Implementation research for advancing action against non-communicable diseases

The failure to translate health and medical research into policy and services action is well-documented  (1). Human behaviour is complex, and results from trials in controlled settings often do not translate into real life settings (2).  Knowing how best to deliver proven life–saving interventions for the management of non-communicable diseases (NCDs), within existing health systems, and across diverse situations, is key to decreasing its burden. This has long been overlooked, with the focus more often being on generation of new evidence rather than its integration into practice. It is only recently that the attention has shifted towards implementation. Implementation research (IR) is an emergent area in global health. IR offers the tools, techniques and methods to translate research into practice, thus, bridging evidence-practice gap.

What is implementation research and how it can support management of non-communicable diseases?

“IR is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality, effectiveness and equity of health services and public health” (3).

It takes around 17 years for just 14% of the research findings to be embedded into practice (1), meaning, a lot of proven interventions are never implemented . Evidence that is “lost in translation” can not only result in financial loss, but also lead to death and disability which could otherwise have been averted. In the context of NCDs, evidence of various life–saving cost-effective “best-buy” interventions exists (4). If successfully implemented, best-buy interventions are expected to prevent 8.1 million premature deaths (5). This represents almost 15% of the premature deaths due to NCDs. However, without comprehension of how interventions and policies can be executed and adapted in different settings in order to promote access, quality, equity and effectiveness of the services (6) this is not possible. IR promotes learnings on enhancing implementation strategies, and how to scale up, evaluate and sustain the impact of those interventions (7, 8).

Thinking beyond the clinical outcomes and the statistical significance: evaluating implementation outcomes

As the saying goes ‘content is king, but context is god’, the right content can only generate results if tailored to the contextual diversities. IR enables us to understand the rigorous and adaptive processes for optimizing the impact of an intervention in varying contexts and  across multiple levels of intervention (personal, community, organizational and policy) (9).

It is critical for research findings to extend beyond statistical significance to program implementation processes, adaptive features and contextual issues (9). Not only does IR promote the uptake of positive results, but also seeks to identify reasons for failure of an interventions: whether failure was due to an ineffective policy/intervention (intervention failure) or due to  the incorrect transitioning of  a so-called good policy/intervention (implementation failure) (1). Not stopping at clinical outcomes (efficacy studies), an intervention must also be tested and evaluated for several implementation outcomes such as acceptability, adoption, appropriateness, feasibility, and sustainability (1).

Building capacity for implementation research on non-communicable diseases

Implementation science is a new research paradigm to improve clinical and population health. Attention and interest in embedding research into practice is very recent in nature. Governments and non-governmental organisations are testing various interventions globally. We need to use the findings from IR and conduct evidence synthesis to understand how interventions and policies can be implemented in different settings. Like any other new field, IR too requires extensive sensitization and capacity building. Targeting early and mid-career researchers, academicians, policy makers, program implementers and intervention beneficiaries would be useful.

There is a need for rigorous reviews, discussion and updates on the concepts, theories, models and frameworks to optimize the potential of implementation science in NCDs. Further, there is a need for uniform taxonomy to be used across the field, to allow evidence synthesis and knowledge sharing (8). We also need research around methods, designs and reporting of the implementation studies in order to enhance the rigor and external validity of  findings.

Future research priorities include understanding scale-up processes and sustainability of cost-effective interventions. It is critical that IR studies have adequate description of  implementation characteristics. This will enhance the potential of the findings to be integrated and rolled out at a system level (10). Partnering with multidisciplinary teams, engaging communities, developing capacity, networking, and maximising resources for management of NCDs is critical in optimizing the potential of the IR and achieving the sustainable development goal (SDG) 3.4: reducing the NCDs related deaths by one-third by 2030.

About the Authors:

Rajshree Thapa is a PhD candidate at Department of Medicine, Monash University,  Melbourne, Australia. Her project focuses on investigating the role of community health workers in management of NCDs.

Kiran Bam is a public health professional working in Nepal. He has experience in planning and implementing various public health programs.

Soumyadeep Bhaumik is Research Fellow, Policy Impact at the George Institute for Global Health, India. He tweets at @DrSoumyadeepB

Competing Interest:

We have read and understood the BMJ Group policy on declaration of interests and we have no relevant conflicts of interests to declare.

Acknowledgements: Thanks to all the participants and facilitators at the GACD- HSRI-MU Implementation science school (5-9 November, 2019) at Bangkok, Thailand. Special Thanks to Prof. Amanda G. Thrift and Ms. Tara Purvis, Department of Medicine, Monash University for their comments that improved the blog

References

  1. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research. 2011;38(2):65-76.
  2. Boaz A, Baeza J, Fraser A, Group EISC. Effective implementation of research into practice: an overview of systematic reviews of the health literature. BMC research notes. 2011;4(1):212.
  3. Eccles MP, Mittman BS. Welcome to implementation science. BioMed Central; 2006.
  4. World Health Organization. Tackling NCDs:’best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. World Health Organization; 2017.
  5. World Health Organization. Saving lives, spending less: a strategic response to noncommunicable diseases. World Health Organization; 2018.
  6. Peters DH, Tran NT, Adam T. Implementation research in health: a practical guide: World Health Organization; 2013.
  7. Lobb R, Colditz GA. Implementation science and its application to population health. Annual review of public health. 2013;34:235-51.
  8. World Health Organization. A guide to implementation research in the prevention and control of noncommunicable diseases. 2016.
  9. Theobald S, Brandes N, Gyapong M, El-Saharty S, Proctor E, Diaz T, et al. Implementation research: new imperatives and opportunities in global health. The Lancet. 2018;392(10160):2214-28.
  10. Alonge O, Rodriguez DC, Brandes N, Geng E, Reveiz L, Peters DH. How is implementation research applied to advance health in low-income and middle-income countries? BMJ global health. 2019;4(2):e001257.

 

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