Embedding Equity into Implementation: The Equity Iceberg
By Dr. Sobia Khan, Director of Implementation & Dr. Julia E. Moore, Executive Director
9-min read
Over the past few years, there has been a focus on more seriously and intentionally addressing equity in both implementation science and practice. In 2021, we at TCI reflected on our own equity practice and looked to the field to see how we could improve everything we do to ensure equity is woven into all our work. We performed a review of the literature and had important discussions with people in the field, which ultimately culminated in two important products that we use regularly and share widely with others: our equity guiding questions (meant to help people reflect on equity in different ways throughout each implementation action or activity) and the equity iceberg. The equity questions are publicly through our Embodying Equity event and in the process of being refined and revised.
The equity iceberg as a tool to think deeply about equity in implementation
The equity iceberg was created as we did our own sensemaking about how people think about equity in different ways. Once we started talking about the equity iceberg to others, we noticed that the concept really resonated and provided a useful tool to start conversations around equity and to really pinpoint what we mean when we are discussing how to embed equity into implementation. The equity iceberg has four key levels: actions, relationships, system and structures, and mental models.
The things we do: equity in implementation processes and actions
The most surface level equity that tends to be practiced in both implementation science and practice are the specific actions we perform to make technical implementation tasks and activities more equitable. We like to think of the different process models in implementation – for example, those used to design for implementation or to implement, spread and scale – as the key guidance for what these tasks and activities might be in the first place. Then we think about what we can do to maximize equity for each of these tasks and activities. Some examples:
Most implementation models include an assess barriers and facilitators step. An equity action here would be to summarize barriers by different groups rather than “taking the average” to understand the unique challenges faced by certain people. Another action would be to analyze barriers and facilitators in the context of broader upstream causes (e.g., historical, social and political determinants).
Most people consider readiness in implementation. It is commonly assumed that we can’t work with sites that aren’t ready, which can be inequitable because those left behind are often the ones that need the most help. An equity action here would be to not treat readiness assessments as “ready or not” but as “meet them where they are” – so that more support can be given to sites that are less ready.
The people we work with: equity in relationships
We know that implementation is inherently a social process. No one person can do implementation work alone, and most actions described at the surface level are deeply rooted in how we interact with people in equitable ways. Therefore, relationships are one level deeper in the equity iceberg and are the bedrock for equity actions. For example:
Are we doing what we can to mitigate negative power dynamics so that everyone involved feels safe, comfortable, and has a sense of agency?
Have we considered how trust and mistrust is formed between groups of people not just at an interpersonal level, but at an upstream level informed by historical, social, and political determinants?
The institutions that govern us: equity in our systems and structures
We go deeper into the iceberg by questioning and addressing inequities in our institutions, which broadly refers to the organizations, fields, and policies that dictate what we do and how we do it. These institutions are the ones that shape how we form relationships and perform our implementation actions based on leniencies, restrictions, and norms. Examples include:
Promotion practices in an organization that consider the life circumstances of individuals rather than holding up a standard that favors certain people. For example, not penalizing certain groups of people who must take more time off (e.g., women on maternity leave, people with chronic illness) or who need to work from home (e.g., people with physical disabilities).
Changing the notion of “impact” in the academy to include methods of capturing more meaningful collaboration and work with communities, so that pathways to funding or promotion don’t heavily rely on extensive publications and presentations.
Our worldviews, values and beliefs: equity in our mental models
The mental models that we hold individually and collectively are under the surface but drive everything above. Components of equity-based theories and implicit bias tests and frameworks attempt to tap into this piece: how do we think the world works? What values and beliefs inform our world views? These mental models are often the basis of our systems and structures, shape our relationships and inform our actions. For example:
Believing that community / patient partners should have an equal voice in the planning process
Believing that Indigenous forms of knowledge are equally as valuable as other forms of knowledge
Putting the pieces together: an example
So how can the equity iceberg help you think more deeply about equity in your implementation work? Here is an example from a recent project I have been collaborating on. An action that a group took was to increase diversity on their implementation team by including community members. They attempted to create an inclusive environment through certain relationship dynamics where there was equal and transparent decision making, rotating chairs, and activities that helped foster psychological safety and trust. However, one major barrier to participation was that community members weren’t being paid for their time. When the team approached the organization to ask if community members could be compensated through grant funding, the systems and structures of the organization did not permit this. This ruling was seen to be driven by a mental model that community members aren’t skilled experts that deserve compensation, and there was no willingness to work around the system and structures because of this mental model. The conflict in mental models between the team and the organization created conflict in the work overall. Equity was attempted at the top two levels of the iceberg, but couldn’t go deeper – which ultimately disrupted relationships and therefore the actions.
Hopefully the equity iceberg can be useful to you and your work.
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