Implementation research: from theory to practice

Implementation research is the scientific inquiry into questions concerning implementation, as the World Health Organization's practical guide of 2013 defines it. The guide starts from a key challenge for global health: how to take proven interventions and implement them in the real world. As the guide puts it, the field knows what works, but does not always know how to make it work in the real world.

The guide's answer has four parts: a definition, eight outcomes to measure, the people the work needs and questions that test it.

What implementation research is

Broadly speaking, the guide uses the term for the scientific study of the processes used to implement initiatives. It covers, too, the contextual factors that affect those processes.

Implementation research does not, as a rule, set out to discover new health products. Nor does it test the safety or efficacy of clinical interventions. Instead, it often deals with the strategies it takes to deliver or implement those products and interventions.

The guide calls these implementation strategies. It uses the term to keep them distinct from clinical and public health interventions themselves.

Beyond that, the guide places implementation research inside the work it serves. In its words, implementation research is in fact an integral part of programme planning and execution.

Embedded in the real world, it also captures and analyses information in real time. In turn, that allows the assessment of performance and helps to strengthen health systems.

Where monitoring and evaluation fit

Implementation research also draws on work that many programmes already do. According to the guide, monitoring and evaluation play a significant part in this kind of implementation research. Many implementers and managers already carry out those activities on a routine basis. Often, they also help to define the important research questions.

The eight outcomes of implementation research

Implementation outcome variables serve as indicators of how well a given implementation is actually working. WHO's guide sets out eight of them, each with a working definition.

1. Acceptability: the perception among stakeholders, such as consumers, providers, managers and policy-makers, that an intervention is agreeable.
2. Adoption: the intention, initial decision or action to try to employ a new intervention.
3. Appropriateness: the perceived fit or relevance of the intervention in a given setting.
4. Feasibility: the extent to which an organisation or setting can carry out an intervention.
5. Fidelity: how closely an intervention follows the design in its original protocol, plan or policy.
6. Implementation cost: the incremental cost of the delivery strategy, for example the way a particular setting delivers its services.
7. Coverage: the degree to which the population that is eligible to benefit from an intervention actually receives it.
8. Sustainability: the extent to which an intervention continues over time.

Which outcomes matter most depends on the intervention. With a novel intervention, for example, the main focus might be on acceptability, adoption, appropriateness and feasibility.

For existing interventions, by contrast, fidelity to the original design often matters a great deal. Costs and coverage often matter just as much.

Who implementation research needs

Research on implementation, the guide says, requires the engagement of diverse stakeholders and multiple disciplines. It needs them to address the complex implementation challenges that they face.

Likewise, research design needs to reflect the specific problems that implementers are addressing. It needs to reflect, too, the contexts in which those problems occur.

Hence the guide stresses collaborative ties between the people who generate policy, manage programmes and conduct research. As the guide notes, implementation research is often at its most useful where implementers have played a part in identifying, designing and conducting it.

The guide is equally firm on method. In implementation research, the question determines the method used, rather than the method determining the kinds of questions asked.

Richnovex works with universities, research groups and technology transfer offices to take research outputs to market, as its work with academia sets out.

Questions that test the work

The guide also offers questions for judging implementation research. Among them, it asks whether the work:

1. involves an implementation strategy;
2. takes place in a real-world setting;
3. properly considers implementation outcome variables;
4. properly considers context and the other factors that influence implementation;
5. clearly identifies its target audience, and how that audience can use it.

Accordingly, the guide encourages implementers to ask those questions. It also urges them to take a lead in demanding better research.

Implementation research turns proven interventions into practice

Implementation research takes on the challenge of making proven interventions work in the real world. Accordingly, WHO's guide treats it as an integral part of programme planning and execution. It is often most useful when implementers help to shape it, and its eight outcome variables show how well an implementation is working.

Sources

1. Peters DH, Tran NT, Adam T, Implementation research in health: a practical guide, Alliance for Health Policy and Systems Research, World Health Organization (2013): ahpsr.who.int, the guide