Learning Implementation Science through the Polio Eradication Experience

OLAKUNLE ALONGE: So learning implementation science through polio eradication experience. Implementation science– what is it and the why is it the approach of this course? For a program like the Global Polio Eradication Initiative that involves multiple contexts, multiple [INAUDIBLE],, different strategies and activities across different countries, there’s an obvious need to contain the lesson, the knowledge, and the experiences for this program within a generalizable fund. And if we think about it, even though the polio program revolves around having an effective intervention, which is the vaccine, that delivering the vaccine to children. I mean, that’s in the simplest form. That’s really what the program is trying to achieve.

And then, on the [INAUDIBLE] to ensure that cases are detected and preventive measures are deployed, the cases are being detected. But in of itself, the intervention requires a lot of unpacking. So there’s a lot of– to get vaccine to the individuals that needs it, there’s a lot of logistics that is involved. There’s a lot of sourcing and resourcing that is required to get the vaccine. And we want to deliver the vaccine to the children.

There’s a lot of coordination, a lot of training, a lot of health expertise that is required to actually physically deliver the vaccine, and also a lot of implementation barriers and challenges that would need to be overcome, either posed by the geography, posed by the social context, or the political context, or [INAUDIBLE] context, and so on. So you need implementation science. All of these experts of polio program that we’re talking about really fit nicely into this subject of implementation science.

So again, implementation science provides the challenges, and the principles, and the methods to actually study all of these different aspects of the polio program, given the nature of the science, which emphasizes implementation, which forms the bulk of what really entails within the Global Polio Eradication Initiative. So as you see from the picture here, even though you have the vaccine, but somebody needs to get the vaccine across some of these challenging turnings to the people that requires it. So you have the gentleman who’s carrying this bike across the pond. And then, you have the vaccine in the cooler strapped to the back of the bicycle.

And so these are challenges that if you think about the program just basically as an intervention, you would miss. So because you have the vaccine does not mean it’s going to get to the people that needs it. It does not mean that it’s going to achieve the impact that you want it to achieve. So there is a long and wide gap between what we know can work and how we know it can work. And implementation science actually tries to bridge this [INAUDIBLE] gap. And a lot of the activities in the Global Polio Eradication Initiative actually revolves around bridging this [INAUDIBLE] gap. And therefore, implementation science provides a useful lens for learning about the polio program. So what is implementation science?

There are different definitions for implementation science, what we would describe to be of certain definitions. The first is really from the NIH, which describes the United States National Institutes of Health, which defines implementation science as this study of methods to promote the adoption and integration of evidence based practices, interventions, policies into routine health care and public health settings. That is to say study that emphasizes how you carry an evidence based practice or intervention into routine practice or into a routine setting. It’s really what implementation science is all about.

So emphasis is not on determining the efficacy of an intervention, but really, it’s really to describe effectiveness of the intervention within large populations and to deliver evidence supported intervention of practices within the typical setting where such intervention or practices should be delivered to achieve an impact under real world population conditions. Another definition by the coalition of the Global Alliance for Chronic Diseases and the Medical Research Council of the United Kingdom, Wellcome Trust, and the other groups really describes implementation science as the study of methods and strategies to promote the uptake of interventions that have proven effective into routine practice, with the aim of improving population health. So again, the emphasis is on uptake.

It’s an adoption, as in spread over an effective intervention, of an effective practice of an effective policy. So again, unlike traditional approach to [INAUDIBLE],, which often emphasizes trying to determine whether something work or not, implementation science is not trying to determine whether an intervention works or not. That’s not the primary goal. The primary goal is really to take that intervention that works to achieving its impacts at scale. And you do that by facilitating the uptake of the intervention, the adoption of the intervention, into routine practice or into a widespread scale up of the intervention among population that needs the intervention so that you can then achieve the full potential of the intervention– of the interventional scale.

