Making decisions and taking actions: Embracing the complexity of implementation to reduce health inequalities

Research problem and specific questions: This program sheds light on the implementation challenges involved in changing health determinants to achieve improvements in public health.

The aim of the program is to explore implementation challenges related to decision-making and practical implementation of structural interventions as well as preventive programs and their implication for health equity.

The program combines expertise in public health and implementation science with the goal of identifying ways to close the gaps in health among societal groups.

Data and method: The program builds on complexity theory to reflect that implementation of public health initiative involves multiple, often interdependent, stakeholders, decisions and activities. The program has three phases.

The first is an exploratory qualitative phase including interviews with local politicians and administrators (in municipalities and regions) to understand how they make decisions about public health, including how the needs of different societal groups and conflicting societal goals are prioritized.

The second phase involves several naturalistic experiments of local implementation and de-implementation cases investigating barriers and facilitators to these processes, strategies to overcome barriers, management of fidelity and adaptations and implementation outcomes.

This entails a participatory approach in which the local actors implement initiatives and participate in collecting data. Analysis includes qualitative and quantitative cross-case comparisons.

In the third phase, implementation capacity-building interventions aimed at decision-makers and implementers of public health initiatives are designed and evaluated.

Relevance and utilisation: Although Sweden has one of the most developed welfare systems and ambitious public health policy goals, health inequalities are growing and systematic inequalities in health remain in almost all health outcomes and determinants.

Implementation of structural interventions and preventive programs are needed, yet implementation research shows that these too often fail to reach, retain and deliver value to those most in need.

If implementation between groups diverge, implementation of public health initiatives may increase rather than decrease health inequalities.

This program addresses this contradiction by developing new knowledge on how public health initiatives can be implemented for disadvantaged populations.

Plan for program realisation: This multidisciplinary program takes a participatory approach involving three research environments at two universities. A total of 63% of the costs cover salaries for the 12 participating junior and senior researchers. Operating costs (15%) include reference group reimbursement, communication activities and data collection.