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      Need for more and better implementation science in global health

      editorial
      1 , 2
      BMJ Global Health
      BMJ Publishing Group

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          Abstract

          ‘We know what we have to do, but we don't know how to do it’ has been a recurring comment among global health actors for a long time. In 2010, for example, the United Nations affirmed that ‘we know what works’1 in taking care of the health of women and children. The WHO Commission on the Social Determinants of Health (2008) has highlighted effective interventions to improve the health of populations and to establish health equity.2 However, while the content of interventions, which are theoretically effective, are relatively well known, their level of coverage is weak.3 Furthermore, the conditions of their implementation are less understood. An old meta-analysis shows that the potential effectiveness of interventions is reduced by 50% because of multiple contextual factors which act against the implementation.4 Therefore, it is not enough to know if a health intervention is effective; it is also necessary to understand why the intervention works, how, for whom and in which contexts. It is here where implementation science is an undeniable aid. In this editorial, the focus will not be on the controversies concerning the definition of implementation science or the academic arguments made in order to appropriate or better sell the training of implementation science. Essentially, what is of interest is to call on the community of students, researchers, implementers and donors to commit themselves to further and a better quality research in order to have a greater understanding of how to implement health interventions. To quote Joseph Durlak, an important author in this field, ‘studying programme implementation is not easy but it is essential’.5 Implementation is comprised of one or several processes organised in a particular context so as to bring about the desired changes of an intervention (whether policy, programme or project) through the means necessary to deploy it. Implementation science is about mobilising theories, concepts and methods to better ‘understand what, why, and how interventions work in ‘real world’ settings’.6 There is a movement away from implementation research, which is centred on analysing the way interventions consider evidence, a field that is close to knowledge transfer, which is also not fully developed in low and middle income countries (LMICs).7 However, we do agree with the fact that ‘research in both fields deals with the challenges of translating intentions into desired changes’.8 A meeting of major journal editors has been organized by the Canadian Institutes of Health Research Institute of Population and Public Health and the Canadian Journal of Public Health in April 2016 (http://sparkingsolutions.ca). They will soon launch the Ottawa Statement to promote publications in the field of population health intervention research. BMJ Global Health wishes to participate in the development of implementation science but with a focus on equity and on a better adaptation and/or creation of theoretical, conceptual and methodological approaches in the context of LMICs. In fact, a review of writings (1933–2003) concerning research on the implementation of public policies shows that only 4% concerned Africa, 2% Latin America and 15% was on health.9 The author of this review clearly highlighted ‘the ethnocentric bias in implementation studies’.9 This observation was confirmed in another analysis (1986–2006) of research in public policies in the field of health promotion: ‘all the most authoritative conceptualizations mentioned here were modelled on Western-style democratic governance systems’.10 Two rapid bibliographic searches using Pubmed database show an important increase of papers about global health and implementation since 1970, but implementation still concern just around 5% (figure 1). Therefore, there is an urgency to act, since both analyses confirm that we are far from having a body of theories, frameworks and approaches which is sufficient for the in-depth study of the implementation of interventions;9 11 12 interventions which still need to be largely ‘tested and operationalised in real-world settings’.13 Figure 1 Global health and implementation science papers from 1970 to 2015. Two rapid bibliographic searches using PubMed database were performed. Search 1, in order to obtain all references about global health, the following was used: [Global health (MeSH, major topic) OR international health (title / abstract)], given that the MeSH term was introduced only recently. In order to exclude interventions studies about pharmaceutical treatment, the following terms were added: NOT [pharmaceutic (Title/Abstract) OR drug (Title/Abstract) OR vaccine (Title/Abstract)]. Results of search 1 are presented with the black line (left axis) per year since 1970. Search 2, in order to extract in these results, studies focusing on implementation science, the following terms were added: AND [implementation (Title/Abstract)]. Results of search 2 are presented with the red line (left axis) per year since 1970. In the blue dotted line (right axis) the calculated percentage of references focusing on implementation science (search 2) in the global health area of research (search 1).Data analysis performed by Stéphanie Degroote. This urgency should not be taken lightly. It is important that implementation studies in LMICs adhere to what is often called the third generation, which uses more rigorous research design.14 While global health actors appear to have discovered implementation science recently,15 it was actually mobilised at least more than 30 years ago by political science researchers.9 It is not necessary in this editorial to discuss the history of the analysis of intervention implementation8 9 11 which should be better understood (and thus better taught16) and used by those who study implementation. However, research on global health implementation should better exploit the theories, conceptual frameworks and approaches of the social sciences.12 As essential as the inductive and empirical approaches may be, recourse or contribution to theoretical and conceptual development is as important, if not even more.17 As a reminder, among the health promotion studies which analysed public policy, only 18% made reference to a theoretical framework.18 Studies showed that Kingdon's stream theory19 along with Lipsky's street-level bureaucrats20 and Rogers’ innovation theory,21 which were all developed in the USA, could also have been adapted in the context of certain LMICs in order to better understand implementation. Additionally, the role of ideas in the implementation (rather than the emergence) of interventions in LMICs have not really been tackled,22 whereas the writings on high-income countries in this regard have been abundant.23 Implementation science clearly cannot be developed alone without considering the effects of interventions (or the principles of effectiveness, to borrow from Patton's words24), because it risks falling into ‘type 3 error’, where an intervention is evaluated even though it has not yet been implemented as anticipated.25 Thus it is important to better describe the content of interventions using available tools26 27 and to report on the (classic) fidelity and intensity of implementation. It is also necessary to update the adjustments of interventions—inevitable in a natural context—and the fidelity of the theory.28 29 It is in this contextual and holistic research approach that we should conduct and report implementation science. The recurrence of several types of interventions in many settings, the links between the effects (expected or not), the processes, the actors and their context should be brought to light, notably with the theoretical approach of critical realism, which is still not well-tested in LMICs.30 Critical theory could be used to better understand power relations. Individual relations and the role that context plays in the matter should be studied to understand, for example, the heterogeneity of effects in the implementation of interventions.31 When not forgotten, contextual analysis specifically associated with interventions is often the poor parent.32 The use and presentation of methods should also be considered in developing this field by making it more credible to those who think that qualitative research or the flexible approach to research design,33 34 which are integral parts of implementation science, are not rigorous enough. For this, it is necessary that authors are more precise in the description of their methods of qualitative sampling and of their analysis procedures. Beyond these interdisciplinary, boundary-spanning approaches, which are necessary in global health,35 36 the recourse to mixed methods and to multiple case studies, if longitudinally possible, would be a major benefit for implementation science.14 It is certainly time to seriously consider the charge which was made almost 10 years ago on policy research in LMICs: ‘more work on implementation, and specifically, the challenges of implementing equity-oriented policies, as well as more examination of successful policy change experiences’.37 We invite authors to participate in this by proposing and submitting implementation science articles to BMJ Global Health.