So studies around how to do this, how to implement effectively is really what implementation science is about. One of the definition that I use in the course that I teach on implementation science at the Johns Hopkins School of Public Health is really to think about it as involving what the process of implementation science involves, what the process of generating evidence concerning implementation. So that is to say that it needs scientific study or research that you undertake to provide evidence for effective or ineffective implementation, or whatever the supported intervention really will follow that umbrella of implementation science. So thinking about strategies, thinking about understand the context in which implementation is effective or less effective, and so on, and so forth.

So all of the process of studying that will fall on that implementation science. But not just that. It will also involve the knowledge that you’re able to generate from that process of evidence making. So for instance, findings that you get, maybe in terms of a particular [INAUDIBLE] or a particular context under which implementation is most available, or sets of processes for better implementation. All of these knowledge, and products, and the evidence that you’re able to generate and how you use that knowledge, even to further implementations [INAUDIBLE] implementation science. So again, looking at processes for generating evidence, and also the knowledge products that are generated from that process, all combined together, falls under the umbrella of implementation science.

And when we say implementation, it’s really the act of carrying an intervention or an intention into effect. Mostly, in public health and in global health it’s [INAUDIBLE] intervention. And when I say intervention, I use it more broadly, loosely. Intervention could involve– I’m trying to mention in terms of a specific set of commodity or items, like a drug and vaccine they can deliver for eliminating or stopping, if this is carcinogen. Or it could also, intervention could also include programs that a set of activities that you put together to facilitate a desirable outcome.

[INAUDIBLE] policy as well could be thought of as intervention– policy, which are laws, or regulations, or guidelines that are put in place to achieve a particular outcome at the population level. So again, all of the set of activities that you do to carry this intervention, used broadly, into an effect to produce an outcome involves implementation. Based on that definition, you can see that there are four pillars that implementation science actually sits on. So most activities in implementation science, or most research, or studying, or knowledge revolves around these four pillars. So one is implementation strategies.

Because if you’re thinking about carrying an evidence supported intervention into effect, you’re going to be thinking about adverse and various challenges, putting in measures to facilitate the intervention. So all of these are implementation strategies. And a lot of the discussion that we would have over the course of this course, we’ll really talk about strategies, implementation strategies, for addressing challenges for the Polio Program Eradication Initiative at different levels. The second pillar for implementation science is the contexts. So the diversity of the context often poses challenges and facilitators as well of effective implementation of an intervention. So there are contexts that are favorable. There are contexts that are not favorable.

And context, we use it very broadly, involving both the internal and the external context– internal context to the organization or to the recipient beneficiaries, external context to the organization that is implementing or to the recipient beneficiaries. So again, these are different typologies across different geographies and boundaries across the world. The third pillar is the use of implementation research outcomes and models. So the idea is that you really want to deliberately study implementation. So you choose an outcome that are able to show the direction of implementation, whether that implementation is successful or not.

And these outcomes that are further able to distinguish the direction and the effect of implementation form the effect of the intervention are what we call implementation research outcomes. So these are things that are very proximal, outcomes that are very proximal to your implementation activities, as opposed to health outcomes, mortality and morbidity outcomes, that we often measure to assess outcomes of an intervention. So for instance, if you take vaccine as an example, what vaccine does? Vaccine is the intervention. And the end outcome that you hope to see with the vaccine is reduction in mortality. That is deaths from polio or reduction in disability or paralysis from polio.

So these are end clinical outcome that you often use to assess the effectiveness of the vaccine in of itself. But when you think about implementation research outcome, you think about OK, because there are this vaccine, and I know that this vaccine can actually reduce death or disability. But there are other things that needs to happen in the process of delivering the vaccine. So for instance, if the health worker that has delivered the vaccine is not really cautious to the mother of the child that is supposed to receive the vaccine. Maybe the mother of the child might not find a vaccine acceptable. Maybe they might refuse the vaccine.

