Design and method considerations for equity-centered implementation science and practice: A PEDALs approach

The persistent "know-do gap"-the lag between the development of evidence-based practices (EBPs) and their routine use in health systems-remains a barrier to achieving global health equity. Implementation science offers a pathway to bridge this gap, but without an explicit equity focus, it risks reinforcing existing disparities. In this perspective, we propose an equity-centered adaptation of the PEDALs model (Problem, Evidence-based practice, Determinants, Action, Long-term use, and scale) to guide more just and context-sensitive implementation efforts in global health. We describe how each stage of PEDALs can be used to embed equity considerations in implementation research and practice. These include identifying root causes of inequity-linked health problems (P), using both scientific and practice-based evidence while adapting or de-implementing interventions (E), engaging marginalized voices when analyzing barriers and facilitators (D), co-designing contextually grounded implementation strategies (A), and measuring long-term implementation outcomes through an equity lens (L), including attention to scalability, iterative learning, and proper design and methods (s). We highlight methodological considerations-such as hybrid designs, embedded and workflow-based research, and rapid and participatory methods-that support timely, relevant, and equitable implementation. Our model builds on the concept of "radical incrementalism" to emphasize steady, equity-driven change that is responsive to diverse settings, especially in low- and middle-income countries. This modified PEDALs-based approach offers a practical structure for design and methodological considerations in advancing equity-centered implementation science.