Interventions to promote health equity: implications for implementation science in behavioral medicine

Abstract

Disparities in health persist despite the development of innovative and effective behavioral interventions. Both behavioral medicine and implementation science are vital to improving health care and health outcomes, and both can play a critical role in advancing health equity. However, to eliminate health disparities, more research in these areas is needed to ensure disparity-reducing behavioral interventions are continually developed and implemented. This special issue on interventions to promote health equity presents a diverse set of articles focused on implementing behavioral interventions to reduce health disparities. The current article summarizes the special issue and identifies key themes and future considerations. Articles in this special issue report on behavioral medicine intervention studies (including those examining aspects of implementation) as well as implementation science studies with implications for behavioral medicine. Articles discuss community-, provider-, and system-level interventions; implementation processes; and barriers and facilitators to implementation. Also included are commentaries calling for greater prioritization of behavioral medicine and implementation research. As evidenced in this special issue, behavioral medicine is primed to lead the implementation of behavioral interventions in historically marginalized and minoritized populations to advance health equity and improve overall population health.

An overview of the special issue on interventions to promote health equity that discusses the issue’s articles, key themes, and future considerations.

Implications.

Practice: Behavioral medicine practitioners are integral stakeholders for facilitating the implementation of health equity-focused behavioral interventions.

Policy: Policies should prioritize behavioral medicine intervention research and implementation science to advance health equity.

Research: Through intervention and implementation research, behavioral medicine researchers have a pivotal leadership role in maximizing the health equity impact of interventions.

IMPLEMENTING BEHAVIORAL INTERVENTIONS FOR HEALTH EQUITY

Persistent health disparities—recently highlighted during the COVID-19 pandemic [1–3]—indicate an urgent need to advance health equity. Behavioral medicine is vital to improving healthcare delivery and health outcomes and can play a central role in reducing disparities in health. Effective and innovative behavioral interventions hold great potential for improving health. However, the potential of behavioral medicine is hindered by a focus in research on documenting health disparities more so than identifying solutions to reduce or eliminate them [4]. Intervention research is integral to behavioral medicine, yet increased efforts are needed to identify scalable and sustainable interventions that can be implemented in diverse communities and settings.

Currently, implementation of interventions in clinical practice and/or community settings and, specifically, among socially disadvantaged and historically marginalized populations, is inadequate [5, 6]. For example, new and potentially lifesaving health technologies are inequitably distributed, with lower availability or adoption in socioeconomically disadvantaged populations [7, 8]. Neglecting to ensure health-focused innovations and strategies have equitable reach to, and benefit for, all populations can exacerbate existing health disparities (and social inequities) based on race, ethnicity, gender, sexual orientation, geography, socioeconomic status, and other factors [7, 9].

Implementation science can be instrumental in advancing health equity. Implementation science is the study of methods that promote the systematic uptake of evidence-based strategies and practices, considering contextual influences at multiple socioecological levels [10, 11]. Implementation research can enhance the reach and sustainability of behavioral interventions and consequently, increase behavioral medicine’s impact on reducing health disparities. A growing body of literature emphasizes the critical need for closer integration of health equity and implementation research [12–16]. Similarly, more health equity-focused implementation research in behavioral medicine is vital to eliminating disparities in health.

OVERVIEW OF THE SPECIAL ISSUE

This special issue of Translational Behavioral Medicine focuses on interventions to promote health equity. The issue offers a diverse set of articles that have implications for implementation science in behavioral medicine. Articles in the issue present studies illustrating how intervention research and implementation science can inform behavioral medicine strategies to advance health equity. Included are reports of behavioral medicine intervention studies (including those examining aspects of implementation) as well as implementation science studies with implications for behavioral medicine. The articles report on topics such as community-, provider-, and system-level interventions; implementation processes; and barriers and facilitators to implementation. Also included are commentaries calling for greater prioritization of behavioral medicine and implementation research.

Interventions based in clinical settings may have considerable implementation advantages and challenges. Hitsman et al. [17]. assessed the preliminary effectiveness of an automated intervention for smoking cessation among Federally Qualified Health Center (FQHC) patients. Findings from this study demonstrate the utility of technology for targeted outreach and intervention to socioeconomically disadvantaged patients and to augment clinical care. A provider-focused study, by Conley et al. [18], examined genetic counseling discussions between Latina breast cancer survivors and their providers who participated in a randomized trial of an educational genetic counseling/genetic testing intervention. Findings highlight the importance of equitably implementing evidence-based genetics guidelines as well as the need for targeted provider-level interventions to help reduce disparities in breast cancer among Latinas.

Hessler et al. [19]. report on findings from a pragmatic trial, focusing on patient engagement and relationship building. Results revealed that an enhanced diabetes self-management strategy is associated with dietary and psychosocial improvements. Another article that emphasized relationship building is by Chavez et al. [20], who employed a community-based participatory research approach to assess COVID-19 priorities and needs in four communities of color. Insights from the study suggest that factors such as intervention adaptability, cultural appropriateness, and transparency are important aspects of community-partnered intervention planning and implementation.

DePuccio et al. [21] investigated, among stakeholders, the implementation of an intervention addressing food insecurity among primary care patients. This qualitative study identified barriers and facilitators to implementation and can guide the development and implementation of food referral programs in clinical and community settings. Baucom et al. [22] examined implementation barriers among stakeholders as well, in an investigation of barriers to participation and behavioral change in a national diabetes prevention program. Some differences in the number and types of participant barriers were identified by income level, pointing to practical considerations for future planning when designing and implementing interventions for socioeconomically disadvantaged populations.

