The "case" for case studies: why we need high-quality examples of global implementation research

A qualitative evaluation of the short and long-term impacts of an implementation science training program in South Africa

BACKGROUND

As implementation science (IS) in low and middle-income country settings continues to grow and generate interest, there is continual demand for capacity building in the field. Training programs have proliferated, but evaluations of these efforts are sparse and primarily from high-income countries. There is little knowledge about the impact of IS training on students' careers post-graduation. This evaluation of the first cohort of students who graduated from the 18-month implementation science concentration in HIV/AIDS within the Master of Science program at University of the Witwatersrand in South Africa addresses this gap.

METHODS

We conducted two rounds of virtual interviews with the students, who were from eight African countries, immediately after the training program ended (n = 10 participants) and again five years later (n = 9 participants). The first survey captured student perceptions of IS before they entered the program and their opinions just after graduation. The follow-up evaluated their perceptions five years after graduation. Interviews were recorded, transcribed, and coded in ATLAS.ti (first round) and MAXQDA (second round), using the framework method and thematic analysis.

RESULTS

Prior to the training, all students, even those with no knowledge of the field, perceived that the IS training program would help them develop skills to address critical public health priorities. These expectations were generally met by the training program, and most students reported satisfaction despite what they felt was a limited timeframe of the program and insufficient mentorship to complete their dissertation projects at their home institutions across the African continent. Five years post-graduation, most of the students did not have jobs in IS but continued applying their training in their roles and had subsequently pursued further education, some in IS-related programs.

CONCLUSIONS

IS training in Africa was clearly seen as valuable by trainees but IS job opportunities remain scarce. Training programs need to be more closely tied to local government priorities, and training for in-country policy and decision-makers is needed to increase demand for qualified IS researchers and practitioners.

A case study of the development of a valid and pragmatic implementation science measure: the Barriers and Facilitators in Implementation of Task-Sharing Mental Health interventions (BeFITS-MH) measure

BACKGROUND

Few implementation science (IS) measures have been evaluated for validity, reliability and utility - the latter referring to whether a measure captures meaningful aspects of implementation contexts. We present a real-world case study of rigorous measure development in IS that assesses Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), with the objective of offering lessons-learned and a framework to enhance measurement utility.

METHODS

We summarize conceptual and empirical work that informed the development of the BeFITS-MH measure, including a description of the Delphi process, detailed translation and local adaptation procedures, and concurrent pilot testing. As validity and reliability are key aspects of measure development, we also report on our process of assessing the measure's construct validity and utility for the implementation outcomes of acceptability, appropriateness, and feasibility.

RESULTS

Continuous stakeholder involvement and concurrent pilot testing resulted in several adaptations of the BeFITS-MH measure's structure, scaling, and format to enhance contextual relevance and utility. Adaptations of broad terms such as "program," "provider type," and "type of service" were necessary due to the heterogeneous nature of interventions, type of task-sharing providers employed, and clients served across the three global sites. Item selection benefited from the iterative process, enabling identification of relevance of key aspects of identified barriers and facilitators, and what aspects were common across sites. Program implementers' conceptions of utility regarding the measure's acceptability, appropriateness, and feasibility clustered across several common categories.

CONCLUSIONS

This case study provides a rigorous, multi-step process for developing a pragmatic IS measure. The process and lessons learned will aid in the teaching, practice and research of IS measurement development. The importance of including experiences and knowledge from different types of stakeholders in different global settings was reinforced and resulted in a more globally useful measure while allowing for locally-relevant adaptation. To increase the relevance of the measure it is important to target actionable domains that predict markers of utility (e.g., successful uptake) per program implementers' preferences. With this case study, we provide a detailed roadmap for others seeking to develop and validate IS measures that maximize local utility and impact.

Strengthening healthcare delivery in Rwanda: Implementation science training for reproductive health researchers

BACKGROUND

Addressing the gap between research and practice is crucial for enhancing reproductive healthcare outcomes. In Rwanda and other low- and middle-income countries, bolstering health researchers' implementation science (IS) capacity is essential. We present a pre-post-intervention study assessing the influence of an intensive IS training program on Rwandan reproductive health researchers' perceived IS knowledge and self-efficacy in applying IS in their own research.

METHODS

To introduce IS principles, we held a one-day training for a diverse cohort of 25 sexual and reproductive health researchers in Rwanda. The training encompassed modules on IS concepts, methodologies, and practical applications. Pre- and post-training assessments gauged changes in participants' perceived IS knowledge and self-efficacy in applying IS in their own work.

RESULTS

The study revealed a significant improvement in self-efficacy related to performing IS related tasks. Researchers reported heightened confidence in designing and implementing evidence-based interventions. In terms of perceived knowledge, participants retained what they learned at 4 months. The training fostered a collaborative learning environment, encouraging participants to exchange ideas and experiences.

CONCLUSION

Targeted training in IS appears to enhance reproductive health researchers' capacity to translate research into practice, potentially leading to improved healthcare outcomes in Rwanda. Moving forward, we advocate for the Ministry of Health to establish structures for IS research agenda-setting, particularly for sexual and reproductive health and rights. Ideally, universities, health systems, and research institutions will incorporate IS capacity strengthening into their routine activities. Ongoing training is crucial to reinforce and expand IS knowledge. Our findings are expected to inform future interventions and guide policy development.

