Post on 05-Jul-2020
Implementation Science: Evidence to Action
Wafaa El-Sadr, MD, MPH, MPA ICAP at Columbia University
Outline
• Achievements and challenges in HIV response
• Knowledge-impact gap (Know-do gap)
• Research pathway
• Implementation science
• ICAP and implementation science
• Summary and conclusions
HIV Treatment Coverage and AIDS-related Deaths, global, 2000–2015
Reaching the Third 90: Implementing High Quality VL Monitoring at Scale – Ezulwini,
Swaziland, June 27-30, 2016 3
New WHO Treatment Guidelines
New WHO guidelines
recommend HIV
treatment for all
4
HIV Treatment: Global Targets By 2020
90%
of all people living with HIV will know their
HIV status
90%
of all people diagnosed with HIV will receive
sustained antiretroviral
therapy
90%
of all people receiving
antiretroviral therapy will have
durable suppression
UNAIDS 2014
5
HIV Continuum
Continuum of HIV Care
80
62
41 37
28
40
24 16
11
0
10
20
30
40
50
60
70
80
90
100
HIV Positive Diagnosed Linked toCare
Retained/Initiated
Retained onART
VirusSuppressed
US SubSaharan Africa
NA
Challenges in HIV Care Continuum
Critical Issues
• How to define the target population?
• How to reach and engage the target population?
• How to adapt intervention(s) to specific contexts?
• How to deliver and package the intervention(s)?
• Why did intervention(s) work/not work?
• What is acceptability, feasibility and cost-effectiveness of intervention(s)?
• Etc. etc.
Initial research often involves populations, procedures and settings that differ substantially from the context of
implementation
Knowledge to Impact Gap
Knowledge • Efficacious interventions • Often demonstrated
through randomized clinical trials
• High level of internal validity
Implementation • Engaged communities and
target populations • Infrastructure • Equipment & Supplies • Staff • Policies • Processes
Sanders et al, PLoS Medicine, 2006
Explanatory versus Pragmatic Research
Explanatory Research
• Descriptive and epidemiologic research
– What, why, where, who?
• Intervention research
– What?
Pragmatic Research
• How to translate knowledge into practice within health and social systems
Eccles et al. Implementation Science, 2012 Sanders et al, PLoS Medicine, 2006 El-Sadr et al. NEJM 2014
Research Pathway
https://www.brown.edu/about/administration/biomed/clinical-translational-science/index.php?q=about/translational-research
What is Implementation Science? • ‘Research to promote the uptake & successful implementation of
evidence-based interventions and policies’ (Sanders)
• ‘Evidence that informs effective, sustained & embedded adoption of interventions by health systems & communities’ (Allottey)
• ‘All aspects of research relevant to the scientific study of methods to promote the uptake of research findings into routine settings in clinical, community and policy contexts’
• ‘Research to significantly improve access to efficacious interventions by developing practical solutions to common implementation problems’ (WHO)
• ‘Study of how to accelerate the translation of research-tested interventions into policy and practice’ (Best)
• 'Implementation Research is the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, and hence to improve the quality (effectiveness, reliability, safety, appropriateness, equity, efficiency) of health care. It includes the study of influences on healthcare professional and organizational behaviour.'
Sanders et al, PLOS Med, 3:e186; Allottey et al, BMC Pub Health 8:343, WHO;, Best Am J Health Promot 2011 Adapted: http://www.implementationscience.com/info/about/ accessed 10 February 2009
Factors affecting Implementation of health innovations
Chaudoir et al. Implementation Science 2013
Characteristics of Implementation Science
• Systematic
• Multi/interdisciplinary
• Contextual
• Complex
Characteristics of Implementation Research
• Systematic – Adheres to norms of scientific inquiry
– Specific intervention, specific setting
– Balances relevance with rigor
• Multi/Interdisciplinary – Considers biological, social, economic, political,
system and environmental factors that impact implementation
– Collaborations between behavioral and social scientists, clinicians, epidemiologists, statisticians, policy makers, stakeholders
Characteristics of Implementation Research (continued)
• Contextual – Relevant to local circumstances and need
– Generates generalizable knowledge that can be applied across contexts
• Complex – Dynamic and adaptive
– Occurs at multiple levels of health care system, community
– Analyzes multi-component programs
Where ICAP Works
Implementation Science Studies
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HIV infected DiagnosedHIV
Linked toCare
Retained inCare
Initiated ART Viral LoadSuppression
Assessed for ART
eligibility
Retained in care
Link4Health: Intervention Combination Intervention Strategy (CIS)
23
Cas
cad
e
Ste
p
Linked to Care
Assessed for ART
Eligibility
Initiated ART
Retained in Care
CIS
Co
mp
on
ents
1. Point-of-care CD4 at HIV testing X X X
2. Accelerated ART for CD4 < 350 X X
3. SMS appointment reminders X X
4. Basic care and prevention package X X
5. Non-cash financial incentive X X
Link4Health: Study Design
• Cluster-randomized controlled trial – 10 study units randomized to CIS versus
Standard of Care
– Study unit included 1 secondary and 1 affiliated primary-level health clinic
• Study population: – > 18 years identified as HIV+
Primary outcome: Linkage: HIV clinic visit within 1 month after HIV testing at assigned study unit
and
Retention: HIV clinic visit within 12 months (+/- 3 months) after HIV testing at assigned study unit
24
Pragmatic Design (PRECIS-2)
Loudon et al. BMJ 2015
*
*
*
Mapping of Studies
Thorpe et al. J of Clin Epi, 2009
Link4Health Study
Loudon et al. BMJ 2015
*
*
*
Approach to the Research
• Conduct of feasibility assessments with the target population and consultation with program managers and policy makers
• Interdisciplinary engagement
• Research done by facility staff rather research staff
• Selection of standard program outcomes as research outcomes
Approach to the Research- 2
• Measuring the research outcome through routinely-collected data
• Adaptation of intervention(s) without loosing fidelity to the core of the efficacious interventions being studied
• Capturing why and how interventions work/don’t work rather than solely focusing on if they work/don’t work
Summary
• Many implementation gaps that stand in the way
of achieving impact of efficacious interventions
• Implementation science critical to advancing
population health
• Rigorous and pragmatic research designs are
needed that adhere to the principles and
framework of implementation science
• Need for focus on why interventions work/don’t
work in addition to if they work
• Partnership between researchers,
implementation experts and other stakeholders
is critical to the success of research
Thank you Asante Sana