Commentary on “Advancing health equity through a theoretically critical implementation science”
“Theories, models and frameworks (TMFs)” are core concepts in implementation science. Every new student is introduced to the bewildering alphabet soup of numerous “TMFs” that have evolved in this field. However, despite their proliferation, researchers have continued to argue that the current theories, models, and frameworks still do not capture critical aspects of the complex nature of implementation, particularly the role of outer-setting elements such as policies, financing, social processes or structural factors. Recent publications have advocated for the use of policy process[1] and organizational theories[2] to better represent and measure outer setting elements.
The paper by Snell-Rood and colleagues addresses another critical gap in the current implementation science theories, models and frameworks. The authors point out that despite some new frameworks in implementation research focusing on health equity, many TMFs still do not explicitly consider upstream structural factors that result in inequitable adaptation or implementation of interventions. To address this, the authors propose the integration of three classes of theories into implementation science: (a) postcolonial theory to investigate the extent to which evidence-based interventions selected for implementation promote Western medical tradition to the exclusion of local knowledge and practices; (b) structural competency, syndemics and intersectionality theories that explore how systemic factors such as stress, food insecurity, or gender violence affect the implementation process and (c) governance theories that explicitly describe how policy decisions affect the service delivery processes and organizations responsible for implementation and sustainment of interventions. In a series of detailed tables, the authors present relevant questions that can be answered by these theories, and also propose how they can be integrated into the popular TMFs such as CFIR or TDF.
This article is a welcome addition to the growing body of inquiry and is a good basis for further exploration into how principles of equity can be integrated into implementation research. One limitation of this article is that its primary focus is on interventions rather than on the implementation process. The paper encourages researchers to ask questions about the extent to which interventions developed in the West include local indigenous knowledge, or how “cultural” adaptations may inadvertently propagate historical and structural factors causing inequity, or how policies specifically designed to exercise power over populations could be the focus of interventions. Implementation scientists should use these questions as a starting point to ask similar questions about implementation outcomes, determinants and strategies (e.g, the extent to which a coaching and facilitation implementation strategy reflects Western norms of engagement and interaction). However, in doing so, it is also useful to also reflect on the fact that the three classes of theories presented in the article have been created in the West, and that their application in non-Western settings may need local adaptation. While interventions and implementation approaches can benefit through a careful analysis through an equity lens, the TMFs themselves have the same need, and it is important to ensure that the new theories themselves do not become a barrier to entry to those not trained in Western anthropological methods.
[1] Howlett, M. (2019). Moving policy implementation theory forward: A multiple streams/critical juncture approach. Public Policy and Administration, 34(4), 405–430.
[2] Leeman, J., Baquero, B., Bender, M., Choy-Brown, M., Ko, L. K., Nilsen, P., Wangen, M., & Birken, S. A. (2019). Advancing the use of organization theory in implementation science. Preventive medicine, 129S, 105832