An Introduction to Implementation

Research:Contributions from TRAction for CORE Group Workshop

Why Implementation Research is Important

The current situation )

• Billions of dollars invested in developing effective interventions to reduce morbidity and mortality, but many are never brought to scale

• Two-thirds of child mortality could be reduced by scaling up existing evidence-based interventions

• Figuring out how to scale up such interventions is consistently listed as a top priority during MCH prioritization exercises

• The science of scaling up to optimize the effectiveness of interventions gaining increasing visibility and traction

Many programs and interventions could save lives, but their potential has never been met…

The Copenhagen Consensus 2012: panel of economists including four Nobel laureates identified smartest ways to allocate money to respond to world’s biggest challenges Top 5:1. Bundled micronutrient interventions to fight

hunger and improve education2. Expanding the subsidy for malaria combination

treatment 3. Expanded childhood immunization coverage4. Deworming of schoolchildren, to improve

educational and health outcomes 5. Expanding tuberculosis treatment 

Implementation Research: bridging the “know-do gap”

• IR seeks to determine the best ways to implement evidence-based interventions in real world settings

• IR seeks to optimize programs that are currently not achieving adequate coverage or quality

Public Health Knowledge

(what we know)

Public Health Practice(what we do)

Implementation Research

Remme JHF, Adam T, Becerra-Posada F, D’Arcangues C, Devlin M, et al. (2010) Defining Research to Improve Health Systems. PLoS Med 7(11): e1001000. doi:10.1371/journal.pmed.1001000

Introduction to Implementation Research

What is focus of implementation research?

• Identifying implementation problems or barriers

• Understanding factors that help or hinder access to health interventions

• Developing and testing solutions to implementation barriers

• Determining the best way to introduce new intervention

Unique features of implementation research

• Done in real world rather than controlled settings

▫Real world settings with existing staff, facilities, and budgets

▫Real world populations rather than select sub-groups

• Focus on context

▫Political, social, economic, cultural

▫Existing health care system and network of stakeholders

• Central role of stakeholders and end-users

▫Health managers, policy makers

▫Involved closely in setting agenda

▫Goal of efforts is to help them, not publish papers

Formulating IR Questions

Consider where the intervention falls on the intervention “spectrum”

(e.g. what is the goal of the intervention?)

Real-life effective-ness Equitability Program

integration Replication Sustain-ability Common practice at scale

‘Spectrum’—consider the goal of the intervention?

Real-life Effective-

nessReplication

Sustain-ability

Common practice at

scale

1.) Under what conditions does the program work?

2.) Is the tool, intervention, or strategy worth it? Is it cost-effective?

3.) Does the program achieve the intended public health impact?

1.) Why don’t tested programs work when transferred to new settings or work in some new settings and not others?

2.) How can implementation be improved to assure reliability?

TRAction Experience

•Convened advisory group to consider TRAction agenda

•Gathered existing data and determine gaps in the evidence within each focus area

•Craft request for proposal or engage USAID Missions with particular needs

•Select projects to fund

•Engage sub-awardees to give feedback throughout, this includes technical support from TRAction team, TAG inputs

TRAction Examples: Disrespect & Abuse during Facility-based Childbirth

RFA Objectives Research Questions Methods

1. Identify the manifestations and causes of D&A

2. Design, implement, monitor an approach to reduce D&A

3. Evaluate the impact of the intervention(s) D&A

4. Develop plans for adoption of intervention(s) in regular use.

What are the types and prevalence of D&A?

How do we ensure appropriate program design and enable success in this context?

What are the core elements of the intervention that make it effective and so are needed for implementation at scale?

Did the intervention achieve its intended impact?

• Baseline assessment to determine prevalence and determinants of disrespect and abuse of women during childbirth.

• Intervention design, based on baseline assessment and stakeholder input.

• Program implementation, with continuous monitoring to identify necessary adaptations to the

• Impact assessment to evaluate the effect of the intervention on D&A and on women's use of facilities for childbirth. program design.

Disrespect & Abuse during facility-based delivery

No previousestimates of prevalence; had

tostart withmeasurement of the problem

Basic Science

(Epi)

Real-life

effective-ness

Equit-ability

Program

integration

Replica-

tion

Sustain-ability

Common

practice at

scale

Interventions being tested

•Training on health rights and law

•Influence on implementation of maternal health bill

•Values and attitudes clarification training

•Maternity open days

•Strengthen Health Facility Management Committee

•Community dialogue forums

•Training on health rights and law

•Encouraging male partner participation

TRAction Example: Taskshifting in C-SectionsRFA Objectives Research Questions Methods

Gather evidence on:

•Deployment of community health workers to provide uterotonics during the third stage of labor;•Deployment of community health workers to treat neonatal sepsis with antibiotics; and•Deployment of nurses, nurse midwives, or other non-physician clinicians to•Perform caesarean sections in areas where physicians are not available.

What are the core barriers and challenges for lack of success in scaling-up the use of task shifting to increase access to caesarean deliveries (Zambia, Kenya, Tanzania, Malawi)?

How can scale-up of task shifting for access to caesarean deliveries be facilitated?

Case study approach

•Systematic literature review•Document collection•Timeline•Formative research•Domain selection (based on WHO’s Optimizing Health Worker Roles…”)•Qualitative data collection (IDIs)•Realist evaluation

•The research looks at how to replicate experiences from other contexts (e.g. Mozambique), sustain and scale-up taskshifting for c-sections

Real-life effective-

ness

Equitability

Program integrati

on

Replication

Sustain-ability

Common practice at scale

TRAction Example: Taskshifting in C-Sections

Importance of Dissemination

What to do after the research is done?

•“A new way of thinking is needed about the relationship between knowledge translation and implementation research. Emphases must be placed not only on the production of implementation research, but also on the uptake and use of its results…” – WHO platform on IR

Dissemination

•Need to understand audience for information dissemination

•Determine the best methods of dissemination▫What products are needed?▫What are the spaces in which we can share this information?

▫Are their communities of practice in which the information can be further disseminated?

Implementation Research Requires Collaboration

Implementers

Policy -maker

s

Advocacy

Researchers

Question: Partnership Challenges

•Who should be involved during each step of the process?

▫Issue identification▫Research question development▫Methods/approaches development▫Data collection/analysis▫Dissemination