Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. It is primarily focused on improving health outcomes by considering how real-world, context-specific insights influence program implementation. (Theobald, et al., 2018; Peters, et al., 2013).
Implementation research focuses on bridging what many experts call the “know-do” gap (University of Washington, 2021). This gap refers to a common research focus that prioritizes the identification of effective health interventions over research on how to implement interventions in a way that ensures that they are acceptable, effective, equitable, and sustainable. Implementation research is the bridge between knowing what to do in theory and what happens in practice.
As implementation research gains recognition in the global health sphere, questions arise surrounding jargon and definitions, specifically regarding the difference between implementation research and implementation science. Implementation research has been described as a subdomain, and the “heart and soul,” of implementation science (Hoke, 2019). The relationship between the two practices correlates with the “know-do” gap: implementation science supplies what we know about how to make interventions successful; implementation research allows us to examine how the knowledge can be effectively applied within specific contexts and settings, as well as how it can be scaled-up and used in broader settings (MEASURE Evaluation, 2012). Implementation research is, therefore, more expansive than operations research, a practice for generating monitoring and evaluation data, which primarily focuses on a specific setting and context. For example, operations research addresses questions such as: “What are the barriers to implementation in this setting?” and “How should the intervention be implemented in this setting to achieve the best outcomes?” Implementation research, on the other hand, starts within a specific context but aims to apply its findings more broadly. It addresses questions such as: “How can access be increased for individuals in this setting who are not currently receiving intervention benefits?” and “How can we ensure equitable access to this intervention beyond this setting?” (MEASURE Evaluation, 2012). Both are useful, but due to its focus on scale-up and sustainability, implementation research is increasingly gaining traction in the public health field.
Timing and Participatory Approach
Ideally, implementation research should begin before an intervention is underway to identify challenges that may arise during implementation and context-specific strategies to address them (Peters et al., 2013). Prior research demonstrates that it is rare for implementation to be entirely successful during its first installment. While certain key outcomes may be achieved early in the implementation process, others may not be. It is therefore important to continue implementation research during the life of the intervention to pinpoint existing barriers and the new strategies needed to overcome them and achieve the desired goals (MEASURE Evaluation, 2012). Implementation research is useful even when outcomes are successfully achieved, as it can be used to identify strategies for adapting to new contexts, scale-up, and greater cost-effectiveness, among other possibilities.
Starting implementation research before the intervention is launched also provides the opportunity to engage crucial stakeholders early on. Stakeholders may include local or national governments, funders, implementers, and beneficiaries of the intervention. Implementation research is most effective when those designing the research questions include stakeholders participating on the ground, such as policy makers designing policy around the intervention, healthcare workers delivering the intervention, beneficiaries of the intervention, and any others directly involved with or affected by the intervention (Peters, et al., 2013). Emphasis should be placed on soliciting perspectives from beneficiaries whose voices have historically been unheard or overlooked to ensure research questions will lead to appropriate and equitable outcomes for all. Research questions can focus on specific barriers, strategies, or other aspects of implementation that prompt the questions of “why?” and “how?” Aspects of relevance, urgency of need, feasibility, and ethical acceptance, among others, may be helpful to consider when determining research questions (MEASURE Evaluation, 2012).
Implementation research frameworks can help identify the barriers, facilitators, and strategies that may influence implementation. One widely used framework is the Consolidated Framework for Implementation Research (CFIR). CFIR provides the major domains and categories for barriers and facilitators, such as cultural, political, economic, and geographic, among others (Damschroder, 2009). Moullin, et al. (2020) also provides recommendations for the use of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework; Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework; and the Theoretical Domains Framework (TDF). Outlining potential barriers and facilitators into an organized, visual framework enables researchers to identify strategies and address them with more clarity. There are also various frameworks and methods available for identifying specific implementation strategies, which, similar to frameworks for implementation barriers, start more broadly and then allow researchers to narrow down to specifics. See, for example, a taxonomy of implementation strategies in Powell, et al., (2012).
Outcomes and Indicators
Eight distinct outcome areas are commonly used by implementation researchers: acceptability, adoption, appropriateness, feasibility, fidelity, cost, penetration, and sustainability (Proctor, et al., 2010). When assessed, these outcome areas serve as measurable indicators of success and allow researchers to ensure implementation achieved what it intended to.
