Implementation Processes Across Individual, Provider, and System Levels

The research on implementation strategies addressing cardiometabolic disparities among Black men remains limited, particularly strategies targeting patients, healthcare providers, and healthcare systems [20, 21]. However, existing approaches–such as culturally tailored health education programs, peer-led models, barbershop-based interventions, and policy-level changes–offer valuable insights into enhancing engagement, adoption, and sustainability of evidence-based interventions while also addressing the unique barriers faced by Black men [21, 32,33,34,35].

Patient-Level Strategies

Patient-level strategies prioritize culturally tailored interventions that improve health literacy, support self-management behaviors, and enhance treatment adherence by addressing the specific needs and barriers faced by Black men. Through application of the CFIR framework, these strategies can be examined by considering how they incorporate culturally relevant intervention characteristics, leverage trusted community networks to address external influences (outer settings), and enhance individual capacity through education and support. This approach allows for systematic assessment of both the strategies themselves and the contextual factors that influence their implementation. Community-based interventions, such as peer-led barbershop programs, exemplify this approach by creating culturally appropriate environments that promote health management. For example, Ebinger et al. (2020) demonstrated the effectiveness of barbershop-based interventions in managing hypertension, leveraging trusted community spaces to foster engagement and address outer setting factors such as trust and cultural norms [32]. Griffith et al. (2013) highlighted how male peer influence motivates Black men to adopt healthier behaviors, illustrating the role of peer models in enhancing individual-level factors such as self-efficacy and motivation [32]. Similarly, Luque et al. (2014) further emphasized how characteristics of interventions, in this case barbershop-based programs, can empower community leaders to deliver culturally relevant health education, making health messaging more impactful and increasing intervention effectiveness [31]. While these strategies have shown promise, scalability and long-term sustainability remain significant challenges due to resource demands. This underscores the need for systemic investment and infrastructure to support their broader implementation.

Provider-Level Strategies

Provider-focused strategies aim to improve workforce diversity, deliver implicit bias training, and incorporate peer models to foster culturally competent care. These strategies fall within CFIR’s inner setting (e.g., organizational readiness and training) and individual characteristics (e.g., healthcare providers’ skills and attitudes) domains. Of note, increasing representation among Black healthcare providers has been shown to enhance trust and patient engagement. Promising interventions for enhancing cultural competence among providers include structured cultural humility training programs, interactive case-based learning, and community immersion experiences. For example, programs that combine didactic education with experiential learning in community settings have demonstrated significant improvements in providers’ understanding of cultural factors influencing health behaviors among Black men. Additionally, ongoing mentorship by culturally competent senior providers and involvement of community members as educators have shown positive impacts on care delivery and patient satisfaction.

For instance, Powell et al. (2019) reported that medical mistrust and perceived racism in healthcare can delay preventive health screenings among Black men, emphasizing the need for culturally tailored care and diverse healthcare teams [33]. Earl et al. (2021) demonstrated the role of culturally competent providers in increasing colorectal cancer screening rates, highlighting how these tailored approaches improve engagement and outcomes [36]. Rayford et al. (2021) further underscored the importance of informed, diverse care teams in addressing the unique genomic and immunological differences in prostate cancer among Black men [35]. Lillard et al. (2022) emphasized the value of peer-driven models in prostate cancer care, where peers act as trusted advocates and bridge the gap between patients and providers in healthcare systems [38]. Despite their potential, these strategies face systemic barriers, including underrepresentation of Black providers in both direct-service and leadership roles in health care systems and insufficient resources for implicit bias training.

System-Level Strategies

Cardiometabolic interventions targeting system-level strategies address structural determinants of health through policy reforms and community-based interventions. These strategies can be characterized by CFIR’s outer setting (e.g., external policies and community needs) and inner setting (e.g., organizational readiness and resources). Of note, Barbershop-based interventions illustrate a community-based model that integrates health education and screenings into trusted local spaces. For example, Gardner et al. (2020) highlighted the success of barbershops in hosting an HIV prevention program, leveraging community networks and norms to enhance engagement and trust [39]. Such interventions can be adapted to create culturally appropriate environments that address barriers to participation and improve access to tailored health education [39,40,41].