Challenges and Opportunities for Paving the Road to Global Health Equity Through Implementation Science

Implementation science focuses on enhancing the widespread uptake of evidence-based interventions into routine practice to improve population health. However, optimizing implementation science to promote health equity in domestic and global resource-limited settings requires considering historical and sociopolitical processes (e.g., colonization, structural racism) and centering in local sociocultural and indigenous cultures and values. This review weaves together principles of decolonization and antiracism to inform critical and reflexive perspectives on partnerships that incorporate a focus on implementation science, with the goal of making progress toward global health equity. From an implementation science perspective, wesynthesize examples of public health evidence-based interventions, strategies, and outcomes applied in global settings that are promising for health equity, alongside a critical examination of partnerships, context, and frameworks operationalized in these studies. We conclude with key future directions to optimize the application of implementation science with a justice orientation to promote global health equity.

Implementing and evaluating integrated care models for non-communicable diseases in fragile and humanitarian settings

In this commentary, we advocate for the wider implementation of integrated care models for NCDs within humanitarian preparedness, response, and resilience efforts. Since experience and evidence on integrated NCD care in humanitarian settings is limited, we discuss potential benefits, key lessons learned from other settings, and lessons from the integration of other conditions that may be useful for stakeholders considering an integrated model of NCD care. We also introduce our ongoing project in North Lebanon as a case example currently undergoing parallel tracks of program implementation and process evaluation that aims to strengthen the evidence base on implementing an integrated NCD care model in a crisis setting.

A Case Study of the Development of a Valid and Pragmatic Implementation Science Measure: The Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH) Measure

Background

Few implementation science (IS) measures have been evaluated for validity, reliability and utility - the latter referring to whether a measure captures meaningful aspects of implementation contexts. In this case study, we describe the process of developing an IS measure that aims to assess Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), and the procedures we implemented to enhance its utility.

Methods

We summarize conceptual and empirical work that informed the development of the BeFITS-MH measure, including a description of the Delphi process, detailed translation and local adaptation procedures, and concurrent pilot testing. As validity and reliability are key aspects of measure development, we also report on our process of assessing the measure's construct validity and utility for the implementation outcomes of acceptability, appropriateness, and feasibility.

Results

Continuous stakeholder involvement and concurrent pilot testing resulted in several adaptations of the BeFITS-MH measure's structure, scaling, and format to enhance contextual relevance and utility. Adaptations of broad terms such as "program," "provider type," and "type of service" were necessary due to the heterogeneous nature of interventions, type of task-sharing providers employed, and clients served across the three global sites. Item selection benefited from the iterative process, enabling identification of relevance of key aspects of identified barriers and facilitators, and what aspects were common across sites. Program implementers' conceptions of utility regarding the measure's acceptability, appropriateness, and feasibility were seen to cluster across several common categories.

Conclusions

This case study provides a rigorous, multi-step process for developing a pragmatic IS measure. The process and lessons learned will aid in the teaching, practice and research of IS measurement development. The importance of including experiences and knowledge from different types of stakeholders in different global settings was reinforced and resulted in a more globally useful measure while allowing for locally-relevant adaptation. To increase the relevance of the measure it is important to target actionable domains that predict markers of utility (e.g., successful uptake) per program implementers' preferences. With this case study, we provide a detailed roadmap for others seeking to develop and validate IS measures that maximize local utility and impact.

Connecting the science and practice of implementation - applying the lens of context to inform study design in implementation research

The saying "horses for courses" refers to the idea that different people and things possess different skills or qualities that are appropriate in different situations. In this paper, we apply the analogy of "horses for courses" to stimulate a debate about how and why we need to get better at selecting appropriate implementation research methods that take account of the context in which implementation occurs. To ensure that implementation research achieves its intended purpose of enhancing the uptake of research-informed evidence in policy and practice, we start from a position that implementation research should be explicitly connected to implementation practice. Building on our collective experience as implementation researchers, implementation practitioners (users of implementation research), implementation facilitators and implementation educators and subsequent deliberations with an international, inter-disciplinary group involved in practising and studying implementation, we present a discussion paper with practical suggestions that aim to inform more practice-relevant implementation research.

Development and Validation of Comprehensive Healthcare Providers' Opinions, Preferences, and Attitudes towards Deprescribing (CHOPPED Questionnaire)

Successful implementation of deprescribing requires exploring healthcare professionals’ opinions, preferences, and attitudes towards deprescribing. The aim of this study was to develop and validate the questionnaire exploring healthcare providers’ opinions preferences and attitudes towards deprescribing (CHOPPED questionnaire). This was a cross-sectional on-line survey. A comprehensive 58-item questionnaire, in two versions (for pharmacists and physicians), was developed through an extensive literature review and interviews with experts. The questionnaire was validated, and its reliability was assessed through data collected from 356 pharmacists and 109 physicians. Exploratory factor analysis was performed, and 37- and 35-item questionnaires were developed. Ten factors were identified: knowledge, awareness, patient barriers and facilitators, competencies barriers and facilitators, collaboration barriers and facilitators, and healthcare system barriers and facilitators. The CHOPPED tool has satisfactory face, content (CVR > 0.62) (content validity ratio), construct, and criterion validity. The reliability statistics of all factors in both versions was acceptable with Cronbach’s alpha > 0.6. Test−retest reliability analysis showed that gamma rank correlations of total factor scores were strong and very strong (between 0.519 and 0.938). The CHOPPED tool can be used as a valid and reliable tool to explore healthcare providers’ opinions and attitudes toward discontinuing medications in the primary care setting in Croatia.