Michael A. Sanchez

Implementation science approaches for integrating eHealth research into practice and policy

PURPOSE To summarize key issues in the eHealth field from an implementation science perspective and to highlight illustrative processes, examples and key directions to help more rapidly integrate research, policy and practice. METHODS We present background on implementation science models and emerging principles; discuss implications for eHealth research; provide examples of practical designs, measures and exemplar studies that address key implementation science issues; and make recommendations for ways to more rapidly develop and test eHealth interventions as well as future research, policy and practice. RESULTS The pace of eHealth research has generally not kept up with technological advances, and many of our designs, methods and funding mechanisms are incapable of providing the types of rapid and relevant information needed. Although there has been substantial eHealth research conducted with positive short-term results, several key implementation and dissemination issues such as representativeness, cost, unintended consequences, impact on health inequities, and sustainability have not been addressed or reported. Examples of studies in several of these areas are summarized to demonstrate this is possible. CONCLUSIONS eHealth research that is intended to translate into policy and practice should be more contextual, report more on setting factors, employ more responsive and pragmatic designs and report results more transparently on issues important to potential adopting patients, clinicians and organizational decision makers. We outline an alternative development and assessment model, summarize implementation science findings that can help focus attention, and call for different types of more rapid and relevant research and funding mechanisms.

How pragmatic is it? Lessons learned using PRECIS and RE-AIM for determining pragmatic characteristics of research

BackgroundThe need for high-quality evidence that is applicable in real-world, routine settings continues to increase. Pragmatic trials are designed to evaluate the effectiveness of interventions in real-world settings, whereas explanatory trials aim to test whether an intervention works under optimal situations. There is a continuum between explanatory and pragmatic trials. Most trials have aspects of both, making it challenging to label and categorize a trial and to evaluate its potential for translation into practice.MethodsWe summarize our experience applying the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) combined with external validity items based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to three studies to provide a more robust and comprehensive assessment of trial characteristics related to translation of research. We summarize lessons learned using domains from the combined frameworks for use in study planning, evaluating specific studies, and reviewing the literature and make recommendations for future use.ResultsA variety of coders can be trained to use the PRECIS and RE-AIM domains. These domains can also be used for diverse purposes, content areas, and study types, but are not without challenges. Both PRECIS and RE-AIM domains required modification in two of the three studies to evaluate and rate domains specific to study type. Lessons learned involved: dedicating enough time for training activities related to the domains; use of reviewers with a range of familiarity with specific study protocols; how to best adapt ratings that reflect complex study designs; and differences of opinion regarding the value of creating a composite score for these criteria.ConclusionsCombining both frameworks can specifically help identify where and how a study is and is not pragmatic. Using both PRECIS and RE-AIM allows for standard reporting of key study characteristics related to pragmatism and translation. Such measures should be used more consistently to help plan more pragmatic studies, evaluate progress, increase transparency of reporting, and integrate literature to facilitate translation of research into practice and policy.

Implementation science in cancer prevention and control: a decade of grant funding by the National Cancer Institute and future directions

BackgroundThe National Cancer Institute (NCI) has supported implementation science for over a decade. We explore the application of implementation science across the cancer control continuum, including prevention, screening, treatment, and survivorship.MethodsWe reviewed funding trends of implementation science grants funded by the NCI between 2000 and 2012. We assessed study characteristics including cancer topic, position on the T2–T4 translational continuum, intended use of frameworks, study design, settings, methods, and replication and cost considerations.ResultsWe identified 67 NCI grant awards having an implementation science focus. R01 was the most common mechanism, and the total number of all awards increased from four in 2003 to 15 in 2012. Prevention grants were most frequent (49.3%) and cancer treatment least common (4.5%). Diffusion of Innovations and Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) were the most widely reported frameworks, but it is unclear how implementation science models informed planned study measures. Most grants (69%) included mixed methods, and half reported replication and cost considerations (49.3%).ConclusionsImplementation science in cancer research is active and diverse but could be enhanced by greater focus on measures development, assessment of how conceptual frameworks and their constructs lead to improved dissemination and implementation outcomes, and harmonization of measures that are valid, reliable, and practical across multiple settings.

A systematic review of eHealth cancer prevention and control interventions: new technology, same methods and designs?

There has been a recent surge of eHealth programs in cancer and other content areas, but few reviews have focused on the methodologies and designs employed in these studies. We conducted a systematic review of studies on eHealth interventions on cancer prevention and control published between 2001 and 2010 applying the Pragmatic Explanatory Continuum Indicator Summary (PRECIS) criteria and external validity components from the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. We identified 113 studies that focused on cancer prevention and control of eHealth interventions. Most studies fell midway along the explanatory/pragmatic trial continuum, but few reported on various practical feasibility criteria for translation. Despite vast interest in cancer eHealth and the applied nature of this field, few studies considered key external validity issues. There is a need for use of alternative pragmatic study designs and transparent reporting of external validity components to produce more rapid and generalizable results.

Evolution of Cancer Control P.L.A.N.E.T.: moving research into practice

Evidence-based interventions (EBIs) are not broadly implemented, despite widespread availability of programs, policies, and guidelines. Systematic processes for integrating EBIs with community preference remain challenging for cancer control and prevention, as well as other areas. The Cancer Control P.L.A.N.E.T. (P.L.A.N.E.T) Web portal provides a platform to access data, EBIs, and resources to foster local partnerships and assist public health researchers and practitioners design, implement, and evaluate evidence-based cancer control programs. This article summarizes the evolution of P.L.A.N.E.T. and describes effective and innovative Web 2.0 strategies to increase Web visits, create more interactive platforms for researchers and practitioners to integrate evidence-based resources, community preferences, and the complex context in which programs and policies are implemented. Lessons learned could benefit public health settings and reach low-income, high-risk communities. Researchers, community practitioners, and government partnerships should continue to develop and test innovative ways to address pressing issues in cancer control, health disparities, and health delivery.

