Contributions to the literature
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Improving implementation and scale-up of effective health interventions is critical to support universal health coverage schemes globally.
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Co-production of implementation research by researchers and end-users has the potential to reduce wastage of research and enhance evidence-informed policy and practice.
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Empirical knowledge on the impact and processes of co-production approaches remains limited.
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This multi-country study suggests that implementation research led by decision-makers and embedded into policy and practice stimulates the relevance and applicability of empirical findings, while promoting decision-makers’ engagement and likelihood to use evidence for implementation improvements.
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Key facilitators to embedding research into policy and practice include actionability of findings and relevance of implementation research questions, whereas the main barriers include policy implementation timeframes and complex political processes.
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Embedding research to support implementation raises questions around the competing interests of stakeholders and the need for capacity strengthening, particularly in low- and middle-income countries.
Introduction
Methods
Document review
Country | Policy, programme or intervention | Research question | Design and methods | Implementation research variables |
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Argentina | Policy of regionalization of perinatal health services within the province of Santa Fe | What is the current situation for implementation of the regionalisation strategy in Santa Fe? Which are the main barriers and facilitating factors for policy implementation? | Mixed; Document review, secondary data collection to build process indicators for implementation, and key informant interviews; Delphi method among stakeholder groups; deliberative dialogue, stakeholder analysis | Fidelity, Appropriateness, Acceptability |
Argentina | National Chagas Program | What is the best strategy to implement the decentralised distribution of trypanocidal at scale? | Mixed; Secondary data collection, health facility survey, in-depth interviews, focus group discussions | Feasibility, Coverage |
Bolivia | Policy of screening for syphilis during antenatal care in Los Andes Health Network | What are the barriers to screening for syphilis during antenatal care? | Mixed; Secondary data collection, in-depth interviews | Coverage |
Brazil | Regional program of tuberculosis (TB) control | How to enhance the care of individuals living with TB/HIV co-infection in the setting of specialised care facilities in the state of Ceará, Brazil? | Mixed; Secondary data collection, focus group discussions | Acceptability, Adoption |
Chile | Sexual and Reproductive Health Program and National Comprehensive Program for Adolescent Health in the Municipality of Huechuraba | What are the existing problems and shortcomings of the primary care services in Huechuraba that limit adolescents’ access to contraception? | Qualitative; Descriptive study based on participatory action research, which incorporated document review, secondary data collection, and semi-structured interviews with key informants | Appropriateness, Coverage |
Chile | National Program for Clinical Practice Guidelines | How can the management of implementation of clinical practice guidelines by the National Program for Clinical Practice Guidelines be optimised? | Qualitative; Semi-structured key informant interviews and focus group discussions | Optimisation, awareness, acceptability |
Colombia | Clinical practice guidelines for sexually transmitted infections in Antioquia and Cundinamarca States, Colombia | How does acceptability, perceived usefulness and uptake of implementation tools impact the implementation process of clinical practice guidelines in the Colombian health system? | Mixed; System mapping, surveys, semi-structured interviews and stakeholder analysis | Adoption, Uptake, Acceptability, Perceived usefulness |
Mexico | TeleHealth Program in public health services in Oaxaca | What is the process and logistics for implementing TeleHealth (through teleconsultations) in Oaxaca? What is the fidelity of the programme and how can it be improved? What are the requirements to institutionalise the programme? | Mixed; Descriptive study, document review of manuals and management reports, secondary data collection, survey and interviews | Fidelity, Adoption |
Peru | National strategies for HIV/AIDS and tuberculosis | What are the barriers to integration of services for HIV/AIDS and TB? | Mixed; Key informant interviews and secondary data collection from TB and HIV registries of the healthcare facilities | Appropriateness, Coverage |
Saint Lucia | Modernized newborn screening program for sickle cell disease | What are the barriers to administering neonatal heel prick screening for sickle cell disease sickle? | Mixed; Survey and focus group discussions | Acceptability, Coverage |
Country | Results | Implementation strategies | Dissemination methods | Policy/programme impact |
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Argentina | Implementation of the of perinatal health regionalisation strategy is heterogeneous across different sub-regions of the province; communication among all stakeholders and organisation of transport between levels were identified as the main barriers; general agreement with the strategy is a potential facilitator | Action plan to enhance monitoring and improve implementation | Policy brief; deliberative dialogue | Involvement and participation of key stakeholders from the five sub-regions; establishment of new process indicators to monitor implementation of the regionalisation strategy |
