Written by Morgan C. Shields, PhD, assistant professor at the Brown School
On September 7th, the Center for Dissemination and Implementation was pleased to host Karen Emmons, PhD, professor at the Harvard T.H. Chan School of Public Health, for her talk, The Role of Policy in Implementation Science and Health Equity.
While understanding how policy impacts human behavior is at the center of study among several other fields – such as health policy, political science, and economics – implementation science has tended to “wave our hands” at policy as some extraneous context, as Dr. Emmons described. The objective of Emmon’s talk was to encourage the field of implementation science to consider how policy might be leveraged to improve the use of evidence-informed practices, and to outline some opportunities for implementation scientists to expand their scope of study.
Policy can be a major enabler (and inhibitor) of behavior change within organizations, such as hospitals, schools, and the workplace. Indeed, policy is often used as an implementation strategy in the real world. Some examples provided by Emmons included requirements by accrediting bodies, taxes on sweetened beverages, and smoking bans. In my area of work focused on quality of healthcare for vulnerable patients, financial incentives, guidelines, and regulations are often leveraged with the goal of improving experiences of patient-centeredness, strengthening safety, and in de-implementing harmful, or “low value,” practices.
The quest to understand how best to systematically implement evidence-informed practices, and address inequities, requires the use of policy. Indeed, much of the drivers of inequity are structural. However, even the most well-intentioned policies are bound to have unintended consequences. As Elvin Geng, MD, MPH, described in a recent blog post, it is a rule to expect unintended consequences from policy changes, and those with the least power are most likely to carry the cost of these unintended consequences. It is for this reason that we must also center equity and power in both the study and actual implementation of systematic behavior change. It is perhaps at the intersection of policy and organizations’ responses to those policies where implementation scientists and practitioners can identify appropriate methods for maximizing benefits and reducing unintended consequences.
Specific Recommendations for the Field of Implementation:
- Examine whether existing implementation science conceptual frameworks can more explicitly focus on policy. Most of our frameworks give only superficial consideration to policy and are instead anchored at the organizational level.
- Look to existing policy frameworks in other fields. For a quick orientation, you can refer to the CDC’s Policy Process to see where policy and implementation science most clearly intersect. For example, there is a role for implementation science to inform both the Strategy and Policy Development Stage, where the policy can be conceptualized as an implementation strategy to achieve a specific behavior change goal, and in the Policy Implementation Stage, where the policy can be conceptualized as the intervention being implemented.
- Collaborate with existing experts in policy research. Don’t just jump right in. Partner with an expert or join a team.
- Develop and use policy-relevant measures. There is a need to measure characteristics of a policy with an eye towards equity.
- Develop academic-community partnerships. There might be opportunities for researchers to partner with local state agencies, for example, in ways that would be mutually beneficial and would most efficiently improve population health.
- Greater appreciation for observational and quasi-experimental research designs. Policy is difficult to manipulate prospectively, which means that most policy research uses observational study designs. These designs need to be valued by academic leaders and funders.