Health Research Program

Introducing implementation research

Imagine that you are the national program manager for newborn health in an African country where newborn mortality is unacceptably high. Published research from Bangladesh has shown that providing postnatal home visits (PNHVs) to newborns can reduce newborn mortality. Three years ago, your department designed an implementation strategy to deliver PNHVs and scaled it up nationally. Routinely collected monitoring and evaluation data show that health workers report making PNHVs to most newborns. However, a recent survey revealed that neonatal mortality has not fallen. You wonder why your intervention has not achieved expected results. What can you do? Implementation research (IR) can help you find some answers

What is IR and what does it help us to do?

Implementation research is a systematic approach to understanding problems related to program implementation, then identifying and testing possible solutions in an adaptive or iterative process. In IR, we study how to ensure interventions are successful by understanding and mitigating implementation challenges. Implementation research recognizes that bottlenecks to achieving desired health outcomes are often found in the processes of program implementation. Therefore, IR focuses on identifying critical• Understand root causes of implementation problems • Develop and test solutions to overcome problems • Improve quality, effectiveness, and efficiency of programs • Promote equity in service delivery • Make sure that effective interventions are scaled up • Establish successful and sustainable implementation implementation problems in a setting, investigating why and how an intervention is—or is not—achieving good results, and then empowering decision makers to use the findings to adapt programs, solve problems, and improve population health (Box 1.1). The “know-do gap” is the difference between the research-based results that we “know” can be achieved and the result that we achieve when we “do” the intervention. Implementation research is one way to understand the reasons for the “know-do gap” and find ways to overcome it, translating knowledge into action and improved programs.

How does IR lead to more effective implementation?

Why do health interventions like postnatal home visits that are proven to save lives in one setting fail to achieve similar results when they are implemented elsewhere? Why do some programs not perform as well as we thought they would (see Box 1.2 for examples)?

• Monitoring data show that many pregnant women do not make all recommended antenatal visits • Client surveys show that many women are not satisfied with family planning services • Trained health workers resist shifting certain tasks to community health workers

Implementation research can help answer these questions by taking a critical look at the processes involved in implementing a program or policy, taking into consideration the importance of context. Implementation research investigates how these processes are carried out and what their effect is in a setting, helping to identify where the problems are. Like other research approaches, IR can help to answer questions of effectiveness, but its strength lies in uncovering why there are problems with implementation and how local factors affect implementation. This information can guide program managers as they develop locally appropriate, feasible, and effective strategies to overcome problems with implementation. Figure 1.1 illustrates the focus of IR on studying contextual factors as well as implementation processes and outcomes to allow us to better understand why and how implementation succeeds or fails.

IR Tip#1_Figures_1.1

When is it appropriate to adopt an IR approach?

Most decision makers are comfortable and familiar with monitoring and evaluation (M&E) of health program implementation. Simply put, monitoring is an ongoing process of counting, tracking, and collecting routine data that measure progress toward achieving program objectives over time. Is the program reaching the target group? Is the program being implemented as planned? Monitoring can be used to identify where activities may need to be adjusted during the intervention. Evaluation is the process to assess if a program has met its objectives by collecting data at the beginning and end of a program to see if certain indicators have changed. IR is a critical tool that should be used in conjunction with routine M&E efforts because it embodies the key practices of real-time inclusive planning and data-driven solutions and it engages the key actors in the process of generating knowledge to answer a specific research question about the implementation outcomes. While IR can be very useful in some circumstances, it may be neither necessary nor relevant in others. The first step in determining when IR is appropriate for your situation is to describe the problem by reviewing available data (see IR Tip #4). Box 1.3 outlines key questions that a decision maker should consider before advocating for an IR approach. See IR Tip #3 for additional guidance on deciding if IR is appropriate for your situation.

What are the key steps in conducting IR?

While there is no single “correct way” to conduct IR, the action steps generally include the following:

Smallpox was eradicated by one of the most successful global health campaigns ever conducted. At one point during the campaign, a shortage of the smallpox vaccine in Nigeria threatened the mass vaccination strategy. Implementation research was used to test a different strategy of “ring vaccination” that targeted areas where new smallpox cases were reported. Ring vaccination contained the outbreak within a short time frame and has since been adopted across the region and worldwide. Most recently, it helped to contain the Ebola outbreak in Guinea (Theobald 2018).

  • Engage key stakeholders at the beginning and then throughout the IR initiative (see IR Tip #5)
  • Identify and define the priority implementation problems that the IR will focus on (see IR Tip #4)
  • Define the research questions (see IR Tip #6)
  • Design and plan for the IR with key stakeholders (see IR Tip #6, IR Tip #7, and IR Tip #8)
  • Collect and analyze data from the IR and document the findings to support decision making (see IR Tip #9)
  • Communicate findings to stakeholder community (see IR Tip #10)
  • Use IR evidence to develop solutions to improve implementation
  • Continue to assess as part of routine M&E efforts
  • Repeat this process as necessary

These actions can be pursued efficiently with a strong partnership of implementers, researchers, and policymakers even in the most challenging circumstances. IR is iterative so the processes can overlap, changes can be made at any time, and using the results to strengthen implementation can lead to a new cycle of discovery (Figure 1.2).

Figure 1.2: Key steps in conducting IR


Key resources

Health Systems Global. (2014) Statement on advancing implementation research and delivery science.

MEASURE Evaluation Implementation Research Technical Working Group. (2015) Fundamentals of implementation research

Peters DH, Tran NN, Adam T. (2013) Implementation research in health: A practical guide.

World Health Organization. Implementation research toolkit.


References

Bauer MS, Damschroder L, Hagedorn H, Smith J, Kilbourne AM. (2015) An introduction to implementation science for the non-specialist. BMC Psychology 3(1), 32.

Bhattacharyya O, Reeves S, Zwarenstein M. (2009) What is implementation research? Rationale, concepts, and practices, Research on Social Work Practice 19(5), 491-502.

Peters DH, Tran NT, Adam T. (2013) Implementation research in health: a practical guide, Geneva: World Health Organization.

Proctor EK, et al. (2009) Implementation Research in Mental Health Services: An Emerging Science With Conceptual, Methodological, and Training Challenges. Adm Policy Ment Health Jan;36(1):24-34.

Theobald S, et al. (2018) Implementation research: new imperatives and opportunities in global health, The Lancet 392(10160):2214.