At the policy level, Medicaid expansion under the Affordable Care Act (ACA) has addressed financial barriers to care, leading to higher rates of diabetes and hypertension screenings among low-income Black adults [40]. This expansion facilitated timely diagnosis and treatment of chronic conditions for underserved populations, addressing structural determinants of health at the policy level [40]. Despite these advances, challenges related to sustainability and integration persist, as these programs often rely on external funding and lack system-wide adoption.

Bridging Levels of Implementation

Barbershop interventions exemplify strategies that bridge patient-level and system-level implementation. At the patient level, they provide culturally tailored health education and empower individuals to manage their health. At the system level, they build infrastructure within trusted community spaces and establish pathways to improve access to care through collaborative models. This dual impact highlights the versatility and effectiveness of community-based interventions in addressing the complex health disparities experienced by Black men.

Barriers and Facilitators to Implementation

The success of cardiometabolic interventions for Black men depends on navigating a complex array of barriers and facilitators across patient, provider, and system levels. Application of CFIR, RE-AIM, and FRAME-IS, provide structured approaches to analyze and address these challenges. Figure 1 illustrates how these frameworks interact to inform the identification and mitigation of implementation barriers while enhancing facilitators at multiple levels. This integrated approach allows for comprehensive assessment of how interventions can be optimized for Black men. CFIR identifies barriers and facilitators within key domains, such as the outer setting (e.g., structural inequities, community factors) and inner setting (e.g., organizational culture, resource availability) [23]. RE-AIM evaluates how these factors influence intervention reach, effectiveness, and sustainability, while FRAME-IS provides insights into the equity-driven adaptations needed to overcome obstacles and enhance cultural relevance.

Fig. 1

Application of Implementation Science Frameworks to Address Cardiometabolic Disparities in Black Men. Note: Showing the integrated application of CFIR, RE-AIM, and FRAME-IS frameworks with arrows connecting specific components between frameworks

Barriers to ImplementationMedical Mistrust

Medical mistrust remains one of the most pervasive barriers to engaging Black men in cardiometabolic interventions [32, 33, 42,43,44,45]. This mistrust is deeply rooted in historical injustices, such as the Tuskegee Syphilis Study, and persists due to ongoing racial disparities in healthcare access and outcomes [40, 41]. Within CFIR, this barrier falls under the outer setting domain, reflecting how societal and historical factors shape perceptions of the healthcare system. For example, Alsan et al. (2019) demonstrated that Black men were significantly more likely to engage in preventive health visits when treated by Black providers, highlighting the potential to mitigate mistrust through increased representation and culturally concordant care [43].

Using RE-AIM, mistrust affects the reach and adoption of interventions, as programs may fail to engage participants if they do not address underlying concerns or involve trusted community leaders. Community-led research partnerships have shown promise in reducing medical mistrust and improving engagement. For example, the Men of Color Health Awareness (MOCHA) program utilized a community-based participatory research approach where community members served as equal partners in research design, implementation, and evaluation [46, 47]. This approach resulted in significantly higher participation rates and improved trust in health information compared to traditional researcher-led interventions. Similarly, the Partnership for Robust Minority Engagement in Clinical Trials (PROMPT) demonstrated that when Black men were involved in all stages of clinical trial development, from question formulation to data interpretation, both enrollment and retention rates improved substantially [48, 49]. FRAME-IS underscores the importance of equity-driven adaptations, such as incorporating Black-led businesses, organizations and racially-congruent peers to foster trust and credibility. These approaches build relationships that reduce mistrust and improve participation.

Limited Representation in Research and Clinical Trials

The underrepresentation of Black men in clinical trials and implementation research is a persistent barrier that limits the development of effective, culturally relevant interventions. For instance, fewer than 10% of participants enrolled in clinical trials are Black men, making it difficult to tailor interventions that adequately address their specific health needs [21]. This lack of representation means that many cardiometabolic interventions fail to consider social determinants of health—such as food insecurity, transportation barriers, and economic instability—that disproportionately impact Black men. CFIR categorizes this barrier within both intervention characteristics (e.g., lack of cultural tailoring) and the outer setting (e.g., misalignment with community needs). Analysis with the RE-AIM framework reveals that limited representation hinders the reach and effectiveness of interventions, as strategies developed without input from Black men may fail to resonate with their lived experiences. FRAME-IS can be used to highlight missed opportunities to adapt interventions by incorporating culturally relevant components, such as community-specific dietary advice or addressing systemic barriers to accessing care.

