implementation research

1. An Introduction to
Implementation Research:
Contributions from TRAction
for CORE Group Workshop

2. Why Implementation Research is Important

3. 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

4. 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 education
2. Expanding the subsidy for malaria combination
treatment
3. Expanded childhood immunization coverage
4. Deworming of schoolchildren, to improve educational
and health outcomes
5. Expanding tuberculosis treatment

5. 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

6. 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

7. Introduction to Implementation Research

8. 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

9. 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

10. Formulating IR Questions
Consider where the intervention falls on
the intervention “spectrum”
(e.g. what is the goal of the intervention?)

11. Real-life
effective-
ness
Equitability
Program
integration
Replication
Sustain-
ability
Common
practice at
scale
‘Spectrum’—consider the goal of the intervention?

12. Real-life
Effective-
ness
Replication
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?

13. 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

14. 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.

15. Disrespect & Abuse during facility-based
delivery
No previous
estimates of
prevalence; had to
start with
measurement 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

16. TRAction Example: Taskshifting in C-Sections
RFA 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

17. • 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
integration
Replication
Sustain-
ability
Common
practice at
scale
TRAction Example: Taskshifting in C-Sections

18. Importance of Dissemination

19. 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

20. 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?

21. Implementation Research Requires Collaboration
Implementers
Policy -
makers
Advocacy
Researchers

22. 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