Implementation Science and Global Health: From theory to practice in West Africa
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The document discusses implementation science in the context of global health, particularly in West Africa, outlining definitions, methodological approaches, and outcomes related to the implementation of health interventions. It emphasizes the importance of quality implementation, monitoring, and collaboration among stakeholders and identifies various factors that influence the success of these interventions. The conclusion highlights key insights about effective programming and the complex nature of implementation as a process.
Implementation Science and Global Health: From theory to practice in West Africa
- 1. Implementation Science and Global Health From theory to practice in West Africa Ridde, Valéry April 14, 2017 @equitesante @valeryridde
- 2. OUTLINE 1. Definitions 2. Methodological approach 3. Implementation outcomes 4. Conclusion
- 6. Definitions of implementation science in HIV/AIDS Odeny, Thomas A et al. The Lancet HIV , Volume 2 , Issue 5 , e178 - e180 69 articles 96-2013 73 definitions
- 8. DEFINITIONS • Scientific investigation of factors associated with effective implementation(Franks and Schroder, 2013) • implementation = process of putting an intervention into use - either evidence-based or theory-based – in a setting(Damschroder et al., 2009; Nash et al., 2006; Thompson et al., 2003)
- 11. EMERGENCE FORMULATION IMPLEMENTATION SWIRL PROCESS FORMULATION IMPLEMENTATION Lemieux 2002; Monnier 1992
- 12. INTERVENTION Planning, implementation, evaluation, sustainability
- 13. BLACK BOX AND TYPE 3 ERROR INTERVENTION R E S S O U R C E S I M P A C T S
- 15. There was no global effect of the availability of ORI on facility-based delivery rates, nor on the use of antenatal and postnatal care services, except for qualified antenatal services.
- 16. 16
- 17. THE TREE THAT HIDES THE DRILL 0 20/m 40/m 60/m 80/m 100/m 110 SONU Fins de mois 0 3 2004 6 9 12 3 2005 6 9 12 3 2006 6 9 12 3 2007 6 9 12 3 2008 6 9 12 3 2009 6 9 Koutougou 0 20/m 40/m 60/m 80/m 100/m Nombre mensuel 110 SONU Fins de mois 0 3 2004 6 9 12 3 2005 6 9 12 3 2006 6 9 12 3 2007 6 9 12 3 2008 6 9 12 3 2009 6 9 0 20/m 40/m 60/m 80/m 100/m 110 SONU Fins de mois 0 3 2004 6 9 12 3 2005 6 9 12 3 2006 6 9 12 3 2007 6 9 12 3 2008 6 9 12 3 2009 6 9 • Informal payment • Past experiences • Perceived quality • Geographical access Belaid et Ridde, 2015
- 19. DIFFERENT TYPES OF THEORIES • “Hypotheses on which people, consciously or unconsciously, build their program plans and actions.” (Weiss, 1997) Program theory • “Basic, usable structure of ideas, less abstract than grand theory, and more abstract than empirical generalizations or micro-range theory.” (Stinchcombe, 1968, quoted by Moore et al., 2012) Middle-range theory • “Unified theory that will explain all the observed uniformities of social behavior, social organization, and social change.” (Merton, 1969) Grand theory Ladderofabstraction What about the Theory of Change? Or the Implementation Theory? Or the Logic Model? Robert and Ridde, 2016
- 23. StrengtheningofhealthsystemstowardsUniversalHealthCoverage Supporttopolicydialogueprocessesforhealthplanning&financing Approach (SOFT) On-going technical support Training Capacitystrengtheningof MoH Knowledge and resources production Components of support (HARD) FlexibilityResponsiveness Ad hoc technical expertise Policy dialogue for health planning & financing What is expected from such a policy dialogue GoalResults MAKE IT HAPPEN MAKE IT HAPPEN Outcomes Formulation of robust and comprehensive health policies, strategies & plans Alignment and harmonization of stakeholders Strengthened leadership of MoH Fed by knowledge Inclusive and participatory Led by MoH Robert & Ridde, 2017
- 27. SOLENZO HSPC + HSPC + HSPC - HSPC - HSPC +/- HSPC +/- RBF1 RBF4 DIEBOUGOU HSPC + HSPC - RBF1 HSPC + HSPC - RBF2 HSPC + HSPC - RBF3 OUAHIGOUYA HSPC + HSPC - RBF1 HSPC + HSPC - RBF2 HSPC + HSPC - RBF3 R H C RBF1 M C S S RBF1 M C S S RBF1