Efforts to address this gap must prioritize targeted recruitment initiatives and the inclusion of Black men in intervention design to ensure that research findings translate into meaningful health improvements. Expanding community partnerships and integrating trusted messengers–such as barbers, and other peer models–into clinical research can enhance recruitment and retention while improving health outcomes.

Facilitators to ImplementationCommunity Engagement and Trust-Building

Community-based interventions, particularly those conducted in culturally relevant settings such as barbershops and churches, have been shown to significantly improve health outcomes for Black men. Interventions based in trusted community spaces facilitate recruitment and retention by embedding health promotion efforts within familiar, culturally significant environments [21]. For example, barbershops provide an ideal setting for delivering health education and screenings because they offer a culturally congruent space where Black men feel comfortable discussing health-related topics [32]. Building on this, a study demonstrated the success of a barbershop-based hypertension intervention that trained barbers as lay health advocates, resulting in significant reductions in systolic blood pressure among participants [50].

Importantly, research indicates that effective peer models may differ across generations. For younger Black men (18–35), peer mentors with shared lived experiences and similar social contexts have proven most effective, with digital engagement strategies enhancing connection. Middle-aged men (36–55) respond well to respected community leaders and those who have successfully managed health challenges. For older adults (56+), healthcare partners from faith-based organizations and veterans’ groups have shown the strongest impact on engagement and behavior change. These generational differences highlight the importance of age-appropriate tailoring when developing peer-led interventions to ensure cultural and contextual relevance across the lifespan.

CFIR’s outer setting domain captures the importance of leveraging community norms and values to foster engagement, while FRAME-IS assists in the identification of key adaptations such as training community leaders to deliver culturally relevant health messaging. Applying the RE-AIM framework, these interventions demonstrate substantial reach and adoption, though their long-term sustainability often depends on securing institutional support and resources.

Culturally Tailored Messaging and Delivery

Culturally tailored interventions are a key facilitator in addressing the specific needs, values, and preferences of Black men. These interventions integrate culturally relevant content, such as dietary guidance rooted in traditional foods, and employ communication strategies that resonate with the lived experiences of participants [32]. Research indicates that interventions lacking cultural saliency—those that do not align with the values and preferences of the target community—produce less effective results, leading to challenges with recruitment, retention, and engagement. For example, a diabetes prevention program that incorporated culturally specific dietary advice and motivational interviewing resulted in improved weight loss and reduced T2DM incidence among Black men [32]. Recent work emphasizes the importance of deep structure tailoring, which ensures that interventions address not only surface-level cultural elements (e.g., language, recruitment materials) but also deeper cultural values, lived experiences, and the social contexts that shape health behaviors [21]. CFIR identifies culturally tailored interventions as addressing intervention characteristics, making them more acceptable to participants. FRAME-IS facilitates the identification of equity-driven adaptations, such as tailoring communication styles and incorporating community-specific knowledge, to ensure interventions are both effective and relevant.

Use of Peer-Led Models

Peer-led models have proven particularly effective in engaging Black men in cardiometabolic interventions. Peer mentors serve as trusted liaisons between patients and healthcare systems, addressing social determinants of health, providing emotional support, and promoting care coordination [22, 32,33,34, 52]. Research suggests that Black men prefer receiving health information from peers rather than from traditional healthcare sources, reinforcing the effectiveness of peer-led interventions. For instance, Griffith et al. (2013) highlight how peer influence increases motivation for engaging in health behaviors such as physical activity [50]. Their study found that Black men were more likely to engage in exercise when encouraged by peers, who provided accountability, encouragement, and a shared cultural perspective. Similarly, a hypertension management program utilizing peer mentors reported improved blood pressure control and medication adherence among participants due to the culturally sensitive guidance peers provided [51].

Successful implementation of peer-led models requires comprehensive infrastructure and support. This includes structured training programs for peer mentors (typically 20–40 h covering health education, communication skills, and resource navigation), ongoing supervision and support from healthcare professionals, regular community of practice meetings to address challenges, and appropriate compensation that values peers’ time and expertise. Additionally, effective programs establish clear role definitions, integrate peers into clinical workflows, provide access to relevant patient information while maintaining privacy, and create formal referral pathways to connect patients with needed services. CFIR’s inner setting domain highlights the organizational readiness, training, and structural support required for successfully integrating peers. FRAME-IS helps to illustrate how peer roles are adapted to reflect shared lived experiences and community ties, ensuring cultural alignment and enhancing trust.