Argentina | Major obstacles in the implementation of the National Chagas Program included little articulation between stakeholders, lack of training, difficulties in follow-up of patients and barriers associated with access to services | Decentralisation strategy | Report; website communications | A pilot of decentralisation was carried out, evaluating strategies to optimise intervention on a large scale; results will be reintegrated in scale-up activities |
Bolivia | Although healthcare workers believe 100% of pregnant women should be screened, only 55% of the reviewed clinical records indicate syphilis laboratory results and only 37% of perinatal medical histories are reporting the syphilis laboratory results; barriers to syphilis screening included insufficient time for staff to raise awareness among pregnant women about the benefits of screening for syphilis and other diseases, and gaps in communication between medical and laboratory staff | Action plan for periodic review of the coverage of syphilis testing in pregnant women | Workshops and meetings with key stakeholders, including health services providers of Los Andes Health Network, and coordinators of health networks of El Alto rural and urban areas of La Paz Department; discussions on syphilis testing coverage in pregnant women | Strengthening the clinical records and registry; follow-up and monitoring |
Brazil | Barriers of tuberculosis (TB)/HIV co-infection management included lack of knowledge of clinical protocols, insufficient human resources, low commitment to address the two diseases, differences in recommendation, e.g. frequency of visits for TB/HIV, and oversubscription of specialist services | Monitoring strategy for integrated TB/HIV care | Results were discussed with managers and health promoters of the HIV/AIDS/hepatitis and TB programmes | Development of a protocol of TB medication adherence |
Chile | Adolescents reported difficulties accessing the centres’ contraception services due to cultural factors, lack of information, administrative requirements and existing bureaucratic practices; there were errors in professionals’ management of standards and legal procedures concerning fertility, and no existing interpretive framework recognising sexual and reproductive rights to guide actions; adolescents’ needs associated with their rights are invisible and unsatisfied, and health professionals do not share common criteria for addressing this topic with adolescents | Strategies to improve the programme, in terms of professionals’ training, process of designing and implementing a protocol outlining how to access contraception needs, and active incorporation of adolescents’ feedback | Presentation of results in the Study Local Committee and incorporation of new ideas arising from the Study Coordinator’s participation in the intersectoral network of the Municipality of Huechuraba Departments of Youth and Education, which was formed to implement public policies focused on adolescents | The findings prompted the creation of a training programme on gender and sexual and reproductive rights for professional teams from health centres in the municipality; additionally, a protocol outlining adolescents’ access to health services will be designed and established; the results of the study also contributed to the planning process of a safe space for adolescents, outside of the clinical setting, and the formation of an intersectoral network focused on public policies concerning adolescents; these actions served to address the identified obstacles and improve the quality of programme offerings directed toward adolescents’ sexual and reproductive rights |
Chile | The main challenge was lack of a structured process for development and management of clinical practice guidelines; the major strategy recommended to overcome this challenge was the development of an optimised workflow for the development and implementation of clinical practice guidelines, tailored to the Chilean context | Workflow, including strategies, flowchart, management protocols, handbook for clinical practice guideline development | Workshops, publications, staff meetings | Eighty clinical practice guidelines were updated by of the Ministry of Health using the GRADE methodology; administrative changes included transferring the current department to the Division of Health Planning and merging with the Health Technology Assessment Department; an internal document was created to guide the roles and functions of the clinical practice guidelines coordinator within the Ministry of Health |
Colombia | Of those who responded to the survey, 86% knew about the clinical practice guidelines (CPG), 86% prioritised the CPG recommendations, 82% used the factsheets and 79% used the interactive flowcharts; 41% had never used the implementation tools; of those who had used the implementation tools, 55% used them on desktops at their work, 24% on smartphones and 21% elsewhere; the most useful implementation tool was the factsheet (98%), followed by interactive flowchart (98%) and prioritised recommendation (92%) | New or revised tools to support implementation | Tools will be disseminated through the Colombian Health Technology Assessment Institute (IETS) web page, conferences and direct technical support to hospitals and other health services providers | Implementation tools will be fine-tuned based on the feedback received; preferred tools will be prioritised |
