In a disaster, historically marginalized populations experience systemic barriers and injustices because of unequal power dynamics across multiple dimensions, such as race, gender identity, sexual orientation, physical ability, language, immigration status, and several other characteristics rooted in the social determinants of health. Reference Kawachi, Subramanian and Almeida-Filho1–Reference Nomura, Parsons and Hirabayashi4 As a result, disasters have consistently exacerbated inequities in morbidity, mortality, and access to health care for historically marginalized populations. Reference Kroll-Smith5–Reference Maness, Merrell and Thompson11 Health-care systems use the Hospital Incident Command System (HICS) to plan and coordinate their disaster response 12 ; however, there is no requirement or explicit guidance to consider health equity in the HICS structure or its implementation. Reference Goralnick, Serino and Clark13
The HICS originated from the Incident Command System (ICS), a core component of the National Incident Management System, which assists public agencies in coordinating their disaster response by providing a common language and guidance across sectors, allowing for cross-coordination among multiple organizations or hospitals within a health system in a Unified Command structure. 14 The fundamental components of the HICS are a clear chain of command with predefined roles to streamline communication and decision-making, a flexible and scalable structure with a modular design that can be adapted for each incident, and a focus on objectives and action planning to provide strategic direction efficiently. 12 The incident commander leads the HICS and collaborates closely with the command team comprising several officers. Each officer and section role has a Job Action Sheet, which details the tasks for each role by time frame. 12 Even though the HICS is structured as a hierarchy, it functions as a centralized network with the incident commander at the center, receiving inputs from HICS members. Reference Moynihan15
When viewed through the lens of implementation science, which is the study of how interventions are translated into practice, one can appreciate potential challenges with implementing the HICS. 16 Context, or how interventions are woven together within a given environment, is a critical component of implementation, Reference Nilsen and Bernhardsson17 and the constantly shifting context of disasters and complexity of roles and relationships involved in the HICS can pose challenges to implementation. Reference Nowell, Steelman and Velez18,Reference Moynihan19 There is a paucity of implementation research on ICSs; however, 1 review of cases found that adding new members as the crisis increased in size and complexity disrupted the stability and efficiency of the ICS. Reference Moynihan15 This creates a tension between inclusiveness and efficiency, with new members adding expertise but costing time in coordination and integration into the established norms. Reference Moynihan15 Even with the loss of efficiency, networks benefit from increasing the heterogeneity of backgrounds and expertise. Reference Nowell, Steelman and Velez18 Additional perspectives are critical when prioritizing health equity, which is more effective when decision-making includes diverse leaders. Reference Eze20
The coronavirus disease 2019 (COVID-19) pandemic led to a widespread activation of HICSs across the United States. 21 Trends from past disasters were repeated, with inequities in infection rates, morbidity, and mortality. Reference Magesh, John and Li7 These inequities were also present within the health-care workforce, with people of color and lower-wage frontline workers disproportionately impacted by the pandemic. 22 The protracted response and dual crises of COVID-19 and systemic racism led to several novel strategies to include equity in the disaster response. Health equity can be considered as a process by removing systemic and structural barriers to health and an outcome with all individuals having a fair and just opportunity to be healthy. Reference Braverman, Arkin and Orleans23
There is a recognized need for practice-based studies incorporating health equity into implementation science and building up the evidence base for public health emergency preparedness and response. 24,Reference Brownson, Kumanyika and Kreuter25 We must explore successful implementation efforts to inform improvements for future disasters. This study aims to address the gap at the nexus of implementation science, health equity, and disaster research to explore how 2 academic health systems centered equity throughout the implementation of their HICS and identify elements that influenced implementation.
Methods
Study Design
This study is a retrospective, qualitative case comparison study. The Consolidated criteria for reporting qualitative research checklist was used as a reporting framework. Reference Tong, Sainsbury and Craig26 The Johns Hopkins Bloomberg School of Public Health IRB has reviewed and approved this study.
