Implementation Epidemiology Part III: In the Field

Well, we’ve reached the end of the implementation epidemiology three-part series. Thank you for coming along on this journey. Thank you for allowing me to give you a peek into my expertise. I hope that you have become interested, in some way, in this novel concept. 

In part I, I guided you through my training as an epidemiologist and several examples of such. I detailed my reasoning for marrying implementation science with the field of epidemiology, and why I feel it necessary. In part II, we dove a little deeper into the well of health equity and several theoretical frameworks that have guided my work – frameworks I will undoubtedly continue using as I move along in my career. Now, it’s time to talk candidly about implementation. To show you how I have used implementation epidemiology and health equity frameworks in the field applying them in my daily work. Putting these things into the perspective of practical application will, hopefully, help bring you out of the clouds of this unique concept and back to the ground. You’ve seen the forest; now, let’s look at a few trees. 

Chronic Disease & Cancer Epidemiology: For the first 5 years of my career as a public health professional, I worked for a large, non-profit, patient advocacy organization focused on eliminating one chronic disease in women – breast cancer. I didn’t realize how much of my education and skills I would be using when I started. But, if I could estimate, I’d say I used over 70% of the skills in my epidemiology tool bag during my time there. I implemented my education and training to programs, projects, and data in the real world. I used my quantitative data collection skills, disease surveillance skills, biostatistics analytics proficiencies, process and impact evaluation knowledge, report writing, and research skills. I transformed databases from Excel to work more efficiently in Access; helped determine mortality predications based on epidemiologic indicators; and, best of all, applied morbidity and mortality disparity data to a national health equity initiative to reduce breast cancer disparities among Black women. The principles of chronic disease & cancer epidemiology I learned during my graduate school education and internship training were bleeding all over my work. There wasn’t a day I wasn’t confronted with the complexities of understanding breast cancer prevalence, incidence, mortality, screening, and diagnostic rates among specific populations and how the social, political, and systemic determinants of health increase racial disparities for each of these indicators by increasing risk factors for Black and brown populations. Because breast cancer largely affects women, I also learned to constantly scrutinize these health outcomes through a gender-responsive lens. This helped me understand the intersections of being a woman, being a minority, being a caregiver, being a breadwinner, bearing children, the desire to do so, breastfeeding, and the like. Honestly, without considering the effects of the construct of gender on breast cancer survivors, there is no true patient advocacy. After all, one cannot advocate for a population one barely understands. Thus, I was consistently open to and privy to applying implementation science to my training in chronic disease and cancer epidemiology.  

Program/Project Design, Development & Implementation: To some of you reading this, a lot of what you’re thinking about the design, development, and implementation of public health programs using implementation science and epidemiology to advance health equity should go without saying. However, it’s not always as easy as dropping in the knowledge where you think it should go. For instance, I played a major role in the design, development, and implementation of a national behavioral health marketing campaign aimed at empowering Black women to know their family health history and breast “normal” to reduce their risk of developing cancer. To say that it wasn’t as easy as showing up to every meeting with my theories in hand and knowledge on display is an understatement. The amazing woman who brought me along on the project (now my mentor) and I took proverbial hit after hit explaining why certain messages, images, verbiage, and depictions weren’t going to work for Black women. I even had to pull out the diffusion of innovation (DOI) theory for an evaluation plan linked to the application of the campaign at a large activation. Partnering with a very large ad agency also meant working with people who just KNEW that their ideas were BEST for Black women. It was not only painful but discouraging, at times. But, every day I showed up with my “health equity hat” on ready to implement what I knew to be true about the epidemiology of breast cancer in Black women – we were, and still are, dying. And no amount of pandering to the point was going to help. We had to be genuinely transparent and put to work what we knew about racism, the social determinants of health as it pertained to getting Black women empowered, the social ecological model (SEM), DOI, and gender responsive communications. In the end, what made this campaign special (after 2 years of multiple iterations), was that it appealed to our, the Black woman’s, sense of womanhood in the sisterhoods we find with all the women in our lives. Something that can only be accomplished by speaking the language of health equity so fluently that you can contribute to a campaign so powerful that it moves people to action. Now, due to unforeseen circumstances, we never evaluated whether the campaign moved people to action. The tales of that bureaucracy are neither important nor appropriate for this piece. But, in so many circles, at several activations, we heard how the TV spots, billboards, and social media content made Black women feel included in the fight to end breast cancer. And, it won an advertising award! I won’t link it here, but if you’d like to see it, ask me for my resume. J

