The Institute for Healthcare Improvement’s 100 Million Healthier Lives campaign endeavors to reach its namesake goal by the year 2020. One initiative (SCALE) supplies 18 coalitions around the USA with tools and resources to become a Community of Solutions; a cornerstone of which is improved health equity among vulnerable populations (Stout, 2017). Using SCALE resources, each coalition sets their own goals and chosen methods for improving health in their region. This paper aims to understand the systemic factors affecting implementation of a key component of this initiative’s theory of change – health equity.
Qualitative Comparative Analysis (QCA) is a promising method for program evaluation and implementation science (Cragun et al., 2016). Based in set theory and complex causality, QCA is a hybrid qualitative-quantitative method that reveals patterns indicative of causal explanations for events (Ragin, 1999). It has been found effective for identifying program factors affecting individual-level outcomes, yet few studies use QCA for identifying systemic factors affecting implementation success within organizations or coalitions. Using the Interactive Systems Framework for dissemination and implementation (Wandersman et al., 2008), delivery system and macro-political factors were analyzed via fuzzy set QCA to determine their relationship to coalitions’ equity action plans. These factors included coalition readiness, setting, target population, and state health policy.
Results determine two combinations of conditions affecting whether coalitions prioritized equity (consistency = 0.86; coverage = 0.54). The first sufficiency recipe shows that coalitions in states that have not expanded Medicaid often (consistency = 0.86) prioritized equity in their plans. These coalitions (N = 6) are working to affect health in states with minimal support for low-income citizens who could benefit from the expansion of Medicaid. The second sufficiency recipe suggests that coalitions working with minority or homeless populations and with low readiness for Community of Solutions (consistency = 0.89) prioritized equity in their plans, but this accounted for a very small amount of the outcome (coverage = 0.08).
Results underscore the significance of macro-political context for achievements in health equity. Among coalitions that did not adequately include equity in their action plans, all are in states that did expand Medicaid, suggesting that community-level implementation efforts may be a lower community priority in states with policies already addressing health of under-resourced citizens. This also highlights that macro-systemic factors, in addition to delivery system factors should be included in analyses of implementation success.