Implementation Science and Cardiovascular Health for All: From Knowledge to Action

What is implementation science and why is it important for advancing equity in cardiovascular health?

Implementation science is the compilation of a set of coordinated activities that occurs at levels higher than the individual¹. Whether it’s a part of a team, practice or population, this science studies the uptake of research findings in the evolution of evidence-based practice into healthcare policy and clinical practice. This science is vital to keep clinicians, administrators, policymakers and researchers accountable to the people they serve, ensuring that their work not only aims to advance equitable health care and outcomes, but also works towards a long-term prevention of health problems.

Implementation science is important for advancing equity in cardiovascular health. Previous research is all too telling of the disparities found in cardiovascular health, especially for groups that have been racially, ethnically, or socioeconomically marginalized. According to the World Health Organization, non-medical factors that influence health disparities such as housing and food insecurity and structural racism create unfair and avoidable differences in health status^1,2,3. Implementation science serves as the bridge of action between our knowledge of these disparities in health outcomes and the path to equity. This bridge is constructed through the consideration of a combination of factors: transdisciplinary research, stakeholder engagement, dissemination and translation initiatives, and sustainability of approaches, all components of implementation science⁴.

A Four-Step Roadmap

To act upon this idea, the American Heart Association Scientific Statement, “Leveraging Implementation Science for Cardiovascular Health Equity” provides a four-step road map ¹. Developed by lead researchers in the field of cardiovascular disparities, the roadmap includes: 1) selecting and adapting evidence-based practices (EBPs) that have been shown to reduce disparities or improve CVD outcomes in populations that have been historically marginalized; 2) identifying barriers and facilitators to CVD equity through evidence-based practices; 3) selecting, using and adapting implementation strategies; and 4) evaluating their success.

Heavy and rigorous study must go into selecting an EBP to address CVD disparity within a certain population, with the proper considerations given to adapting this practice into the setting at hand. To do so with the highest scientific integrity, researchers must develop an understanding of not only the individuals and culture of the group, but the structure and processes that go along with maintaining their daily lifestyle. When appropriate EBPs have been considered and studied, researchers can use the these as a foundation for identifying potential barriers to their successful implementation. Implementation science requires an intersectional approach that includes collaboration among experts in public health and the health professions as well as the social sciences and public policy. These scientists can apply their own frameworks to objectively determine the limiting factors,^1,5. The chosen implementation strategy should be an amalgamation of the lessons learned in these steps while acknowledging the culture and context of the population to address the barriers faced by marginalized groups. Through following these steps, the goal in mind is ensuring a sustainable and equity-informed implementation of evidence-based practices. To measure the effectiveness of the implementation strategy, evaluation should include a multi-level assessment of patient outcomes, clinician and system level equity indices, cost, feasibility to be modeled in other settings, and other factors assessed through a standardized framework¹.

Community Engagement: The Common Thread

Community engaged research and practice are vital to reducing health disparities and ensuring progress toward health equity. Thus, community engagement is the thread that runs through each step of this roadmap. The people to be engaged include all those who seek action to end health disparities – from patients and family members, local organization leaders and members of communities experiencing health disparities, to clinicians and researchers, payers, hospitals and healthcare system leaders and frontline personnel, public health officials, representatives from a variety of societal sectors, and policymakers⁶. Their involvement throughout the process is a critical component of implementation science that must be solidified to achieve cardiovascular health equity.

To understand where community engagement could improve, it is important to identify the barriers to and opportunities for engagement. One such barrier is the frequent incongruence between the culture and context of historically marginalized groups and the culture and context of the institutions that study and serve these communities. The diversity and complexity of stakeholder motivations, priorities, resources, and time available to focus on health problems calls for multi-level interventions, guided by implementation science, that can not only understand these barriers and opportunities, but also create long-term, impactful solutions. To take a holistic approach to solving community engagement, we must additionally consider the ways in which our healthcare and other service delivery organizations provide care, and assess gaps that need to be filled. In particular, the individuals who deliver services could benefit from actions such as continuing education, training in communication skills and cultural and structural competency, and restructuring of care teams to involve persons with a variety of skills and life experiences who can effectively deliver interventions.

These ideas, and the consideration of all relationships in health care are the cornerstone of relationship-centered research⁷. This research values the relationships clinicians and researchers have with themselves, their colleagues, their patients, and their communities⁷. As researchers, we know instinctively that each of these relationships plays a valuable role in our behavior and approach to our work. Thus, community engagement acts as an integral part of the scientific process, that, when based on a foundation of relationship-centered principles, enables researchers to design effective interventions and implement them in ways that lead to lasting change and real health benefits for marginalized populations. Community engagement creates spaces for the voices of our community to be elevated and for our science to be used as fuel for advocacy. Without authentic engagement, it would be impossible to adequately advance health equity.

Conclusion

The American Heart Association’s Scientific Statement, “Leveraging Implementation Science for Cardiovascular Health Equity” serves as a reminder that addressing disparities in cardiovascular health Implementation science bridges the gap between knowledge about the disparities that exist and attainment of the vision of equity in cardiovascular health. To progress toward this vision, they recommend four critical steps including 1) selecting and adapting evidence-based practices (EBPs) that have been shown to reduce disparities or improve CVD outcomes in populations that have been historically marginalized; 2) identifying barriers and facilitators to CVD equity through evidence-based practices; 3) selecting, using and adapting implementation strategies; and 4) evaluating the success of various implementation strategies. Throughout this work, one driving force remains constant: authentic engagement with persons from socially marginalized communities and those who serve them, to adapt evidence-based practices and implement them successfully. Such engagement lays the foundation for sustained and lasting changes that mean better health for all in our society.