Partnering with Stakeholders: When you attempt to implement these concepts in the field, you quickly hit what I call “the people hurdles”. This is where you must learn to partner with stakeholders on all levels –community members, community leaders, patients, advocates, legislators, large organizations, small businesses, health systems, community-based organizations, state leaders, federal legislators, etc. This can be the most fun part of implementing epidemiology and health equity in the field. You can work with people and entities that are reaching for the same goals and envision the same equitable world. Here is also where it was vitally important for me to take inventory of what frameworks I viewed to be undisputable to my work. Those seven frameworks from part II were not only applied in the inner workings of programs and projects, but in my relationship building processes. It was all about meeting people where they were. No matter their place on the stakeholder wheel. No matter their expertise or title. Meeting them where they were to bring them along with the cause of advancing health equity and using epidemiologic data to do it. It also meant understanding who was at the table, who was historically excluded from the table on purpose, who needed to be at the table, and who we could persuade to sit with and guide us. Implementing these theoretical frameworks meant that I had to be honest about working for a predominantly white organization that had led this work from a white lens for decades. Being honest with myself that some stakeholders would question my motives (as they should) and others simply wouldn’t come along. It happened both ways. But, because I remained true to the culture, I always spoke truth to power, I kept showing up, and kept implementing my expertise, I built a heavy personal-professional network and assisted in cultivating a robust stakeholder network for the health equity initiative. When I took account of who had been historically excluded from the table, on purpose, I was sure to be honest about the results of that exploration with every stakeholder. Understanding Dr. Jones’ three levels of racism meant I was sure to name the institution for which I worked as one having had perpetuated institutionalized racism that undoubtedly fueled disparities and drove inequities. This helped to gain and maintain trust among stakeholders who were never even invited to the table before. I could go even deeper into the depths of applying my favorite seven frameworks across partnership and relationship building. I hope that is not necessary at this point. 

Public Health Communications: My graduate school education at Saint Louis University’s College for Public Health and Social Justice, along with my internship training afforded me a robust learning in public health communications. Much of my internship was disseminating complex public health messages to school nurses and updating the county’s website dedicated to reducing STI’s in specific populations. But, nothing, and I mean NOTHING trains a person to be an expert in public health communications like working for a national non-profit for which every written word across every medium (social media, press, website, disease infographics, reports, etc) is scrutinized. During my first few months there, I didn’t quite understand the need for incessant feedback on every single document. Everything went through eight to 10 rounds of edits. No matter its length. No matter its message. No matter its audience. Do you know how resilient you must be to have your professional work scrutinized eight to 10 times by five to six different people? I quickly learned, however, that communications were, arguably, the most important part of my job. We could do all this great work, applying these wonderful theories, using all our great expertise, and it mean nothing if it didn’t reach the right audience, in the right tone, with the right message. So, I grew used to the edits, to appreciate them even. It is because of those seven years (in school and at work) living and breathing in the communications gauntlet, that I can say with the least humility, I have a ton of communications expertise. You may feel it arrogant, but when I speak, be it via written or verbal channels, across any medium, people listen. I am not so arrogant, however, that I miss any areas for improvement. As language is arbitrary, so is the way we communicate it. I could always use more inclusive verbiage, more succinct words, more inviting language, and more culturally appropriate tones. This is where the implementation epidemiology and health equity lens make all the difference. Creating an infographic and writing an evaluation report require two different writing muscles, but should be met with the same lens. I can’t explain in an evaluation report the intricacies of DOI without understanding the intersections of how a Black woman’s social support network heavily influences her decision to be ready to receive information let alone move from contemplation to action. I also can’t create infographics that don’t appeal to Black women and expect to get 50+ likes on LinkedIn or Instagram. It all must make sense. 

Advocacy & Public Policy: One of the projects that I am most proud to have been a part of was the beginning of a Speak Truth to Power advocacy and public policy initiative that sought to train a more diverse cohort of legislative advocates to support policies that sought to advance health equity. The project allowed me the opportunity to train advocates to use data to advance health equity. Understanding trends across and within metropolitan areas for disparities across mortality, incidence, and prevalence rates in constituents’ communities sets the tone for communicating such trends to legislators in meaningful ways. Now, I’m certainly not signaling that you should meet with your lawmakers and lecture them on the social determinants of health or the three levels of racism. What I am saying is that your knowledge of these concepts helps you use public health communications principles to speak to policy makers in their language, meeting them where they are, and persuading meaningful dialogue that will hopefully get bills passed. Likewise, having full working knowledge of all seven of my favorite theories assisted me in evaluating this project; including understanding how to bring it to scale. 

Quality Improvement: Last but certainly not least, I am currently employing these theories in the practice of implementing quality improvement and education projects for clinicians for several disease states. I’ve moved from solely focusing on cancer epidemiology to implementing these principles for prostate cancer, diabetes, heart failure, and COVID-19 health outcomes. While it is difficult to say if my expertise is completely and wholly appreciated by every single partner I work with, I know the majority welcome the implementation science and health equity lens I bring with my understanding of epidemiology and quality improvement. It is often asked of me how to put these concepts into action to improve clinical quality. It begins with a reckoning that you, the practitioner, know little to nothing of health equity. Then, you must take equity on as a cause, and allow it to guide your clinical practices and workflows. You must think of disease not only as a behavioral or genetic issue, but one that is influenced by varying systems that seek to oppress; one in which you operate daily – the healthcare system. You must then behave accordingly, doing what you must to ensure culturally responsive care is top priority. Once it is woven into the fabric of your practice, you can advance health equity via clinical quality improvement by taking on specific activities that focus on a clinical aspect of your process and incorporate standards of care that are culturally appropriate and acknowledge racial and ethnic disparities. 

These are only a few of the professional examples to which I have been blessed to apply implementation epidemiology and health equity innovation. The breadth and depth of the experiences of my short nearly seven – year career are too many to name. So many that I am humbled by the experiences that I have had in such a short time and that they have allowed me the space to cultivate this professional brand of mine. Going forward, I hope I can lead more, do more, innovate more, and learn more of how to apply implementation epidemiology as a health equity champion and innovator. I hope someday this concept takes flight. For now, thank you for reading and stay tuned. 

-Kristen Marie