Conceptual Framework
The Consolidated Framework for Implementation Research (CFIR) is a meta-theoretical framework that includes constructs from existing implementation theories and frameworks and comprises 5 domains: outer setting, inner setting, individual characteristics, intervention characteristics, and process. Each domain contains multiple constructs associated with effective implementation. CFIR can be used after implementation, selecting the most salient constructs to identify barriers and facilitators and inform future efforts to spread and scale the intervention. Reference Damschroder, Aron and Keith27,Reference Kirk, Kelley and Yankey28
Study Setting
The 2 academic health systems, System A and System B, were identified through a literature review focused on embedding equity into the HICS. They are high-performing, high-reputation health systems in the United States located in diverse urban communities. The systems are structured differently, with System A as part of an integrated health system that includes other health systems and over 10 hospitals. In contrast, System B is part of an enterprise comprising the health system and a university. There was a Unified Command for each health system at the level of the integrated health system for System A and enterprise for System B, which had representatives from a Unified Command for each health system, comprised of individual HICS for each hospital or ambulatory location. Our study focused on the health system level so we chose to use the term HICS for the health system Unified Command for simplicity.
Participant Recruitment
This study used purposive sampling first to recruit participants who were members of the HICS or regularly interacted with the HICS during the COVID-19 pandemic response. Then snowball sampling was used to identify other potentially relevant participants by asking for contacts at the end of each interview. Participants were contacted up to 3 times from January through May 2022 by means of secure email.
Data Collection
The CFIR was used as the foundation for the semi-structured interview guide (Supplementary Material 1). This study focuses on constructs within the intervention, inner setting, outer setting, and process domains. We chose the intervention domain because this approach is novel and the process domain because of the challenges with implementing changes in the HICS. The inner and outer settings were chosen because of the importance of the health system and community context in health equity. Reference Brownson, Kumanyika and Kreuter25 For this study, the inner setting is the hospital, health system, and integrated health system; the outer setting is external organizations and the community. Questions corresponded to constructs within these domains and mapped to the interview guide.
Interviews were conducted by 1 researcher (R.M.S.), a female physician assistant with experience in implementation, qualitative research, and emergency medicine. The interviews were 30 min to 1 h over a password-protected video conferencing platform. Interviews were audio-recorded with permission, and an auto-generated transcript was created and reviewed for discrepancies. After the interview, R.M.S. took field notes to capture overall impressions. Data collection continued until at least 1 equity representative and incident commander were interviewed at each site, and participants identified no further contacts. In addition to exhausting contacts, we reached data saturation, with information from new interviews being redundant to information we had already collected. Reference Saunders, Sim and Kingstone29
Data Analysis
During the analysis, the approaches used by the sites to promote equity were consolidated under a single code. Subsequently, these approaches were categorized based on the social determinant of health domain they potentially impacted. 30 This study used a constructivist approach with a hybrid of inductive and deductive thematic analysis as described by Fereday and Muir-Cochrane. Reference Fereday and Muir-Cochrane31 First, we developed a codebook with a priori codes using CFIR constructs and their standardized definitions provided in a CFIR codebook template. 32 Then data were analyzed using Nvivo (version 10.0, QSR International), and data that did not fit into the pre-selected CFIR codes were inductively coded with new themes added under new codes. The first transcript was coded by 2 authors (R.M.S., C.T.Y.) to validate the coding frame which was used for the remainder of the transcripts. After coding was complete, word tables were created for second-order coding and cross-case comparison. Next, relationships were identified between the deductive and inductive codes, connecting related codes. Finally, the tables were reviewed for significant themes and categorized as barriers or facilitators. To enhance rigor this study used member checking, sending all participants a summary of the themes identified and asking for feedback. Reference Lincoln and Guba33 Responses were reviewed for applicability to the research question and integrated into the results.
Results
This study includes 29 individuals, with 16 participants from System A and 13 from System B, representing a mix of roles in the HICS (Table 1).
Table 1. Participant characteristics
a No participants identified as non-binary, transgender, or agender.
b Participants may be represented in multiple categories. No participants identified as American Indian or Alaskan Native, Middle Eastern or North African, Native Hawaiian, or Pacific Islander.