Complementing articles on implementation barriers and facilitators, Daniels et al. [23] conducted a scoping review to identify themes to enhance implementation using an implementation science framework. Findings from this review describe important factors for enhancing the implementation of healthcare practices and programs for socially, physically, or psychologically vulnerable populations. In another article that can inform implementation processes, Hasson et al. [24] conducted a rapid-cycle adaptation of an intervention promoting equity in access to youth physical activity. Findings underscore the value of implementation science frameworks in guiding the adaptation of existing interventions during the COVID-19 pandemic.

These eight articles are complemented by two particularly thoughtful and timely commentaries—one through a broad health equity lens and one from a life course perspective. Baskin [25] presents a call to action for achieving health equity, urging the behavioral medicine community to align our efforts, including by maximizing the implementation of behavioral intervention strategies. The commentary by Burgdorf et al. [26] provides background for the National Institutes of Health’s (NIH) interest in research designed to better understand the causes and consequences of violence and the development, evaluation, and implementation of interventions to address the deleterious implications of violence. Together, these commentaries provide insights into actions and opportunities that can make strides in eliminating health disparities.

KEY THEMES AND FUTURE CONSIDERATIONS

This special issue on interventions to promote health equity highlights how behavioral medicine and implementation science can advance health equity. The studies featured in this issue used a variety of study designs and analytic methodologies, recruited samples from diverse populations, considered interventions in different types of settings, and addressed various health conditions with documented disparities. Common themes included partnering across sectors, ensuring cultural relevance, and appropriateness of interventions, and engaging stakeholders. Intervention factors such as acceptability, feasibility, penetration, appropriateness, sustainability, and adoption are important to ensuring that evidence-based interventions can be successfully implemented across diverse communities and populations [27].

Increasing awareness of health disparities in the absence of providing recommendations for action or implementing solutions is insufficient. The Society of Behavioral Medicine remains strongly committed to the elimination of health disparities through dialogue and action. The research presented in this special issue provides insights into key areas for action, and commentary in this special issue by Baskin [25] offers specific recommendations for taking action to eliminate health disparities and improve outcomes in behavioral medicine.

Behavioral medicine must be inclusive. Progress toward achieving health equity will be limited if novel advancements continue to be developed through research that does not include diverse representation. Historically marginalized communities and populations continue to be underrepresented in clinical trials, and this is especially true for Hispanics, Native Americans, and African Americans [28]. Accordingly, our knowledge of how to best intervene, translate science into practice, and successfully implement evidence-based interventions for broader population reach is limited and remains an important priority area for behavioral medicine research. As noted in this special issue by Hessler et al. [19], meaningful input on study design and support from community stakeholders may lead to increased recruitment and retention of diverse patients in research trials.

Research topic choice, specifically proposals that include research at the community or population level, tend to have lower funding rates for prestigious NIH grants [29]. Research sponsors should prioritize funding for community- and population-focused health equity research. Identifying additional key health equity gaps and increasing sponsor funding in these areas are also priorities. The commentary in this special issue by Burgdorf et al. [26] addresses one of these funding gaps, violence research, as an area that has gained increasing national attention and outlines emerging areas of funding priorities by the NIH.

Finally, greater utilization of and support for community-engaged research approaches, such as those described in this special issue by Chavez et al. [20], are needed. For example, traditional recruitment approaches may be more time-consuming, costlier and less effective than community-engaged strategies in recruiting participants from racial/ethnic minoritized groups [30]. Even when effective community-engaged approaches are employed, recruiting socially disadvantaged, and racial/ethnic minoritized populations into research may take longer than recruiting other populations [31]. Therefore, research sponsors should consider providing additional funding to support the costs associated with recruitment and retention of historically marginalized populations and communities as well as longer timeframes for projects that enroll individuals from these groups.

Delays in translating evidence-based interventions into practice can have a detrimental impact on health outcomes. Several articles in this special issue address the need for faster implementation with the use of rapid-cycle study designs to accelerate the delivery of interventions targeting marginalized and minoritized patients and communities. Because researchers analyze data early in studies that use a rapid-cycle design, interventions can be adapted and implemented in a shorter timeframe, leading to faster uptake of evidence-based approaches.

Other behavioral intervention research approaches can facilitate efficient implementation and foster health equity. These include intervention studies of non-medical factors that influence health disparities such as social determinants of health. For example, a recent study determined the feasibility and acceptability of addressing social needs in a health system and identified likely contributors to participant retention [32]. Other valuable research approaches are studies conducted under real-world conditions rather than highly-controlled studies that may not reflect practical complexities [33]. For example, recent findings from a pragmatic intervention trial of a telehealth diabetes prevention lifestyle program provide insights about overall and race/ethnicity-specific reach, acceptability, and perceived success of the intervention [34]. More studies of this nature are needed in behavioral medicine research.

Additional topics requiring more attention in behavioral medicine research include vaccine uptake, structural racism and intersectionality, and health misinformation. An ongoing need is the application implementation research to policy [35] given the importance of policy in implementing and institutionalizing strategies to reduce structural inequities [8]. Furthermore, the extent to which contextual factors influence the de-implementation of dated or ineffective approaches and implementation of evidence-based findings has not been adequately investigated [36].

In summary, significant gaps remain in behavioral medicine research that thwart achieving health equity. New perspectives and targeted efforts are emerging to reduce the inequitable burden of disease more rapidly. To accelerate the population impact of behavioral medicine, the effective and widespread implementation of interventions must be prioritized. Identifying how to implement behavioral interventions optimally and equitably is essential to ensure all populations can benefit from behavioral medicine innovations.

Funding

K.I. Alcaraz was supported in part by National Institutes of Health grant P30CA006973.

Compliance with Ethical Standards

Conflict of Interest: None declared.

Ethical Approval: This article does not contain any studies with animals performed by any of the authors.

Informed Consent: This study does not involve human participants and informed consent was therefore not required.