Using Data for Impact: A Critical Examination Through the Lens of Implementation Science

David PelletierDivision of Nutritional Sciences

Cornell University

Spring CORE Group Meeting, Wilmington, DE May 1, 2012

Outline

1. 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

Why Implementation Science?

• Efficacy-to-Effectiveness• Knowledge-to-Action• Evidence-Based Interventions• Evidence-Based Decisions• Evidence-Based Policy Making• Scaling Up• Etc.

p2

Fixsen et al., p74

Why Implementation Science?

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

Some Overall Observations from the Literature

1. New: Implementation science is a new and still-emerging field with little consistency in terms, concepts and methods

2. Complex: There are ~40 categories of factors (and hundreds of variations on these) that affect the quality and impact of intervention delivery

3. 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”

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)

What is Implementation Science?

Current State of the Field

Fixsen et al., p74

Current State of the Field

Broadening the Definition

1. 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

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

Beyond “Evidence-Based Interventions”

Body of GeneralizablePrinciples/ Scientific/TheoreticalKnowledge Integration

Application ofKnowledge inProgram Design& Implementation

ImprovedAction

Detached,Highly-Structured orExperimentalResearch

ContextualKnowledge & Tacit Knowledge

Reflection,Learning,Documentation,Codification

Beyond “Scientific” Knowledge

Practice-BasedExperience &EngagedResearch

SystematizedExperience &FeedbackDuringImplementation

FormalM&E

InterventionProven in

A Few Contexts(RCTs)

NewContexts

Dissemination & Implementation

Processes

Opening the Black Box

Outcomes At-Scale

Toward a Comprehensive Framework for Implementation Science

ClientOutcomes

-Health- Function-Symptoms-Satisfaction

A. Intervention/Innovation /Guideline/Practice /Policy (IIGPP)(unadapted)•Core components•Peripheral components

IIGPP (adapted)•Core components•Peripheral components

D. Outer Setting: Participant needs & resources, govt and donor policies & regulations, peer/ network influences , societal & cultural influences, etc.

B. Inner Setting: org size, structure, maturity, management, informal networks, culture, climate (tension, compatibility, priority, incentives, goal clarity, learning climate), readiness (leadership, resources, access to knowledge & info)

C. Individuals (providers and managers): knowledge & beliefs, self-efficacy, stage of change, identification with organization, motivation, values, intellect, competence, capacity, learning style, openness, etc

Perceived and Actual: source, evidence, advantage, adaptability, trialability, complexity, design quality and packaging, cost

E. ImplementationProcesses: •Formative research•Planning•Implem Strategy•Change Theory•Engaging

-opinion leaders -formal leaders -champions -facilitators• Execution -components -sequence -intensity -duration -quality•Feedback•Evaluation•Reflection•Decisions•Adjustments

Context

Implementing Organization

ImplementationOutcomes

1. Efficiency2. Effectiveness3. Equity4. Safety5. Patient- centered6. Timeliness

Acceptability1. Fit2. Feasibility3. Costs

Application1. Adoption2. Adaptation3. Fidelity/Quality4. Penetration5. Sustainability

ServiceOutcomes

Adapted from: Damschroeder et al., Implem Science 4:50, 2009; Proctor et al., Admin Pol Mental Hlth 38:65-76, 2011

A Consolidated Framework of Implementation(factors operate at multiple levels, from provider to organization and country)

Do We Need a Framework?A Simple (Probably Painful) Example

Which of the following best describes the training approach typically used with frontline workers in your programs?

1. Lectures and Discussion

2. Lectures and Discussion + demonstrations

3. Lectures and Discussion + demos + hands-on practice and feedback

Effectiveness of Training Methods: Results of a Meta-Analysis

Outcomes for Assessing Effectiveness

TrainingMethod

Teacher’sKnowledge

Teacher’s Skill

Teacher’s Use of New Practices

Lectures and Discussion

10% 5% 0

+ Demonstrations 30% 20% 0

+ Practice and Feedback

60% 60% 5

+ Coaching in the Classroom

95% 95% 95%

Fixsen, D.L., et al., Implementation research: A synthesis of the literature. 2005, National Implementation Research Network: Tampa, FL.

Why?

ClientOutcomes

-Health- Function-Symptoms-Satisfaction

A. Intervention/Innovation /Guideline/Practice /Policy (IIGPP)(unadapted)•Core components•Peripheral components

IIGPP (adapted)•Core components•Peripheral components

D. Outer Setting: Participant needs & resources, govt and donor policies & regulations, peer/ network influences , societal & cultural influences, etc.

B. Inner Setting: org size, structure, maturity, management, informal networks, culture, climate (tension, compatibility, priority, incentives, goal clarity, learning climate), readiness (leadership, resources, access to knowledge & info)

C. Individuals (providers and managers): knowledge & beliefs, self-efficacy, stage of change, identification with organization, motivation, values, intellect, competence, capacity, learning style, openness, etc

Perceived and Actual: source, evidence, advantage, adaptability, trialability, complexity, design quality and packaging, cost

E. ImplementationProcesses: •Formative research•Planning•Implem Strategy•Change Theory•Engaging

-opinion leaders -formal leaders -champions -facilitators• Execution -components -sequence -intensity -duration -quality•Feedback•Evaluation•Reflection•Decisions•Adjustments

Context

Implementing Organization

ImplementationOutcomes

1. Efficiency2. Effectiveness3. Equity4. Safety5. Patient- centered6. Timeliness

Acceptability1. Fit2. Feasibility3. Costs

Application1. Adoption2. Adaptation3. Fidelity/Quality4. Penetration5. Sustainability

ServiceOutcomes

Adapted from: Damschroeder et al., Implem Science 4:50, 2009; Proctor et al., Admin Pol Mental Hlth 38:65-76, 2011

A Consolidated Framework of Implementation(factors operate at multiple levels, from provider to organization and country)

An Example for Group Work:The 2010 WHO Guidelines on Infant Feeding in

the Context of HIV

The 2010 Guidelines “The Challenges”

Policy Choice

ARV+Breastfeeding No Breastfeeding

Basic Requirements if child survival is to be maximized

a. Widespread HIV testingb. Reliable ARV suppliesc. Full ARV adherenced. Proper EBF adherence and transition to mixed feeding

a. Safe water and sanitation are assured at household and community level

b. Sufficient infant formula is assuredc. Can prepare it cleanly and frequentlyd. Exclusive formula for first six months is possiblee. Family is supportive of this practicef. 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

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.

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?

Thank You!

• 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.

CFIR Domain CFIR Element

Characteristics of the intervention Perceived strength of evidencePerceived advantage

ComplexityCharacteristics of the individuals Knowledge and beliefs

Identification with the organizationCharacteristics of the inner setting Goal clarity

CompatibilityCharacteristics of the outer setting Perceived social, cultural and economic

situation of the mother/caretakerDonor influences on MOH policy

Characteristics of the implementation process

Implementation strategy (train and hope?)Evaluation

Adjustments

Assuming that “Breastfeed + ARVs” is the “National Policy”

What factors will influence the counseling practices of health workersand the feeding practices of mothers?