Author: Philippa Simmonds
Implementation research can be defined as “the scientific inquiry into questions concerning implementation—the act of carrying an intention into eﬀect, which in health research can be policies, programmes, or individual practices” . In other words: if we know what to do, why aren’t we doing it?
During my global health studies, an issue that constantly cropped up was how to overcome the divide between academics and policy-makers. Regardless of the specific topic in question, the slow uptake of evidence-based interventions is a pervasive problem; this lag is what is commonly referred to as “the know-do gap”. In February I had the opportunity to attend a World Health Organization (WHO) workshop on implementation research as an intern, and learn about innovative ways to build bridges in global health.
The workshop was focused on implementation problems to do with non-communicable diseases (NCDs) in the European region. NCDs such as heart disease, cancer, and diabetes are on the rise globally, and are one of the most urgent health challenges facing this region. Most NCDs can be attributed to four major risk factors: tobacco use, unhealthy diet, physical inactivity, and alcohol consumption.
Previously considered to be “lifestyle factors” largely dependent on individual behaviours, attitudes are now shifting towards a better understanding of how our environment shapes exposure to risk factors.
Brownell and colleagues argue that extensive research shows behaviours like smoking, exercising and eating, “…are not simply free and independent choices by individuals, but rather are influenced by powerful environmental factors” . For example, if you live near a lot of fast food restaurants and no supermarkets selling fruit and vegetables, you’re going to have to go out of your way to eat healthily. There’s an increasing focus on policies that make healthy choices more affordable and convenient, in addition to educating people about health.
In response to the rising burden of illness and premature death from NCDs, the WHO trawled through piles of evidence to compile their “Best Buys”; a collection of the most cost-effective interventions that are proven to promote population health. Many of us will be familiar with some of their recommended policies, such as: “Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship”. Because most of the evidence for the Best Buys comes from high-income countries, they often need to be adapted to work well in low- and middle-income countries (LMICs). For example, at the workshop we heard about cooperating with food companies to reduce the salt content of ready-meals; an effective technique in the UK, but not so useful in rural China, where around 70% of salt intake can come from home cooked food.
So how can implementation research help? The field has to take account of multiple stakeholders, changing circumstances and diverse health systems. It’s all very well having a health intervention that works well in experimental trials and pilot studies, but if you want to scale that intervention up to the national level, a whole host of different political, demographic and organisational factors come into play.
Implementation researchers must ask questions that are applicable to complex systems in the real world.
For example, what are the barriers for people belonging to marginalized groups trying to access this health service? How can we adapt the way this programme is delivered to make it work in our community? What factors will promote different stakeholders’ support of this policy? What strategies can we use to accelerate the adoption of effective policies? As you can see, while the common objective is to cross that know-do gap, there are a million different ways to go about constructing a bridge.
During the workshop, representatives from twelve countries across the WHO European region developed and presented research proposals relevant to NCD prevention. Some considered how to scale up cancer screening programs, and asked what factors might be contributing to low uptake. Others looked at how to implement specific Best Buys such as a tax on sugar-sweetened beverages, or a national action plan for salt reduction. Many participants had been involved with this type of research before, and the workshop helped to solidify key concepts while providing an engaging forum for the exchange of ideas. By the end, the participants under WHO leadership had decided to create a network for implementation research in the European region and continue to support one another long-term. I left feeling hopeful that there was a growing field of research bridging the gaps in global health- and inspired to contribute to this type of work in the future.
I attended the workshop described above as part of an internship at the WHO European Office for the Prevention and Control of NCDs in Moscow, Russian Federation. For more information, see their website.