So an outcome like acceptability of the vaccine or refusal the vaccine can be seen as an implementation research outcome, because [INAUDIBLE] about the implementation challenges and how effective or ineffective your implementation activities are. And then, the fourth pillar is study and learning conducted under real world conditions. So that’s really important for implementation science. [INAUDIBLE] actually impact, if we’re going to bridge [INAUDIBLE] gap, then intervention would have to be deployed under the same condition that they expect it to work. So pushed to other types of research that are done under controlled setting, where you control the population. You control the environment, and so on.

Implementation science is really studying things as it occurs in practice, as things are happening in practice under real world context. And that’s the beauty of the polio program. Polio program actually offers lessons across all of these four pillars of implementation science, given the scale of the program, the real world conditions under which most of the activities for the Global Polio Eradication Initiative were deployed. And there’s a lot of activities that you can readily see, use as implementation research outcome to understand the success or the failure of the implementation of different strategies within the Global Polio Eradication Initiative.

And then, given the diversity of context, multiple countries, multiple geographies, multiple populations, cultural groups, and where the polio program has been deployed, it offers– also offers useful lessons on implementation and strategies around a diverse context. And like I said earlier on, it provides a lot of rich knowledge base on strategies for addressing different challenges for global health– global health programs. In the course of this course, what we’ve done is because in of itself is described under we have modules that kind of describes different aspect of global health. Within the modules, you have an application of the four pillars. So we discuss the strategy– implementation strategies.

We discuss implementation research outcomes, context, and try to show videos that describes the real world application of the knowledge or the real world conditions in which the polio program have been done. So the course is designed so that different modules or different aspect of global health for the polio program is actually discussed. And then within each of those modules, we try to emphasize principles of implementation science, be it the strategies, or context, or outcomes of real world conditions. And then across the different modules, there are themes than runs across. So these are themes that really helps you to integrate the different lessons, not just for a specific module of global health. For instance.

Global Alliance would be a module of global health. Epidemiology would be a module of global health. But there are themes that kind of runs across these different modules, including engagements. Engagements is relevant for the different modules that you might consider. So these themes are also further highlighted across the course. And we have eight themes that you will be hearing about over the course of the course. So one is the power of engagement, and incentives, and the old debate around vertical versus integrated approaches. That is to say during a program as a program and ignoring the system or trying to integrate a program into the system using the system as the vehicle to implementing a program.

And context, again, and special consideration for how to reach population or some of the special populations, And the rationale for eradication programs, the role of technology in our education programs, and politics, and politics and corruption. So you will see this themes run across the different modules, the different course, the different aspect of the course series. And they are integrative, in and of themselves, because they allow you to integrate lessons for polio to address a specific theme, which does not necessarily have to sit with being a module.

We also use a case-based method, which is really to describe these themes, as cases to describe scenarios that really happened in polio and stories, so that that we are able to integrate strategies with context, with outcomes, with the real world condition, and for different aspect of global health as it occurs in polio. And the cases are not prescriptive. So it allows you to really discuss in small groups and to look at the relevance for context that you are familiar with. So it allows for obstruction and higher order thinking in terms of how to apply the knowledge and the lessons for the polio program.

So we really think that this is an excellent approach to learning, [INAUDIBLE] a program like the Polio Eradication Initiative and to obstruct in knowledge from such activities to other programs and to other health system initiatives. Lastly, this is just to show you the men and women that are behind this course. This course has been put together by a team of academic construction from each country. So we have professors and researchers from across the different parts of the world coming together to conduct research around Global Polio Eradication Initiative and polio program, more broadly, and to synthesize data. And then, we’ve all worked together to then translate this data to the course that you see here.

So the partners include professors such as from Afghanistan, from Bangladesh, from India, from Indonesia. And in Africa, it Includes professors from Nigeria, from the Democratic Republic of Congo, of Ethiopia, and then also key actors from the United States of America. So we are truly a global alliance to really teach a global course. And we hope that you are able to benefit from the perspective that these different researchers and professors bring, given the setting in which they work.