Mexico | The internet connection bandwidth hampers information exchange for teleconsultations; the specialties most in demand are internal medicine and gynaecology; areas for improvement were identified in the programme’s process manuals | Online courses; manual for implementation and operation of TeleHealth program; refresher training; contingency plan for information technology failure; induction programme | Meetings; workshops; presentations | The activities of the Telehealth Coordination (THC) were integrated in the strengthening strategy of the networks of medical units in the state. The THC in Oaxaca was recognised in the Internal Rules of the Health Services of Oaxaca. It increased the number of rural medical units incorporated into the Telehealth Care Network. The schedule of medical specialists of the internal medicine service was extended and is now available on Saturdays, Sundays and holidays |
Peru | Barriers identified: little or no coordination between TB and HIV teams, management of the TB/HIV co-infected patients at different levels of care, inadequate financing, scarce or poorly trained human resources and the absence of an integrated information system | Strategy for HIV/AIDS and TB co-infection; technical document to regulate TB/HIV joint activities | Meetings, training sessions | Development of a TB/HIV integrated care model; changes to regulatory framework; planning of joint activities |
Saint Lucia | High acceptability of the heel prick (HP) test; the majority of healthcare workers were familiar with the HP test (85.7%) but 74.3% and 72.9% had not attended training sessions on the procedure or the collection of the sample, respectively; a total of 92.9% reported that the HP test was useful; regarding safety, 81.4% felt that the test was not harmful to babies; healthcare workers reported that the test was painful for the baby (74.3%) and 58.6% felt uncomfortable doing the test | Strategy for implementing newborn blood spot screening programme | Presentations and reports; meeting with steering committee | Results have not yet been reintegrated into the screening programme |
Self-administered questionnaire
In-depth interviews with stakeholders
Results
Document review
Questionnaire findings
Country | Affiliation | Level | Sex |
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Argentina | Direction of Child, Adolescence, Sexual and Reproductive Health, Ministry of Health of the Province of Santa Fe, Argentina. | Provincial | Male |
Argentina | National Chagas Program | National | Female |
Chile | Municipality of Huechuraba | Municipal | Female |
Chile | Ministry of Health | National | Female |
Colombia | The Colombian Health Technology Assessment Institute (IETS) | State | Male |
Mexico | Centro Nacional de Excelencia Tecnologica en Salud (CENETEC-Salud) Servicios Estatales de Salud de Oaxaca | State | Male |
Peru | Ministry of Health | National | Male |
Saint Lucia | Ministry of Health | National | Female |
In-depth interview results
Country | Affiliation | Level | Sex |
---|---|---|---|
Argentina | Direction of Child, Adolescence, Sexual and Reproductive Health, Ministry of Health of the Province of Santa Fe, Argentina. | Provincial | Male |
Argentina | National Chagas Program | National | Female |
Bolivia | El Alto Regional Health Service | Provincial | Female |
Brazil | Specialized Assistance Services (SAS) of Ceará | Provincial | Female |
Chile | Municipality of Huechuraba | Municipal | Female |
Chile | Ministry of Health | National | Female |
Colombia | The Colombian Health Technology Assessment Institute (IETS) | State | Male |
Mexico | Centro Nacional de Excelencia Tecnologica en Salud (CENETEC-Salud) Servicios Estatales de Salud de Oaxaca | State | Male |
Peru | Ministry of Health | National | Male |
Saint Lucia | Ministry of Health | National | Female |
Facilitators
Actionability
“This project made it possible to find out whether what we are proposing will be good or not, or if there was a better way to do it.” (Respondent from national health system level)
“The study allows us to produce evidence of where the difficulties are, the gaps at which this policy should aim, so that when we present the policy to the authorities […], it is much better to have evidence to support and back up that policy, and we have been able to get this with the study results.” (Respondent from national health system level)
Relevance
“The [embedded implementation research] project [generated] the evidence that the programme needs [to learn] about how to change.” (Respondent from national health system level)
“Everyone agreed [with the research] because it was in line with the work that we were doing. The issue of implementation […] was bothering us a bit […] and this research came in exactly that […] moment […] so we agreed that this was the ideal combination between research and governance so as to guide the adjustments that had to be made in the implementation.” (Respondent from provincial or municipal health system level)
Engagement
“This research has made it possible for all these separate [stakeholders] to come to an agreement to improve.” (Respondent from provincial or municipal health system level)
“I think [engaging stakeholders] is obviously how we have been working and that has made it possible to maintain the attention of the authorities.” (Respondent from provincial or municipal health system level)
Barriers
Time
“The time that we may need for chang[ing] their habits and the date they have to improve […] were limited.” (Respondent from provincial or municipal health system level)
“It takes a bit of time because it is more demanding, for all of us to agree on one strategy.” (Respondent from provincial or municipal health system level)
Political process
“We don’t really know which are the interests of the new government, but this is really putting some new barriers that were not thought before because we were in the same line and the same objectives with the public health and different kinds of things…and now…” (Respondent from national health system level)
“There are a lot of factors that play into this kind of research and this kind of implementation of interventions, so it is difficult.” (Respondent from national health system level)