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      Seven practices for pursuing equity through learning health systems: Notes from the field

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          Abstract

          Introduction

          Despite learning health systems' focus on improvement in health outcomes, inequities in outcomes remain deep and persistent. To achieve and sustain health equity, it is critical that learning health systems (LHS) adapt and function in ways that directly prioritize equity.

          Methods

          We present guidance, including seven core practices, borne from theory, evidence, and experience, for actors within LHS pursuing equity.

          Results

          We provide a foundational definition of equity. We then offer seven core practices for how LHS may effectively pursue equity in health: establish principle, measure for equity, lead from lived experience, co‐produce, redistribute power, practice a growth mindset, and engage beyond the healthcare system. We include three use cases that illustrate ways in which we have begun to center equity in the work of our own LHS.

          Conclusion

          The achievement of equity requires real transformation at individual, institutional, and structural levels and requires sustained and persistent effort.

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          Most cited references40

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          Structural racism and health inequities in the USA: evidence and interventions

          The Lancet, 389(10077), 1453-1463
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            Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

            Background Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Methods A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1–5 scale). Results In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5). Conclusion This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available. Electronic supplementary material The online version of this article (10.1186/s13012-018-0842-6) contains supplementary material, which is available to authorized users.
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              Defining equity in health.

              To propose a definition of health equity to guide operationalisation and measurement, and to discuss the practical importance of clarity in defining this concept. Conceptual discussion. Setting, Patients/Participants, and Main results: not applicable. For the purposes of measurement and operationalisation, equity in health is the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage-that is, wealth, power, or prestige. Inequities in health systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group) at further disadvantage with respect to their health; health is essential to wellbeing and to overcoming other effects of social disadvantage. Equity is an ethical principle; it also is consonant with and closely related to human rights principles. The proposed definition of equity supports operationalisation of the right to the highest attainable standard of health as indicated by the health status of the most socially advantaged group. Assessing health equity requires comparing health and its social determinants between more and less advantaged social groups. These comparisons are essential to assess whether national and international policies are leading toward or away from greater social justice in health.
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                Author and article information

                Contributors
                carley.riley@cchmc.org
                Journal
                Learn Health Syst
                Learn Health Syst
                10.1002/(ISSN)2379-6146
                LRH2
                Learning Health Systems
                John Wiley and Sons Inc. (Hoboken )
                2379-6146
                22 June 2021
                July 2021
                : 5
                : 3 , Collaborative learning health systems: Science and practice ( doiID: 10.1002/lrh2.v5.3 )
                : e10279
                Affiliations
                [ 1 ] Division of Critical Care Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
                [ 2 ] Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio USA
                [ 3 ] Division of Hospital Medicine Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
                [ 4 ] James M Anderson Center for Health Systems Excellence Cincinnati Ohio USA
                [ 5 ] Community Advocate Cincinnati Ohio USA
                [ 6 ] Community Matters Cincinnati Ohio USA
                [ 7 ] Division of Endocrinology Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
                [ 8 ] Division of General and Community Pediatrics Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
                Author notes
                [*] [* ] Correspondence

                Carley Riley, Division of Critical Care Medicine, Cincinnati Children's Hospital, 3333 Burnet Ave. Cincinnati, OH 45229 USA.

                Email: carley.riley@ 123456cchmc.org

                Article
                LRH210279
                10.1002/lrh2.10279
                8278437
                34277945
                5ac0e913-f3f6-4627-be87-2ad7a63933b2
                © 2021 The Authors. Learning Health Systems published by Wiley Periodicals LLC on behalf of University of Michigan.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                : 17 May 2021
                : 16 December 2020
                : 18 May 2021
                Page count
                Figures: 3, Tables: 4, Pages: 10, Words: 8305
                Categories
                Experience Report
                Experience Reports
                Custom metadata
                2.0
                July 2021
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.0.4 mode:remove_FC converted:14.07.2021

                co‐production,health equity,improvement science,learning networks,population health,social determinants of health

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