- 29. IMPLEMENTATION OUTCOMES • Acceptability • Adoption • Appropriateness • Feasibility • Fidelity • Cost • Penetration • Sustainability Enola Proctor et al, 2010
- 30. SOCIETY FOR IMPLEMENTATION RESEARCH COLLABORATION Lewis et al. Implementation Science (2015) 10:155 mental or behavioral health settings
- 32. Harald Saetren The Policy Studies Journal, Vol. 33, No. 4, 2005
- 33. Saetren, 2005- Articles 1933-2003
- 35. HP AND POLICY SCIENCE : 1986-2006 E. Breton and E. de Leeuw, 2010 ● 7% of HP article are PP studies ● 18% are referring to a theoretical framework 0 0 1 0 0 3 1 1 6 0 1 7 0 12 8 9 10 16 15 26 3 0 5 10 15 20 25
- 36. “We are not even close to a well- developed theory of policy implementation’” Saetren’s (2005, p. 573) « The theoretical base for implementation is relatively new and needs to be tested and operationalized in real-world settings. » Franks & Schroeder (2013, p.12)
- 37. Pulzi et Treib, 2007
- 40. PROBLEM POLITICS POLICY PROBLEM POLITICS POLICY POLITICSPROBLEM POLICY IMPLEMENTATIONFORMULATIONEMERGENCE Voir Ridde (2009), adapté de Kingdon (1995) et Lemieux (2002)
- 41. HOW TO BE SUCCESSFUL ? ‘implementation politics’ (Bardach, 1977), ‘crisis of implementation’ (Mazmanian & Sabatier, 1983), ‘implementation gap’ (Pressman & Wildavsky, 1984), ‘implementation deficit’ (Blackmore, 2001)
- 42. de Leeuw et al. Health Research Policy and Systems 2014, 12:55
- 43. QUALITY IMPLEMENTATION FRAMEWORK • 8 dimensions • 20/23 contextual factors • 14 critical steps Durlak, 2015; Meyer et al, 2012
- 44. Meyer et al, 2012 QUALITY IMPLEMENTATION FRAMEWORK
- 45. CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH Damschroder LJ, et al, 2009
- 46. Kirk et al. (2016) 11:72
- 51. Cole, C, et al 2016
- 52. IMPLEMENTATION INTERVENTION • resources • activities FIDELITY • Content • Coverage • Time IMPACTS MODERATORS • Context • Actors • Mechanisms Adapté de Carroll et al. (2007) ADAPTATION
- 53. 0% 25% 50% 75% 100% Planification Mise en œuvre Outils de mise en œuvre Autres Implanté Non Implanté Adapté Ajouté NR CONTENT FIDELITY Equitesante.org
- 54. DS 1 DS 2 DS3 DS1 DS2 DS3 DS1 DS2 DS3 DS1 DS2 0 DS3 0 0 10 20 30 40 50 60 70 80 90 100 Planification Mise en œuvre Outils de mise en œuvre Autres FIDELITY HETEROGENEITY Equitesante.org
- 55. Sekhon et al. BMC Health Services Research (2017) 17:88 THEORETICAL FRAMEWORK OF ACCEPTABILITY
- 58. Unintended Consequences Turcotte-Tremblay A-M et al, 2017
- 59. Bull World Health Organ 2016;94:58–64
- 60. 4- CONCLUSION
- 61. WHAT EVERYONE SHOULD KNOW 1. Quality Implementation Is the Sine Qua Non of Effective Programs 2. Monitoring Implementation Is an Essential Component 3. It Is Extremely Costly to Ignore Implementation 4. Implementation Is a Multidimensional Concept 5. Implementation Exists along a Continuum 6. Adaptations Are Common and May Improve Program Outcomes 7. Effective Professional Development Services Are Essential 8. Multiple Factors Affect Implementation 9. at Least 14 Related Steps to Achieving Quality Implementation 10. Quality Implementation Requires Collaboration among Multiple Stakeholders 11. The Same Factors That Influence Quality of Implementation Also Influence Sustainability Durlak, 2015; pp. 395–405
Editor's Notes
- #7: Figure: Relatedness of definitions of implementation science in scientific literature Definitions are shown as nodes and citations as arrows. We classified each definition as either a definition (or exact meaning of the term) in pink; a characterization (general description of qualities or features of the term) in blue, or both in green.8 Definitions of implementation science in HIV/AIDS Almost all definitions of implementation science and research referred explicitly or implicitly to the gap between knowledge and evidence from research findings Implementation science is a multidisciplinary specialty that seeks generalisable knowledge about the behaviour of stakeholders, organisations, communities, and individuals in order to understand the scale of, reasons for, and strategies to close the gap between evidence and routine practice for health in real-world contexts.