Description of the Approaches to Incorporate Health Equity Into the HICS Implementation
The systems used several strategies to incorporate health equity in their HICS as they responded to needs in the evolving context of the COVID-19 pandemic. These approaches often happened simultaneously, with some permanently embedded in the HICS and others temporarily responding to a specific need. Both systems included strategies that addressed all 5 domains of the social determinants of health, to reduce structural and systemic barriers for their employees and patients, 30 summarized in Table 2. Although there were many similarities, System B was more outwardly focused on community-based initiatives, while System A had a more operational focus.
Table 2. Summary of approaches categorized by social determinants of health domain
Abbreviations: COVID-19, coronavirus disease 2019; ICU, intensive care unit; PTA, parent-teacher association.
Early in the pandemic response, both systems added an equity representative in the HICS, although they took different approaches, reflected in the networks formed around them (Figure 1). The equity representative was described as someone who provided subject matter expertise, advocated for historically marginalized populations, and partnered with others to operationalize solutions. System A formally added the equity representative to the HICS organizational chart, reporting to the command staff and acting as a bridge for bidirectional communication. In contrast, the equity representative in System B was the Chief Diversity Officer; and although not formally added to the HICS they attended meetings, reported on equity issues, and were involved in several equity-focused committees.
Figure 1. Equity representative networks.
Perceived Success
Every individual interviewed supported sustaining an equity focus when implementing the HICS for future disaster responses. They agreed that the approaches used were successful and care was more equitable because of their efforts. Seven participants qualified this by noting a greater need related to social determinants of health and systemic racism that the HICS could not adequately address.
Implementation Barriers and Facilitators
Nine facilitators and 5 barriers to centering health equity in implementing the HICS were identified in this study (Table 3).
Table 3. Themes and represenative quotes
Facilitator: HICS principles
The HICS provides a template that adapts to the unique needs of different disasters, facilitating the quick addition of an equity representative and the evolution of the role throughout the response. Other fundamental HICS principles that facilitated implementation were situation reporting on equity at meetings (eg, COVID-19 admission rates stratified by demographic identifiers, community outreach events) and including equity in the after-action report.
Facilitator: External partnerships
Both sites partnered closely with external organizations in response to the pandemic, including their state government and health departments, to collaborate on allocating scarce resources, equitable vaccine distribution, and data sharing. The partnerships were bidirectional and synergistic, leveraging each site’s strengths and facilitating sharing resources and information.
Facilitator: Community relationships
Participants stressed that the HICS must hear directly from the community to provide a culturally-attuned disaster response. They did this through community outreach events, such as mobile vaccine and testing initiatives and partnering with community organizations. Relationships that had been formed before the pandemic were activated, allowing for a rapid community response. Information from the community helped the sites identify challenges such as lack of housing and food, create informational campaigns around vaccine hesitancy, and provide critical context to the population they serve.
Facilitator: Senior leadership
Senior leaders, such as the incident commander and other executive leaders (eg, Chief Medical Officer, Health System President) heavily influenced the adoption of health equity into implementation. Influential leaders communicated that equity was an expectation and worked to “pull” equity information up instead of waiting for the equity representative to “push” it up. They proactively sought input on others’ perspectives to understand the historically marginalized populations they serve. In addition, they encouraged others to speak up about equity and propose creative solutions, contrary to the typical hierarchical nature of the HICS.
Facilitator: Health equity experts and networks
Deep expertise in health equity enabled implementation at both sites. The HICS was able to draw from existing subject matter experts and the equity representative leveraged their informal networks with others involved in equity across the organization. They used these networks to break down silos and collaborate on the disaster response, creating solid relationships that participants credited for the sustainability of many efforts.
Facilitator: Champions
The initial catalysts for incorporating health equity into the HICS were vociferous champions who passionately advocated for health equity. The most notable champions included the equity representatives, and those with a close connection to the community (eg, ambulatory health, community liaison). Champions were effective because of their ability to communicate on behalf of historically marginalized populations and their willingness to take initiative and act.
