Using data for impact_Pelletier_5.1.12

670 views

Published on

Published in: Health & Medicine, Education
  • Be the first to comment

  • Be the first to like this

Using data for impact_Pelletier_5.1.12

  1. 1. Using Data for Impact: A Critical ExaminationThrough the Lens of Implementation Science David Pelletier Division of Nutritional Sciences Cornell University Spring CORE Group Meeting, Wilmington, DE May 1, 2012
  2. 2. Outline1. Why implementation science2. Definition and state of the field3. Broadening the field4. A Consolidated Framework5. An Example: Training frontline workers6. An Example: Infant feeding and HIV
  3. 3. Why Implementation Science? p2 • Efficacy-to-Effectiveness • Knowledge-to-Action • Evidence-Based Interventions • Evidence-Based Decisions • Evidence-Based Policy Making • Scaling Up • Etc.
  4. 4. Why Implementation Science? Fixsen et al., p74 U5 Deaths Preventable Through: Achieving 100% Coverage of Existing Interventions 62% Discovering and Delivering New Interventions 21% NIH/BMGF Research Funds (2000-04) Focused on: Improving delivery and utilization 3% Mechanistic and discovery research 97% Source: Leroy et al., AJPH 97(2), 2007
  5. 5. Some Overall Observations from the Literature1. New: Implementation science is a new and still-emerging field with little consistency in terms, concepts and methods2. Complex: There are ~40 categories of factors (and hundreds of variations on these) that affect the quality and impact of intervention delivery3. Contextual: The importance and changeability of these factors varies widely across countries, organizations and communities. Context is King.4. Conclusion: The focus of our research must shift from “technical interventions” to “implementation interventions”
  6. 6. What is Implementation Science? Definition of Implementation (or Delivery) Science (from NIH Fogarty International Center) “Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice. It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions. […] The intent of implementation science and related research is to • investigate and address major bottlenecks , • test new approaches to prevent, detect and/or resolve bottlenecks • determine a causal relationship between the intervention and its impact” (at scale)
  7. 7. Current State of the Field Fixsen et al., p74
  8. 8. Current State of the Field
  9. 9. Broadening the Definition1. Beyond “health care” – To community and prevention – To other sectors (ag, livelihoods, social protection, etc)2. Beyond “evidence-based interventions” – To include IIGPP (next slide)3. Beyond “research findings and evidence” in the usual (privileged scientific) sense – To include practice-based and local knowledge and experience
  10. 10. Beyond “Evidence-Based Interventions”The Narrow View: Implementation refers to efforts to introduce evidence-based interventions into the practices of organizations and professionals (NIH, WHO, etc)A Broader View: Implementation refers to efforts to fulfill a goal or the intent of a policy, even when the evidence is lacking concerning how to do so (European Journal of Social Work 13(1):109, 2010)An Inclusive View: Implementation refers to efforts to introduce interventions, innovations, guidelines, practices or policies (IIGPP) into organizations, systems or communities
  11. 11. Beyond “Scientific” KnowledgeDetached, Body ofHighly- Generalizable FormalStructured or Principles/ M&EExperimental Scientific/Research Theoretical Knowledge IntegrationReflection, Application ofLearning, Knowledge in ImprovedDocumentation, Program Design ActionCodification & Implementation Contextual Knowledge SystematizedPractice-Based & Tacit Experience &Experience & Knowledge FeedbackEngaged DuringResearch Implementation
  12. 12. Opening the Black Box Toward a Comprehensive Framework for Implementation Science New Intervention Contexts Proven in OutcomesA Few Contexts At-Scale (RCTs) Dissemination & Implementation Processes
  13. 13. A Consolidated Framework of Implementation (factors operate at multiple levels, from provider to organization and country) Context D. Outer Setting: Participant needs & resources, govt and donor policies & regulations, peer/ network influences , societal & cultural influences, etc.A. Intervention/ Implementing OrganizationInnovation / E.Guideline/ Implementation B. Inner Setting: orgPractice / size, structure, maturity, manage Processes:Policy (IIGPP) •Formative research(unadapted) ment, informal Implementation networks, culture, climate •Planning•Core components •Implem Strategy Outcomes•Peripheral (tension, compatibility, priority, in centives, goal clarity, learning •Change Theory Acceptabilitycomponents Service climate), readiness •Engaging 1. Fit Client Outcomes (leadership, resources, access to -opinion leaders 2. Feasibility OutcomesPerceived and knowledge & info) -formal leaders 3. Costs 1. Efficiency -HealthActual:source, IIGPP (adapted) -champions 2. Effectiveness - Function Applicationevidence, advant •Core components -facilitators 3. Equity -Symptomsage, adaptability, • Execution 1. Adoption 4. Safety -Satisfactiontrialability, compl •Peripheral -components 2. Adaptation 5. Patient-exity, design components -sequence 3. Fidelity/Quality centeredquality and -intensity 4. Penetration 6. Timelinesspackaging, cost C. Individuals (providers -duration 5. Sustainability and managers): knowledge -quality & beliefs, self-efficacy, stage of •Feedback change, identification with •Evaluation organization, motivation, values, •Reflection Adapted from: •Decisions Damschroeder et al., Implem Science 4:50, 2009; Proctor et al., Admin Pol Mental Hlth 38:65-76, 2011 intellect, competence, capacity, l •Adjustments
  14. 14. Do We Need a Framework? A Simple (Probably Painful) ExampleWhich of the following best describes the training approach typically used with frontline workers in your programs?1. Lectures and Discussion2. Lectures and Discussion + demonstrations3. Lectures and Discussion + demos + hands-on practice and feedback