- #8: IS can be defined as the scientific investigation of factors associated with effective implementation » Franks and Schroder, 2013 Implementation science studies the use of strategies to adapt and use evidence-based interventions in targeted settings to sustain im- provements to population health. Annu. Rev. Public Health 2013. 34:235–51 implementati- on emerged as an actively planned and deliberately in- itiated effort with the intention to bring a given object into policy and/ or practice. fadenhauer et al., 2015). implementation is defined as the process, constellation of processes or means of as- similating or putting an intervention into use - either evidence-based or theory-based – in an organisation or a setting (Damschroder et al., 2009; Nash et al., 2006; Thompson et al., 2003) IS = The science of putting ideas into action—the science of implementation Implemenattion has been described as the .science, practice and policy of getting science into practice and policy » Kixsen, 2011
- #11: Using Rogers’ (2003) classic model, implementation is one of five crucial stages in the wide-scale diffusion of inno- vations: (1) dissemination (conveying information about 123 Am J Community Psychol (2012) 50:462–480 465 the existence of an innovation to potentially interested parties), (2) adoption (an explicit decision by a local unit or organization to try the innovation), (3) implementation (executing the innovation effectively when it is put in place), (4) evaluation (assessing how well the innovation achieved its intended goals), and (5) institutionalization (the unit incorporates the innovation into its continuing practices).
- #12: vortex, whirlpool, whirlwind, swirl, whirl, eddy
- #13: 4 son of a single rope
- #14: Type III error: evaluating a program that has not been adequately implemented
- #16: Obstetric Risk Insurance package (ORI) focusing on maternal and perinatal health has been progressively implemented at the health district level since 2002. The scheme is based on a flat fee pre-payment. = 18$ ny woman attending antenatal care is given the choice to enrol on a voluntary basis. demographic and health survey data between 2002 and 2011. There was no global effect of the availability of ORI on facility-based delivery rates, nor on the use of antenatal and postnatal care services, except for qualified antenatal services. Maternity-related care for the ORI membership included at least: four antenatal visits; all prophylactic treatments; one blood test (haemoglobin level, blood group and rhesus); one urine test (pro- teinuria, glycosuria) at each antenatal visit; one ultrasound scan dur- ing the first trimester; treatment for any pathologies related to pregnancy and delivery, skilled delivery and emergency obstetrical care (EmoC) if needed, including caesarean section; ambulance transportation to a higher level of health care; hospital care if trans- ferred; and one postnatal visit The ORI was firstly implemented in 2002 in two health districts of Nouakchott (Sebkha and El Mina) and since then, has extended still further in other districts outside of the capital. At the end of 2014, the ORI was available in 144 out of 627 public health care facilities
- #18: HETEROGENEITY
- #20: Weiss : Theory of Change = Program theory + Implementation theory Marchal : TOC is essentially prospective (Dickinson, 2006) and seeks to establish the links between intervention, context and outcome (Barnes et al., 2003; Mason and Barnes, 2007; Weiss, 1995). It does so through development and testing of logic models (Douglas et al., 2010). Breuer: approach which describes how a programme brings about spe- cific long-term outcomes through a logical sequence of intermediate outcomes distinct from sociological or psychological the-ories which describe why change occurs RE = uncovering underlying programme theories. These theories are often more abstract than the theories developed through ToC or logic models [18].
- #24: Flexibilité : « la capacité d’un système à s’adapter aisément à l’environnement ». Adaptabilité : capacité de l’organisation à modifier sa Niveau de l’intervention Niveau de l’OMS Dinstinguer pourquoi on soutient le DP (modèle théorique) vs. comment on soutient le DP (modèle opérationnel) Renforcer la gouvernance sanitaire = alignement des bailleurs, leadership des MoH et formuler du NHPSP robustes et complets Alignement = maillage et mise en commun des ressources
- #31: identify quantitative instruments of implementation outcomes relevant to mental or behavioral health settings We identified 104 instruments across eight constructs, with nearly half (n = 50) assessing acceptability and 19 identified for adoption , with all other implementation outcomes revealing fewer than 10 instruments. Only one instrument demonstrated at least minimal evidence for psychometric strength on all six of the evidence-based assessment criteria. The majority of instruments had no information regarding responsiveness or predictive validity. that the majority of instruments consisting of between 11 and 49 items (a rating reflecting “ good” ) may actually reflect unfeasible instrument length in a practical implementation context.