Facilitator: Equity-stratified data
Equity-stratified data enabled System A to monitor effectiveness in real time, identify gaps, and set quantifiable goals around equity. The data were reviewed at every HICS meeting and shared with staff at town hall meetings led by the HICS. This data-driven approach had a powerful effect, providing evidence and an impetus for action. System B relied less on equity-stratified data and primarily accessed data through the local health department.
Facilitator: Teaming
The constantly evolving needs throughout the pandemic required nimbleness, and teaming (ie, forming dynamic teams to address specific problems Reference Edmondson34 ) was the primary mechanism to implement solutions to address gaps in health equity. Teaming occurred on different scales, sometimes as large committees and others as small teams of a few individuals. The teams would expand or contract to ensure the inclusion of the relevant experts, with the equity representative present or leading many of the teams. The willingness to be flexible and partner to accomplish tasks was inspiring to those involved and credited for the robust response.
Facilitator: Culture of health equity
The increased awareness of systemic racism and the data demonstrating inequities in COVID-19 outcomes created tension for immediate changes in the HICS. Participants described the transformation in individuals’ receptivity to equity throughout the pandemic, recognizing that everyone was at different places in the internal work of exploring biases and recognizing the role of systemic racism in society. Each system began the pandemic with differences in the culture around health equity, with System A just beginning the work and System B having equity established as part of its organizational culture.
Barrier: Clarity of the equity representative role
Both sites failed to formally define the role of the equity representative, which created confusion. Even though System A added the equity representative to the organizational chart, there were still questions related to the scope of the role, channels for communication, and the division of tasks among others leading equity-related efforts. System B never formalized the role on the organizational chart, and participants were unsure how the equity representative fit into the HICS, to whom they reported, and the scope of their role.
Barrier: Tokenism
There was tension around the risk of tokenism, with the equity representative only serving a symbolic role. Equity representatives expressed frustration with expectations placed on them to solve any issues related to people of color. They believed they bore the responsibility for entire populations instead of it being the collective responsibility of the HICS. When probed about this topic, participants agreed that equity should be everyone’s responsibility, and some expressed that the equity representative role promoted this by advising and partnering with the HICS as a subject matter expert. However, others believed that having an equity representative abdicates leaders from being responsible for equity. Despite these differences, participants viewed the equity representative as a first step, with future responses including equity subject matter experts in multiple areas of the HICS.
Barrier: Competing priorities
Ensuring an equitable disaster response requires a thoughtful approach and taking the time to consider the needs of different populations. This balance can be particularly challenging in a disaster, with the HICS managing several competing priorities with finite resources. The process of incorporating equity considerations can interrupt plans and be a significant barrier in the rapid decision-making central to the HICS.
Barrier: Insufficient resource allocation
The equity representatives were involved with equity efforts before the pandemic and were able to pivot quickly; however, they spent significant time outside of their regular job responsibilities for their new role. The equity representatives had small teams, which made it difficult to act, with 1 participant commenting that this communicated a lack of power and importance to the role. Both sites provided some financial resources, but there was also a perception that leadership support was largely “theoretical,” which left people scrambling for resources or donating their own time or money.
Barrier: Lack of preparedness
There was no pre-planning around equity, and sites began the pandemic response by implementing their pre-established HICS structure. The HICS response began with everyone running on “fear and emotion,” but within weeks, they recognized the need to embed equity after seeing inequities in infection rates and morality. Implementation was rapid, and the HICS constantly iterated to keep up with the most pressing issues. Participants expressed that it would have been more organized if health equity had already been built in, such as a defined equity representative role and equity as a standing item on the agenda and after-action review.
Discussion
This study explored how 2 health systems incorporated health equity in implementing the HICS during the COVID-19 pandemic. The interventions’ primary strategy was adding an equity representative who advised the incident commander and led many equity-promoting efforts. The systems took different approaches, with System A being more internally focused, formal, and data-driven; and System B being more community-focused, informal, and diffuse, partnering with many external organizations. Despite the differences, both systems took several actions to reduce barriers related to the social determinants of health to advance health equity. Their approaches demonstrated feasibility in the context of the COVID-19 response.
