In this guide we provide an introduction to basic implementation research terms and concepts and briefly outline what implementation research involves. We have collated and summarized recent relevant evidence and provide links to resources for further information on many of the topics covered. The guide also includes case studies that showcase examples of the implementation of NCD prevention and control policies and interventions. At the end of the guide we provide some practical tools to support the implementation research process.
Purpose and objectives of this website
Although some practical tools for facilitating the use of implementation research for the prevention and control of disease already exist, these mainly focus on communicable diseases. None exist specifically for NCDs. The main purpose of this guide is to provide practical guidance, tools and examples for implementation research so as to support effective implementation of NCD policy options and cost-effective interventions. Specific objectives of this guide are to:
- raise awareness about the purpose and potential impact of implementation research;
- assist countries to capture, collate and analyse information and to translate and adapt evidence-based policy options and interventions to local contexts;
- help identify barriers to the implementation of policies and interventions;
- help identify the best approaches to implementation research.
What is implementation research?
Implementation research investigates the various factors that affect how a new policy or intervention may be used (or implemented) in real-life settings. Such research remains relatively new to population-based health programmes, so a common language and terminology are still being developed. For reference, key terms used in this guide are outlined below.
Questions addressed by implementation research include:
- Which policy or intervention is best for a new context?
- What is the best way to implement it?
- How can the target population be reached?
- What factors might affect implementation and adoption?
- How can the costs of implementation be minimized?
- How can uptake and health outcomes be improved?
A specified set of activities designed to put into practice a policy or intervention of known dimensions.(15)
Implementation processes are:
- described in sufficient detail to allow independent observers to detect the presence and quality of the specific set of implementations-related activities(16)
The scientific study of the processes used to implement policies and interventions and the contextual factors that affect these processes.(17)
Investigates all aspects of implementation, including:
- the uptake of evidence-based policies and interventions
- activities used to put these into practice
- factors that influence these activities
- impact of factors on health outcomes
An individual (or group of individuals) responsible for management of the implementation process.
- health professionals
- community-based organizations
The group(s) of individuals that are targeted by an intervention, programme or a policy.
- are at high risk of developing NCDs, or
- have a high prevalence of NCDs
The setting within which a policy or intervention is to be implemented.
Includes all characteristics of said setting, for example:
- social, economic and political environment
- geographical setting
- epidemiologic profile
The identification, assessment and collation of evidence.
- relates to existing policies and interventions
- aims to achieve a desired outcome
The process of collaborative problem-solving.
This occurs throughout the implementation process between:
- decision-makers (including policymakers)
- other relevant stakeholders
The process by which relevant research information is made accessible and available.
Through interactive engagement with audiences, this is used for:
- policy making
Why is implementation research important?
One of the purposes of implementation research is to support the successful selection of policies and interventions that have been shown to be efficacious.(16) It also helps identify how to implement these policies and interventions in contexts where populations and/or resources may differ from that where they were initially formulated and evaluated and helps identify which components of a policy or intervention are needed to obtain intended outcomes. Moreover, when prevention and control efforts fail, implementation research can help identify whether failure was due to a policy/intervention being ineffective in the setting (intervention failure) or whether a so-called good policy/intervention was deployed incorrectly (implementation failure).(18)
In effect, implementation research is about learning how to optimize implementation, scale up promising strategies, evaluate impact and, importantly, how to sustain these strategies over the long term. Notably, implementation research has the potential to bridge the evidence-into-action gap.
Implementation and the implementation research cycle
There is a growing number of theories and models describing implementation and the implementation research process.(19-22) Implementation typically involves a step-wise, cyclical process (Fig. 1).
The first step is to work with key stakeholders in order to define the specific health need and then identify an appropriate policy or intervention to address that need. The second step is adaptation of the selected policy or intervention to the local context and undertaking some piloting. The third step involves implementation of the adapted policy or intervention. The fourth and final step is assessing if the adapted policy or intervention can be more widely implemented or scaled up and, if so, defining the resources and further steps that will be required to achieve this.(23, 24)
In practice, the path from selection (step 1) through to scale up (step 4) is rarely direct, as it is usually determined by multiple stakeholders, the availability of resources and other contextual factors. Instead, it normally has numerous iterations involving going back and forth between two or more process steps.
This cyclical process is often depicted in implementation models and frameworks. One commonly used framework is the Knowledge to Action Cycle outlined by Graham et al.(25) The KT Clearinghouse provides a range of resources, tools and information about this model.
The burden of noncommunicable disease
Noncommunicable diseases (NCDs) are noninfectious health conditions typically caused by genetic and/or environmental and lifestyle factors.
As NCDs tend to be long-lasting or recurrent, they are sometimes also referred to as chronic diseases.(1)
Currently, NCDs account for almost two-thirds of deaths globally.(2)
Global response to NCDs
In 2011, the World Health Organization (WHO) published A prioritized research agenda for the prevention and control of noncommunicable diseases,(3) which identified key areas of research relating to the prevention and control of NCDs. In September of that year, participants at the United Nations High-level Meeting on Noncommunicable Disease Prevention and Control recognized the existence of cost-effective interventions regarding the preventability of NCDs and the numerous opportunities for global action, and subsequently The Sixty-sixth World Health Assembly endorsed the Global Action Plan for the prevention and control of noncommunicable diseases 2013–2020.(4) This called upon international partners to take coordinated action to attain nine voluntary global NCD targets by 2025 – including a 25% reduction in premature mortality due to NCDs.
One of the Global action plan’s main objectives focuses on research. This objective calls on stakeholders to promote and support:
- national capacity for high-quality research related to the prevention and control of NCDs (and so, increase the knowledge base for national, regional and global action);
- the translation of high-quality NCD basic research into practice;
- development for the prevention and control of NCDs.
Achieving national goals and targets in relation to NCDs: The evidence-implementation gap
A major challenge in the prevention and control of NCDs has been that despite a wide range of global, regional and national plans, initiatives, policies and interventions, the impact on health outcomes still needs to be increased significantly. There is still a very notable ‘evidence-into-implementation (or action)’ gap. This translation gap – between research evidence and practice – is now very well recognized in many health fields.(5-7)
For example, a review of healthcare delivered to adults from the USA shows that up to 45% of patients fail to receive treatments that have been shown to be effective,(7) while 11% receive treatments that are not needed or potentially harmful.(7)
Reducing the gap between evidence and practice is associated with reductions in morbidity and mortality(8-10) and reduced healthcare costs.(11) Therefore, in recent years there has been increased attention on barriers to the translation of research and on how to develop evidence-informed implementation in order to improve patient outcomes.(12-14) Evidence is now also needed on effective implementation of primary prevention of NCDs in different contexts through policies and intersectoral health promotion.