|Year : 2022 | Volume
| Issue : 3 | Page : 321-322
Implementation research: The need of the hour
Arun Kumar Sharma1, Poonam Singh2
1 Director, ICMR-National Institute for Implementation Research on Non-Communicable Diseases, Jodhpur, Rajasthan, India
2 Senior Project Fellow, ICMR-National Institute for Implementation Research on Non-Communicable Diseases, Jodhpur, Rajasthan, India
|Date of Submission||27-Aug-2022|
|Date of Decision||04-Sep-2022|
|Date of Acceptance||05-Sep-2022|
|Date of Web Publication||22-Sep-2022|
Arun Kumar Sharma
ICMR-National Institute for Implementation Research on Non-Communicable Diseases, New Pali Road, Jodhpur - 342 005, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Formative research creates evidence. Evidence-based interventions are implemented in community settings. In the past, evidence-based interventions have failed to get desired outcomes. The tuberculosis control program despite being evidence based did not succeed at the beginning. Similarly, evidence-based treatment of hypertension and diabetes has not yet controlled these diseases. This is where the role of implementation research (IR) starts. IR either as part of evidence-based research or independently should be a part of health programs so that the program shall be able to ensure feasibility, fidelity, penetration, acceptability, sustainability, efficiency, effectiveness, and equity.
Keywords: Accessibility, communicable diseases, diabetes, feasibility, fidelity, hypertension, implementation research
|How to cite this article:|
Sharma AK, Singh P. Implementation research: The need of the hour. Indian J Public Health 2022;66:321-2
Evidence-based medicine is the scientific premise of modern medical interventions that provide clarity and scientific credence to interventions of choice. World over, therapeutic, prophylactic, behavioral interventions are first tested in laboratory or controlled community settings as part of formative research, and then rolled out in real-world scenarios to reap the benefits of the generated evidence. For example, effective anti-tubercular drugs were discovered in the middle of 20th century, and the National Tuberculosis (TB) Control program in India was launched in 1962. The program could not achieve the desired success even after three and a half decades, and was considered a “failure.” With the newer drugs and treatment regimens discovered which were backed by evidence; the revised program was launched in 1997. Another 25 years have passed but we are still struggling to control TB despite revising and modifying the program repeatedly. The story can be retold for malaria, dengue, kala-azar, without much variation except for changing the names of the drugs, the programs, and the timelines. The inferential statement will be a pessimistic confession that we have not been able to control, let alone eliminate and eradicate the candidate diseases from the basket of communicable diseases, as we are still struggling to find means of overcoming the problem. On the other side, we are being threatened by re-emergence of nearly eradicated poliovirus and ever-expanding array of potentially threatening zoonotic diseases.
Even for the noncommunicable diseases, the scenario is no better. Let's take the example of the hypertension control program in the country. The standard treatment guidelines on primary hypertension released by the Government of India in 2016 stated that “a majority of the patients with hypertension in India are unaware of their condition.” In a systematic review and meta-analysis of 142 research articles, published by Anchala et al., have found that “the prevalence of awareness of hypertension is only in a quarter of rural and two-fifths of urban Indians, and only a quarter and a third of those identified in rural and urban India receive treatment for it. Those who are identified as hypertensive often receive inappropriate care or fail to adhere to therapy, and remain uncontrolled. The prevalence of controlled hypertension is only in around 10% and 20% of rural and urban patients, respectively.” It is true that the treatment for hypertension is known for more than 50 years. Similarly, it is estimated that in India, 57% of diabetes mellitus is undiagnosed, data on treatment and control are not well analyzed so far. A significant variability exists in terms of performances across states. In case of hypertension treatment, interstate variations range from 13% to 37%.
It can be safely inferred from the above examples that having evidence-based interventions are not necessary and sufficient tools to manage public health problems. Logically, the next step is to identify the reasons for not being able to convert evidence to practice and address these lacunae. This is where the implementation science finds its role. Formally, implementation research (IR) is defined as the scientific study of the use of strategies to adopt and integrate Evidence-based interventions (EBIs) into clinical and community settings to improve patient outcomes and benefit population health. IR is intended to convert local knowledge into generalized knowledge. There are three ways in which implementation mapping can work, first designing intervention in such a way that it will be readily adopted, implemented, and sustained then designing the implementation strategies for adoption, implementation, and sustainment of the intervention and it can also be used to design processes to adopt existing EBIs.
As it deals with challenges of implementation, it cannot be tackled by a public health expert alone, thus it requires an interdisciplinary approach covering health service research, dissemination research, health communication research, and quality improvement science. It should be emphasized that at the level of converting evidence into practice, crucial role is played by policymakers in designing the right policies, preparing the grass root workers for rolling out the program, managing the logistics, and ensuring the training of grass root level program implementers in smooth delivery of the program. It is important at this level to foresee the possible challenges and barriers and built-in solutions or methods of finding solutions to those hindrances. This requires insight, the right kind of training and applications of principles of management throughout the hierarchical delivery structure. Needless to say, most of the programs do provide for these scenarios at the planning stage but what is lacking is the application of the IR methods in a real-time analysis of the problems that arise at the time of rolling out and continuation of the specific program. Hence, it is suggested that the IR be built-in in the project implementation plan right at the beginning; it will be able to take care of the unforeseen challenges in a structured and scientifically validated manner and provide solutions in real time. Ideally, it should substitute the end-stage evaluation because course correction is not possible at the end of the program.
This poses another challenge because IR is a lesser-known domain and the capacity and skills of IR do not exist in the concerned public health departments. Hence, we need to have a multipronged strategy of capacity building, skill training at primary, secondary, and tertiary levels of delivery of public health services as one arm, ensuring the embedding of IR components while rolling out the programs and being able to extract the good practices so that those can be incorporated in future roll-outs spatially as well as temporally, thus ensuring scalability and sustainability. The approaches for IR can be mixed method, pragmatic trials, natural experiments, or a combination of effectiveness and implementation also known as the hybrid type. The major tenets of IR that should be essentially addressed in each program shall be able to ensure feasibility, fidelity, penetration, acceptability, sustainability, efficiency, effectiveness, and equity. De-implementation to remove ineffective, contradicted, mixed, or untested health services should also be considered for EBIs to reduce the burden on health-care services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khatri GR. National tuberculosis control programme. J Indian Med Assoc 1996;94:372-5, 384.
Standard Treatment Guidelines, Hypertension. Quick Reference Guide. Ministry of Health & Family Welfare, Government of India, New Delhi; 2016.
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al.
Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014;32:1170-7.
Hwang S, Birken SA, Melvin CL, Rohweder CL, Smith JD. Designs and methods for implementation research: Advancing the mission of the CTSA program. J Clin Transl Sci 2020;4:159-67.