implementation science is the deliberate inclusion of stakeholders throughout the research process. Stakeholders are individuals who are representative of the key players in the process of implementing an intervention in a specific setting.¹⁸ These include patients, health care providers, administrators, policymakers, or organizational leadership. Inclusion of these individuals into the planning of the research design could be through an advisory panel, which provides feedback throughout the implementation process. Alternatively, research participants could be purposively sampled from each stakeholder group to complete surveys or qualitative interviews of their perspectives on the implementation process.¹⁹

Many SGM health researchers are likely familiar with engaging members of the population in the research process, which is a shared goal in community-based participatory research.²⁰ In implementation science, there is added emphasis on including all stakeholders relevant to the implementation process, beyond the recipient (e.g., patient) population.²¹ Using qualitative methods with multiple stakeholders is valuable for uncovering unexpected barriers to or facilitators of implementation.²² We suggest that stakeholder engagement and qualitative methods could be useful when implementing an evidence-based intervention that was not specifically designed for SGM populations.

These strategies can also be informative when researchers want to collect rich data on the intersectionality of SGM identity with other marginalized identities, such as among racial or ethnic minority SGM populations.²³ Intersectionality perspectives recognize that individuals have multiple identities that are interrelated (e.g., sexual orientation, racial and ethnic identity, and gender identity), that these identities can confer different kinds of privilege and power, and that individuals can experience marginalization due to any one or combination of these identities. Intersectionality posits that these interconnected identities shape people's life experiences in complex ways.²³ Using intersectionality perspectives can also help implementation scientists ensure that implemented interventions do not inadvertently exacerbate existing intersectional health disparities²⁴ (e.g., if a trauma-focused psychotherapy for SGM individuals did not acknowledge the unique experiences of violence that Black SGM individuals experience).

One final consideration for new implementation researchers is the evaluation of implementation outcomes. Implementation outcomes are measured indicators of implementation success, which are conceptually distinct from clinical outcomes (e.g., symptom reduction) and service outcomes (e.g., timeliness) of an intervention in a clinical care setting.¹⁶ Many researchers developing mental health treatment interventions likely already evaluate some of these implementation outcomes (e.g., intervention acceptability or how welcome and appealing an intervention is to participants). However, two important points are worth mentioning. First, it is critical to identify and evaluate all of the relevant implementation outcomes.¹⁶ Second, researchers need to evaluate these outcomes with all appropriate stakeholders (which may be several). For example, during the implementation research stage,¹² there may be an emphasis on the acceptability of an intervention to patients. However, researchers should be mindful that acceptability of the intervention to providers and system leaders is just as important to know for its successful uptake and its sustained use. Moreover, it is critical to plan for sustainability of an implementation effort from the very beginning of a study; hence, assessing providers' and system leaders' perspectives during the preimplementation stage is as important as assessing them when transitioning to sustainment within a health care organization.¹²

Conclusion

SGM health researchers should be keen to draw on implementation science, and to do so early in intervention development. We argue that utilizing implementation science methods will be one essential component of our continued collective efforts to reduce mental health disparities within SGM communities. Implementation science frameworks are flexible enough to incorporate SGM-relevant determinants of health, and many implementation science methods will be familiar to SGM health researchers. However, to fully harness the advantages of implementation science for reducing SGM mental health disparities, researchers will need to learn new theories, design SGM-focused implementation science research, and commit to bringing sustainable evidence-based interventions to SGM populations. In doing so, researchers can ensure that interventions for SGM populations are designed to maximize both clinical and implementation outcomes, leading to effective interventions that are adopted by providers and SGM patients, delivered with fidelity, and sustained in routine care.

Authors' Contributions

N.S.P. and A.R.E. jointly conceptualized the article. N.S.P. was responsible for the initial draft and both N.S.P. and A.R.E. contributed to the writing and editing of the article. Both authors reviewed and approved the article before submission.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the United States government, or the National Institute of Mental Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

N.S.P's time for writing was supported by grant T32MH078788 (principal investigator: Larry K. Brown).