The Need for Implementation Research for Community-based Interventions: Scientific Evidence Is Needed

DEAR EDITOR

As many countries cannot ensure sufficient or good quality of health, there are many community interventions around the world. These are carried out mostly by the health system or non-governmental organizations. The goal of every intervention is to improve physical and mental health, and social well-being on the population level. Many interventional programs are held to address the specific shortcomings, sometimes in the form of pilot studies or as part of a scale-up program at national or regional level. Therefore, appropriate interventions need to be planned and executed based on evidence keeping track if the intervention is performing well. It is also necessary to monitor if all the programs are carried out with the necessary fidelity and dedication. Therefore, it is important to consider implementation research.

Implementation research is the structured use of methods for applying evidence in real-world settings while trying to understand and unravel the complications that may arise. ¹ It is a method that can be integrated in the program planning and execution to help implementers focus on at least five features: the context, stakeholders, existing evidence to implement or adapt the interventions, methods used to implement them, and calculation of the cost-effectiveness. Implementation research goes beyond the intervention that assumes a smooth implementation; it addresses the challenges that arise, as well as the quality, equity, efficiency, and possibility of reproducing and scaling up these actions in other settings. ² This is done using different research methods that help to address the demands of the context and the needs to measure the social and health outcomes. Additionally, implementation research also tracks the behavior of different stakeholders involved in the process which can later help to evaluate and accept the intervention. ²

Interventions are based on evidence or theory. Three challenges play a key role. The first one is that most of the evidence published is related to settings that not necessarily adapt to others. This is mainly because these are pilot initiatives or are not generalizable considering the heterogeneity of the countries. The second one is the difficulty to find evidence of interventions that do or do not work. The third one is to find detailed information on the five features of implementation research and the reason why certain interventions worked or not. Many implementers do not want to inform others about when something does not work as expected, or, if improvement is reached, its extent is not reported. Additionally, only few publications of community interventions show information that did not work out. Hence, it is important to conduct the interventions with accuracy and transparency, and inform others about this, detailing the initial context, what and how the change was brought about, indicating what was done and what was missing (interventions, methods), how different stakeholders were involved and what and why was their behavior receptive or resistant to the intervention, details on cost-effectiveness, and potential pitfalls. Information about why and which actions did or did not work, in what phase of the intervention, could become part of the analysis to establish if a particular intervention worked or not, and what were the challenges. ^{3 , 4} Knowing that something does not work helps improve future implementations or prevents others from using them. The publication of this evidence could allow other researchers to verify and replicate these findings and to assist policymakers to choose the most effective and suitable intervention.

Finally, implementation research also highlights the importance of using robust methods. ² Continuous efforts are being made to adapt the research methods to complex problems with sufficient validity and reliability. The design and implementation choices for interventions matter cause the planning, executing, and monitoring very important. ^{3 , 4} For instance, if participation of stakeholders occurs, their level of involvement along the intervention is important, so it is their participation during the planning and evaluating which needs to be informed. How we consider using the various methods and monitor them with accuracy will define the possibility of an evaluation. ^{3 , 5} The publishers of these results should request that the methods part be detailed sufficiently for transparency. In the end, scientific research needs to be published with the possibility of being verified, repeated, and reproduced, contributing to the body of scientific knowledge. ⁶ Also, to be successful with community interventions that improve the overall health of the society, it is important to think that these initiatives or programs need to be reproduced, sustained, and scaled-up. However, if they do not work as expected, it is also important to inform the how and why because these are lessons to learn from. To conclude, it can be stated that it is necessary that community interventions, notably community-based nursing, and midwifery research, include the five features of implementation research, the context, stakeholders, existing evidence adapted in interventions, methods to implement them, and cost-effectiveness. Moreover, it is important to publish the results with transparency.

Conflict of Interest:

None declared.

References

1. Zolfaghari E, Armaghanian N, Waller D, et al. Implementation science in adolescent healthcare research: an integrative review. BMC Health Services Research. 2022; 22:598.
2. Theobald S, Brandes N, Gyapong M, et al. Implementation research: new imperatives and opportunities in global health. Lancet. 2018; 392:2214-28.
3. Cordova-Pozo K, Hoopes AJ, Cordova F, et al. Applying the results based management framework to the CERCA multi-component project in adolescent sexual and reproductive health: a retrospective analysis. Reproductive Health. 2018; 15:24.
4. Igras S, Plesons M, Chandra-Mouli V. Building evidence on what works (and what does not): practical guidance from the World Health Organization on post-project evaluation of adolescent sexual and reproductive health projects. Health Policy and Planning. 2021; 36:594-605.
5. Ivanova O, Cordova-Pozo K, Segura ZE, et al. Lessons learnt from the CERCA Project, a multicomponent intervention to promote adolescent sexual and reproductive health in three Latin America countries: a qualitative post-hoc evaluation. Evaluation and Program Planning. 2016; 58:98-105.
6. Diaba-Nuhoho P, Amponsah-Offeh M. Reproducibility and research integrity: the role of scientists and institutions. BMC Research Notes. 2021; 14:451.