  15. 15. Effectiveness of Training Methods: Results of a Meta-Analysis Outcomes for Assessing Effectiveness Teacher’s Teacher’s Teacher’s Training Knowledge Skill Use of New Method Practices Lectures and 10% 5% 0 Discussion Why? + Demonstrations 30% 20% 0 + Practice and 60% 60% 5 Feedback + Coaching in the 95% 95% 95% ClassroomFixsen, D.L., et al., Implementation research: A synthesis of the literature. 2005,National Implementation Research Network: Tampa, FL.
  16. 16. A Consolidated Framework of Implementation (factors operate at multiple levels, from provider to organization and country) Context D. Outer Setting: Participant needs & resources, govt and donor policies & regulations, peer/ network influences , societal & cultural influences, etc.A. Intervention/ Implementing OrganizationInnovation / E.Guideline/ Implementation B. Inner Setting: orgPractice / size, structure, maturity, manage Processes:Policy (IIGPP) •Formative research(unadapted) ment, informal Implementation networks, culture, climate •Planning•Core components •Implem Strategy Outcomes•Peripheral (tension, compatibility, priority, in centives, goal clarity, learning •Change Theory Acceptabilitycomponents Service climate), readiness •Engaging 1. Fit Client Outcomes (leadership, resources, access to -opinion leaders 2. Feasibility OutcomesPerceived and knowledge & info) -formal leaders 3. Costs 1. Efficiency -HealthActual:source, IIGPP (adapted) -champions 2. Effectiveness - Function Applicationevidence, advant •Core components -facilitators 3. Equity -Symptomsage, adaptability, • Execution 1. Adoption 4. Safety -Satisfactiontrialability, compl •Peripheral -components 2. Adaptation 5. Patient-exity, design components -sequence 3. Fidelity/Quality centeredquality and -intensity 4. Penetration 6. Timelinesspackaging, cost C. Individuals (providers -duration 5. Sustainability and managers): knowledge -quality & beliefs, self-efficacy, stage of •Feedback change, identification with •Evaluation organization, motivation, values, •Reflection Adapted from: •Decisions Damschroeder et al., Implem Science 4:50, 2009; Proctor et al., Admin Pol Mental Hlth 38:65-76, 2011 intellect, competence, capacity, l •Adjustments
  17. 17. An Example for Group Work:The 2010 WHO Guidelines on Infant Feeding in the Context of HIV
  18. 18. The 2010 Guidelines “The Challenges”
  19. 19. Policy Choice ARV+Breastfeeding No Breastfeeding Basic a. Widespread HIV testing a. Safe water and sanitation are assured Requirements b. Reliable ARV supplies at household and community level if child survival is c. Full ARV adherence b. Sufficient infant formula is assured to be maximized d. Proper EBF adherence c. Can prepare it cleanly and frequently and transition to mixed d. Exclusive formula for first six months is feeding possible e. Family is supportive of this practice f. Access to health care that offers comprehensive child health services•What factors in the framework will affect the policy choice of national policy makers?•What factors in the framework will affect the policy choice of regional and district managers?•What factors in the framework will affect the counseling practices of front-line staff? Note: Factors affecting practices of mothers not included here
  20. 20. Group Instructions (30 mins)1. Each table has been assigned one of the following domains: A. The intervention, innovation, guideline, practice or policy (IIGPP) B. Individuals (providers and managers) C. The Inner Setting (the implementing organization) D. The Outer Setting (actors and conditions outside the organization that affect implementation) E. Implementation processes (activities and practices for “rolling out” the guideline)2. Identify some of the characteristics of your domain that may positively or negatively affect the implementation of the guideline (“implementation” here refers to adoption, adaptation, penetration to all clinics, and quality of delivery)3. How would you collect data or information before implementation in order to plan your implementation strategy?4. Chose one example to report out.
  21. 21. Further work…– Does the framework identify “hidden bottlenecks?”– Are any factors missing from the framework?– How can the framework be made more user-friendly?– How can we be innovative in assessing and re-assessing the factors?– Who needs to be assessing and acting on various ones?
  22. 22. Thank You!
  23. 23. • Title: Data for Impact: A Critical Examination Through the Lens of Implementation Science• Implementation science seeks to improve the effectiveness of large-scale programs by strengthening the frameworks, tools and evidence base for identifying and minimizing implementation bottlenecks. Implementers can make major contributions to this field because of their extensive knowledge, experience and influence in the implementation process. This session provides an overview of this emerging field and introduces one of the many conceptual frameworks in the literature for guiding the assessment and improvement of the implementation process. It also seeks participants’ views on the forms and meaning of “data” in the context of real-world implementation by engaging participants in a rapid application of this framework, using as a case study the WHO Guidelines on infant feeding in the context of HIV.
  24. 24. Assuming that “Breastfeed + ARVs” is the “National Policy”What factors will influence the counseling practices of health workers and the feeding practices of mothers? CFIR Domain CFIR Element Characteristics of the intervention Perceived strength of evidence Perceived advantage Complexity Characteristics of the individuals Knowledge and beliefs Identification with the organization Characteristics of the inner setting Goal clarity Compatibility Characteristics of the outer setting Perceived social, cultural and economic situation of the mother/caretaker Donor influences on MOH policy Characteristics of the Implementation strategy (train and hope?) implementation process Evaluation Adjustments

×