The processes, outcomes, and results of implementation research require specific indicators which are measured through quantitative or qualitative data. While quantitative indicators are more commonly used, qualitative indicators may be essential for assessing some areas, particularly acceptability and appropriateness. Example indicators related to implementation outcomes for Kangaroo Mother Care (KMC), a widely used newborn health intervention, include: number of newborns who were weighed, identified, initially assessed, discharged from or admitted to KMC (adoption); number of newborns who were discharged and received follow-up per protocol (fidelity); and KMC service availability (penetration) (Guenther, et al., 2017). Example indicators related to implementation outcome areas for community-based family planning programs include: number/percentage of community-based family planning providers who receive supportive supervision during program implementation (fidelity); clients’ satisfaction with community-based family planning services (acceptability); percentage of women using a modern family planning method who obtained their current method from a community-based provider (penetration); and percentage of community-based family planning providers who report experiencing a stock-out in the past six months (sustainability).
Indicators should be identified before implementation research begins to ensure that the research stays on track with its measurable goals; however, changes and adaptations can be made to indicators throughout the research stage if all changes are documented.
As Peters (2013) discusses, implementation without implementation research wastes valuable resources without knowing if a program is on track to being successful. By translating research findings into tangible actions, implementation research ensures that identifying robust solutions to address pressing health problems is not done in vain. It prioritizes making interventions effective, equitable, and accessible, which is crucial in a world plagued by inaccessible and inequitable health services. To learn more about implementation research, see the Implementation Research Platform (WHO, 2017).
“The basic intent of implementation research is to understand not only what is and isn’t working, but how and why implementation is going right or wrong, and testing approaches to improve it.” (Peters et al., 2013)
Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A Consolidated Framework for advancing implementation science. Implementation Science. Retrieved October 13, 2021, from https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-4-50.
Guenther, T., Moxon, S., Valsangkar, B., Wetzel, G., Ruiz, J., Kerber, K., Blencowe, H., Dube, Q., Vani, S.N., Vivio, D., Magge, H., De Leon-Mendoza, S., Patterson, J., Mazia, G. (2017). Consensus-based approach to develop a measurement framework and identify a core set of indicators to track implementation and progress towards effective coverage of facility-based Kangaroo Mother Care. J Glob Health, Dec;7(2):020801. https://doi.org/doi: 10.7189/jogh.07.020801. PMID: 29057074; PMCID: PMC5644361.
Hoke, T. (2019). Implementation research: The unambiguous cornerstone of implementation science. R&E Search for Evidence. Retrieved October 13, 2021, from https://researchforevidence.fhi360.org/
Implementation research platform. (2017). Retrieved October 20, 2021, from https://www.who.int/alliance-hpsr/implementation-research-platform/en/.
Measure Evaluation. (2012). Fundamentals of Implementation Research. Retrieved October 13, 2021, from https://www.measureevaluation.org/resources/publications/ms-12-55/at_download/document. University of North Carolina, Chapel Hill, NC, USA: MEASURE Evaluation.
Moullin, J.C., Dickson, K.S., Stadnick, N.A., et al. (2020). Ten recommendations for using implementation frameworks in research and practice. Implement Sci Commun, 1:42. https://doi.org/10.1186/s43058-020-00023-7. Retrieved October 20, 2021, from https://implementationsciencecomms.biomedcentral.com/articles/10.1186/s43058-020-00023-7.
Peters, D.H., Tran, N.T., & Adam, T. (2013). Implementation research in health: a practical guide. Geneva, Switzerland: Alliance for Health Policy and Systems Research, World Health Organization. Retrieved October 13, 2021, from https://apps.who.int/iris/bitstream/handle/10665/91758/
Powell, B.J., McMillen, J.C., Proctor, E.K., et al. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Med Care Res Rev. 69(2):123-157. https://doi.org/10.1177/1077558711430690. Retrieved October 13, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524416/.
Proctor, E., Silmere, H., Raghavan, R., et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. (2011). Adm Policy Ment Health, 38:65–76. Retrieved October 13, 2021, from https://link.springer.com/article/10.1007/s10488-010-0319-7.
Theobald, S., Brandes, N., Gyapong, M., El-Saharty, S., Proctor, E., Diaz, T., et al. (2018). Implementation research: new imperatives and opportunities in global health. The Lancet, 17;392(10160):2214-2228. Retrieved from https://doi.org/10.1016/S0140-6736(18)32205-0.
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