The facilitators identified in this study mirror the new leadership standards released by the Joint Commission to reduce health disparities. 35 The new standards require a leader focused on equity efforts, assessing patients’ needs and the social determinants of health, collecting and reviewing equity-stratified data, and developing action plans and goals around health equity. These standards can be adapted for the HICS and written into emergency preparedness plans and policies. In addition, health systems can begin to strengthen strategic relationships with the community and other organizations while building a culture of health equity in their organization with learning sessions, messages from leadership, and training. Centering equity in day-to-day operations primes systems to provide equitable care in a disaster.
Thoughtful planning can mitigate many of the barriers identified in this study, such as reviewing previous disaster responses for gaps in health equity and revising emergency plans to address these gaps. In addition, systems can add an equity representative in their HICS, with the role clearly defined using a Job Action Sheet, which was created based on the interviews as a template for systems (Supplementary Material 2). Including equity representatives in disaster training and drills provides necessary knowledge about emergency management and builds relationships with other members of the HICS. To avoid tokenism, the HICS should include multiple equity roles with clear messaging from the incident commander that equity is everyone’s responsibility, and leaders should seek diverse representation to provide a variety of perspectives.
To our knowledge, there is little research on this topic. Before beginning this work, we conducted a background literature review and found 3 themes that align with the approaches used by these health systems: embedding equity specialists in the HICS, modifying systems to promote equity, and sensitivity to the local community. Reference Moyal-Smith, Barnett and Toner36 There is a need for future research on this topic, including the critical role of context, with both health systems taking slightly different but seemingly effective approaches to incorporate equity in their HICS. Further efforts are needed to measure the effectiveness of individual components so those can be priorities for widespread adoption and to evaluate the perception of the community on the success of these efforts. Even without these measures, the cases described in this study can serve as a starting point for changes to national policies while providing flexibility for organizations to adapt approaches to their local context. Regulatory bodies can consider incorporating health equity into the HICS structure and training materials and make similar changes to ICSs for other sectors, expanding the potential to advance health equity in all aspects of the disaster response.
Limitations
A limitation of this study was its design as a case comparison study, which was chosen to capture the nuances of implementation; however, the cases selected had similarities that may limit generalizability, especially for smaller community hospitals or rural settings. This study only captured experiences from 2 health systems; there may have been other novel approaches that were not explored. In addition, this study examines approaches used in the context of the COVID-19 pandemic, which differed from other disaster responses because it was a novel virus, with changes as medical knowledge evolved. It also required an unusually prolonged response that lacked nationally coordinated guidance. 21,Reference Haffajee and Mello37 Still, many participants believed their changes would apply to other disasters with some adaptation. Finally, despite a high degree of perceived success, this study did not evaluate health outcomes to assess effectiveness. Currently, measures for equity in disaster preparation, response, or recovery are not formally defined or routinely collected and it would be difficult to determine the effectiveness of specific interventions because of the complexity of social systems and the absence of a 1-to-1 correspondence between an intervention and health equity indicators. Reference Finucane, Warren May and Chang38 Even without direct outcomes, the cases described took several actions to address the different needs in their community, which moved them closer to an equitable response than without these efforts.
Conclusions
Centering health equity in the HICS is essential in advancing health equity in disasters. Building health equity into emergency planning is more critical now than ever, with a predicted increase in natural disasters from climate change, most of which will disproportionately impact historically marginalized populations. 39,Reference Mazdiyasni40 Applying lessons from the cases described provides a starting point for others to build health equity into their emergency preparedness plans and work toward achieving an equitable disaster response.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/dmp.2024.20
Author contributions
R.M.S., J.A.M., and C.T.Y. designed the study with input from D.J.B., P.K., and T.P. R.M.S. recruited participants, conducted interviews, and analyzed the data with oversight from J.A.M. and C.T.Y. R.M.S. drafted the manuscript and all authors contributed substantially to its revision. R.M.S. takes responsibility for the study as a whole.
Competing interests
None.