- #32: Pressman, Jeffrey L. and Wildavsky, Aaron B. (1973)
- #35: Titile and abstratc Total de 724 articles depuis 1970 sur pérennité et 953 sur mise en œuvre Seulement 6%
- #36: Frequency of eligible policy-related articles published in eleven journals pursuing the scholarly development of health promotion (Jan 1986 - Jun 2006 « all the most authoritative conceptualizations mentioned here were modelled on Western-style democratic governance systems » TOTAL 119 = Referring to a theoretical framework? 39 = Of these, from political science 21
- #38: 3 générations : *70 et avant = quali, explo, sans théorie *80 : premier cadre d’analyse *fin 80 = plus recherche, comparative, théorie, longitudinale,
- #40: Les acteurs s’adaptent aux failles du système = épisio remboursé plus car acc dysto mais pas dans les faits
- #41: There is little doubt that Kingdon’s Agendas, Alternatives, and Public Policies (1984) remains a key influence on the study of public policy. Kingdon’s Multiple Streams Approach: three separate “streams” must come together at the same time—and they must do so during a brief “window of oppor- tunity”—for policy to change markedly: Ambiguity (there are many ways to frame any policy problem); Competition for attention (few problems reach the top of the agenda); An imperfect selection process (new information is difficult to gather and sub- ject to manipulation); Actors have limited time (which forces people to make choices before their pref- erences are clear); and, Decision-making processes are neither “comprehensively rational” nor linear.
- #44: 25 reviewed frameworks 8 dimensions de l’implantation : Fidélité, qualité, dosage, adaptation, participant, engagement, couverture, différenciation, suivi de conditions de comparaisons 20 facteurs contextuels (e.g., various features of the interven- tion, front-line providers, and the organization hosting the in- tervention;) 1-Community-level factors 2-Characteristics of staff delivering the program 3-Features of the program to be offered 4- Features of the host organization and its operating systems 5- Features of Professional Development services 14 critical steps in the Quality Implementation Framework ABLE 26.1. Examples of Factors That Influence Quality of Implementation Community-level factors a. Theory and research in the relevant area b. Political/administrator pressures c. Funding d. Educational policy and curriculum mandates Characteristics of staff delivering the program a. Perceived need for the program b. Perceived program benefits c. Sense of self-efficacy or self-confidence d. Mastery of new skills Features of the program to be offered a. Compatibility or fit with the host setting b. Flexibility or adaptability of the program Features of the host school and its operating systems a. Positive work climate Organizational norms related to openness to change How well the program fits with usual school practices Shared vision regarding buy-in and commitment to the new program Shared decision making and supporting collaboration among stakeholders Working partnerships with other agencies Effective communication practices Effective formulation of workgroups and tasks Strong leadership A program champion advocating for the program Administrator support Features of Professional Development services a. Quality of preprogram training b. Quality of ongoing technical assistance
- #45: PHASE ONE: INITIAL CONSIDERATIONS REGARDING THE HOST SETTING ASSESSMENT STRATEGIES 1. Conducting a needs and resources assessment 2. Conducting a fit assessment 3. Conducting a capacity/readiness assessment Decisions about adaptation 4. Possibility for adaptation Capacity-building strategies 5. Obtaining explicit buy-in from critical stakeholders and fostering a supportive community/organizational climate 6. Building general/organizational capacity 7. Staff recruitment/maintenance 8. Effective pre-innovation staff training PHASE TWO: CREATING A STRUCTURE FOR IMPLEMENTATION STRUCTURAL FEATURES FOR IMPLEMENTATION 9. Creating implementation teams 10. Developing an implementation plan PHASE THREE: ONGOING STRUCTURE ONCE IMPLEMENTATION BEGINS Ongoing implementation support strategies 11. Technical assistance/coaching/supervision 12. Process evaluation 13. Supportive feedback mechanism PHASE FOUR: IMPROVING FUTURE APPLICATIONS 14. Learning from experience
- #46: five major domains : intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation 37 constructs
- #47: 26 articles (6 % of 429) were included in the final sample. This figure includes only studies which specified CFIR constructs used (n=15). Nine studies specified only domains that were used and no constructs. Two studies made no explicit reference to any CFIR domains or constructs
- #48: Esther qui utile le CFIR + Étape Durlak pour compléter
- #52: se strength?: System Strengthening Lessons From Applying the CFIR to Maternal Health Positive Deviance Cases in Nampula, Mozambique
- #55: Mise en oeuvre correspond aux activités de vérification et de détermination et paiement des subsides. La dimension ‘autres’ comportent les activités de recherche-action.
- #56: Fidélité de couverture
- #57: an overview of reviews
- #58: C,est donc un très vieux débat et les écrits en SP sont très nombreux, quels sont ils donc en santé mondiale ?
- #60: Unintended consequences : "changes for which there is a lack of purposeful action or causation that occur to a social system as a result of the innovation" (Ash et al., 2007) Design: Multiple case study Data collection • 6healthcarecenters • Fieldwork for ~ 2 weeks/center Falsification of community verification records Staged supervisions Dissatisfaction Loss of patient confidentiality Work overload created by patient sampling Inconclusive process for identifying fictitious patients Fear and apprehension among patients regarding community verification Fear of and conflicts regarding payment modalities
- #61: OXFORD IMPLEMENTATION INDEX FOR TRIAL
- #63: Concept multidimensionnel= 8 dimensions