Applying an equity lens to assess context and implementation in public health and health services research and practice using the PRISM framework

Abstract

Dissemination and implementation science seeks to enhance the uptake, successful implementation, and sustainment of evidence-based programs and policies. While a focus on health equity is implicit in many efforts to increase access to and coverage of evidence-based programs and policies, most implementation frameworks and models do not explicitly address it. Disparities may in fact be increased by emphasizing high intensity interventions or ease of delivery over meeting need within the population, addressing deep-rooted structural inequities, and adapting to local context and priorities. PRISM (Practical, Robust Implementation and Sustainability Model), the contextual expansion of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework has several elements that address health equity, but these have not been explicated, integrated, or illustrated in one place. We present guidance for applying PRISM with an equity lens across its four context domains (external environment; multi-level perspectives on the intervention; characteristics of implementers and intended audience; and the implementation and sustainability infrastructure—as well as the five RE-AIM outcome dimensions. We then present an example with health equity considerations and discuss issues of representation and participation, representativeness and the importance of ongoing, iterative assessment of dynamic context and structural drivers of inequity. We also elaborate on the importance of a continuous process that requires addressing community priorities and responding to capacity and infrastructure needs and changes. We conclude with research and practice recommendations for applying PRISM with an increased emphasis on equity.

Implementation science for cancer control: One center’s experience addressing context, adaptation, equity, and sustainment

“…The COISC3 developed both qualitative interview guides and survey questions to assess PRISM issues [ 10 , 19 , 24 ]. Most recently, we focused on how PRISM can be used with a health equity lens to assess and reduce health disparities, including attention to systems issues such as relationships among different RE-AIM outcomes and unintended consequences [ 25 ]. Of note, PRISM highlights the importance of both (i) representativeness or equity on all RE-AIM outcomes; and (ii) equitable representation of all vested parties throughout program planning, delivery, evaluation, and dissemination.…”

Aligning the planning, development, and implementation of complex interventions to local contexts with an equity focus: application of the PRISM/RE-AIM Framework

“…This paper proposes a model of interactions that could enhance an equitable implementation process. We expand our previous work from co-authors and others [ 4 , 25 – 27 ] on the application of the Practical, Robust Implementation and Sustainability (PRISM) model from equity and systems perspectives. Our goal is to offer guidance to researchers and practitioners on the use of a) PRISM to align contextual needs with the design and evaluation of healthcare and public health interventions from a systems thinking perspective, b) a co-creation engagement approach to actively inform that alignment process [ 28 ], and c) the RE-AIM ‘Outcomes Cascade’, framed as a way to inform and support a formative evaluation, to achieve an intervention-to-context alignment using reflective micro-cycles.…”

“…The second point concerns representativeness (or equity) of results on the various RE-AIM outcomes. It is important to stress that representativeness-or equity-is important across all RE-AM dimensions-not just reach as is most commonly reported [38,39].…”

“…Having a good understanding of the local contexts where interventions are implemented is crucial to meeting this health equity goal [ 3 ]. Local contexts reflect not only the physical setting, richness of values, needs, priorities, resources, and healthcare systems, but also the political, historical, economic, and social factors that influence health [ 4 ].…”

“…The PRISM contextual domains pragmatically identify key factors relevant to equity. and when addressed, can enhanced equity within broader socio-political-historical-structural contexts that sustain or challenge inequities [ 4 ]. We also encourage ongoing assessment of PRISM domains during the pre-implementation, implementation, and post-implementation phases of specific factors relevant to equity.…”