Table 2.

| Understanding and addressing health disparities

Implementation science tenets	Unintended consequences	Theories to further equity
• Interventions must be adapted to be culturally acceptable and appropriate. • Increasing the uptake of existing interventions from the evidence base through proper implementation will decrease health disparities.	• Communities and cultures can be constructed as homogenous groups. • Strengthening implementation alone can distract from fundamental inequities in health.	Structural violence: exposure to social and economic forces that make people sick Structural competency: health systems and providers actively address structural violence Syndemics: clusters of diseases that result from shared risk factors. Intersectionality: social and economic forces intersect to make certain populations especially vulnerable
Examples of operationalizing theories across core domains and processes		Recommendations for methods and research design
Outer setting: patient needs and resources • What social and economic forces generate the greatest burden of sickness in target communities? Are some interventions or implementation strategies better suited to ameliorate these forces? • What disease clusters are most common in the target community? Intervention characteristics: relative advantage • Does the intervention selected address historical and continued inequalities shape the health problem being targeted? • Does the intervention include unstated cultural values (e.g., model of recovery premised on individualism) or assumptions about engagement within healthcare (e.g., assumes trust in providers)? Adaptation • When should implementation efforts address multiple illnesses? • What other forms of marginalization can adaptation address (e.g., stigma, discrimination)? • What system-level implementation strategies are needed to decrease discrimination that serves as a barrier to all healthcare (e.g., data collection and structuring of space)?		Research design • Test intervention strategies that address intersectional risks [45] • During intervention planning stage, examine relative advantage by assessing how intervention characteristics will impact who is reached and retained • Identify nontraditional stakeholders (e.g., urban planning and food provision) to create structurally focused implementation strategies • Critical assessment of reach and retention Relevant Conceptual Frameworks and Methodological Tools • The ADAPT-ITT planning framework explicitly involves people who will use interventions throughout planning and evaluation [44]. • The Behavioral Change Wheel [47] is well suited to combining intervention approaches to address interactions between healthcare, environment, and policy. • The Cultural Framework for Health [46] can identify cultural values and assumptions in interventions and communities. • Diversify research teams and research oversight committees to ensure that implementation questions address structural risks and needs of particularly vulnerable groups • Periodic reflections are an ethnographic tool [51] that can be used to document the differential experience of the intervention for practitioners and community members throughout implementation. • Collect more data on health outcomes and reach of interventions by intersectional identity in order to identify where additional intervention needed [45,55]