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          Most cited references31

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          Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.

          Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face to face panel meeting. The resultant 12 item TIDieR checklist (brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), how well (actual)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with an explanation and elaboration for each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.
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            The terrain of health policy analysis in low and middle income countries: a review of published literature 1994–2007

            This article provides the first ever review of literature analysing the health policy processes of low and middle income countries (LMICs). Based on a systematic search of published literature using two leading international databases, the article maps the terrain of work published between 1994 and 2007, in terms of policy topics, lines of inquiry and geographical base, as well as critically evaluating its strengths and weaknesses. The overall objective of the review is to provide a platform for the further development of this field of work. From an initial set of several thousand articles, only 391 were identified as relevant to the focus of inquiry. Of these, 164 were selected for detailed review because they present empirical analyses of health policy change processes within LMIC settings. Examination of these articles clearly shows that LMIC health policy analysis is still in its infancy. There are only small numbers of such analyses, whilst the diversity of policy areas, topics and analytical issues that have been addressed across a large number of country settings results in a limited depth of coverage within this body of work. In addition, the majority of articles are largely descriptive in nature, limiting understanding of policy change processes within or across countries. Nonetheless, the broad features of experience that can be identified from these articles clearly confirm the importance of integrating concern for politics, process and power into the study of health policy. By generating understanding of the factors influencing the experience and results of policy change, such analysis can inform action to strengthen future policy development and implementation. This article, finally, outlines five key actions needed to strengthen the field of health policy analysis within LMICs, including capacity development and efforts to generate systematic and coherent bodies of work underpinned by both the intent to undertake rigorous analytical work and concern to support policy change.
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              Never the twain shall meet? - a comparison of implementation science and policy implementation research

              Background Many of society’s health problems require research-based knowledge acted on by healthcare practitioners together with implementation of political measures from governmental agencies. However, there has been limited knowledge exchange between implementation science and policy implementation research, which has been conducted since the early 1970s. Based on a narrative review of selective literature on implementation science and policy implementation research, the aim of this paper is to describe the characteristics of policy implementation research, analyze key similarities and differences between this field and implementation science, and discuss how knowledge assembled in policy implementation research could inform implementation science. Discussion Following a brief overview of policy implementation research, several aspects of the two fields were described and compared: the purpose and origins of the research; the characteristics of the research; the development and use of theory; determinants of change (independent variables); and the impact of implementation (dependent variables). The comparative analysis showed that there are many similarities between the two fields, yet there are also profound differences. Still, important learning may be derived from several aspects of policy implementation research, including issues related to the influence of the context of implementation and the values and norms of the implementers (the healthcare practitioners) on implementation processes. Relevant research on various associated policy topics, including The Advocacy Coalition Framework, Governance Theory, and Institutional Theory, may also contribute to improved understanding of the difficulties of implementing evidence in healthcare. Implementation science is at a relatively early stage of development, and advancement of the field would benefit from accounting for knowledge beyond the parameters of the immediate implementation science literature. Summary There are many common issues in policy implementation research and implementation science. Research in both fields deals with the challenges of translating intentions into desired changes. Important learning may be derived from several aspects of policy implementation research.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                August 2016
                8 August 2016
                : 1
                : 2
                Affiliations
                [1 ]Universite de Montreal, School of Public Health (ESPUM) , Montreal, Quebec, Canada
                [2 ]Universite de Montreal Institut de recherche en sante publique (IRSPUM) , Montreal, Quebec, Canada
                Author notes
                [Correspondence to ] Professor Valéry Ridde; valery.ridde@ 123456umontreal.ca
                Article
                bmjgh-2016-000115
                10.1136/bmjgh-2016-000115
                5321336
                aef46c99-aea0-42ae-a4ff-237fa84ee2b6
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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