Implementation Science in Cancer Prevention and Control: A framework for research and programs in low and middle-income countries

Implementation science is a set of tools, principles, and methodologies that can be used to bring scientific evidence into action, improve health care quality and delivery, and improve public health. As the burden of cancer increases in low- and middle-income countries, it is important to plan cancer control programs that are both evidence based and delivered in ways that are feasible, cost-effective, contextually appropriate, and sustainable. This review presents a framework for using implementation science for cancer control planning and implementation and discusses potential areas of focus for research and programs in low- and middle-income countries interested in integrating research into practice and policy. Cancer Epidemiol Biomarkers Prev; 23(11); 2273–84. ©2014 AACR.

Research to Reality (R2R) Mentorship Program: Building Partnership, Capacity, and Evidence

Despite a wealth of intervention research in cancer control, full integration of evidence-based interventions into practice often fails, at least in part because of inadequate collaboration between practitioners and researchers. The National Cancer Institute piloted a mentorship program designed for practitioners to improve their ability to navigate evidence-based decision making within a context of inadequate resources, political barriers, and organizational constraints. The National Cancer Institute simultaneously sought to provide opportunities for practitioners and researchers to share and learn from each other. We identified four key successes and challenges related to translation as experienced by mentees: (a) establishing and maintaining partnerships, (b) data collection and analysis, (c) navigating context, and (d) program adaptation and evaluation. Mentorship programs have the potential to facilitate increased and more successful integration of evidence-based interventions into practice by promoting and building the capacity for collaborative decision making and generating in-depth understanding of the translation barriers and successes as well as strategies to address the complex contextual issues relative to implementation.

News from NIH: Global Health

The work of the CDC, National Institutes of Health (NIH), and other HHS agencies on communicable diseases in the developing world is well known. However, today, noncommunicable disease accounts for more than 60% of deaths around the world, of which 80% are in the developing world [1]. The epidemic of noncommunicable disease is growing and shifting from high-income countries to low- and middle-income countries (LMICs), where little research has been done, and minimal research capacity currently exists. Another challenge is the development of a “rapid learning science” grounded in methodology that is rigorous while also being responsive to short-term needs of communities, health systems, and policy makers [2]. There is a need to apply the lessons learned from HIV/AIDS, which ultimately converted erroneous myths that HIV was too complex, costly, and prevalent to prevent in the developing world into effective strategies to reduce costs, increase access to health services, and strengthen health systems [3]. This lesson from HIV/AIDS suggests that research conducted in LMICs could provide significant and innovative advancements in understanding, preventing, and treating chronic diseases for both developing and developed countries. Such research would likely include “disruptive innovations” as proposed by Paul Farmer [4], Clayton Christensen [5], and Santosh Krishna [6], providing needed services in innovative ways that bring a much more affordable product or service that is simple to integrate into a health service market. New international collaborations dedicated to an implementation and evaluation research agenda in chronic diseases are needed, and the behavioral and social sciences will be critical to advance research in global health. NIH, and particularly the NIH Fogarty International Center (FIC), has long supported international collaborations for research, training, health communications, and other activities related to preventing and controlling disease. One of the goals in the new FIC strategic plan is to expand training in and application of implementation science [7]. NIH, and specifically the FIC and the National Heart Lung and Blood Institute, are members of the Global Alliance for Chronic Diseases [8]. This alliance has global reach and brings together six major national health research councils. A major focus of the alliance is on chronic diseases in LMIC and among low-income and indigenous populations in developed countries. The goal is to support research on low-cost interventions and to build capacity in research, training, and healthcare delivery. Another example of NIH involvement in global health is the National Cancer Institute’s (NCI) co-funding of the International Tobacco and Health Research and Capacity Building Program. This program supports transdisciplinary research and capacity-building projects that address the burden of tobacco consumption in LMICs and promotes international cooperation between scientists and institutions in LMICs and investigators in high-income nations. The International Tobacco Control Policy Evaluation Project (ITC Project), funded by NCI, will evaluate and improve the understanding of the effect of the tobacco control policies implemented as part of the Framework Convention on Tobacco Control (FCTC). The ITC Project includes more than 20 countries, including many LMICs. It is the only international study that is specifically evaluating the effectiveness of the FCTC policies, such as implementing clean indoor air policies and graphic health warnings on cigarette packages. Disease-screening initiatives, such as the International Cancer Screening Network (ICSN) sponsored by NCI, are dedicated to collaborative research aimed at identifying and fostering efficient and effective approaches to disease control worldwide through population-based screening. ICSN is a voluntary consortium of 28 countries that meets biennially and has active population-based screening programs. The 4th Annual NIH Conference on the Science of Dissemination and Implementation: Policy and Practice, held on March 21–22, 2011, provided a forum for communicating and networking with international experts about the science of dissemination and implementation. One of the goals of this year’s conference was to facilitate international partnerships and expand the research base focused on global health issues. In parallel with the conference, NIH offered a workshop on impact evaluation, focused on how to incorporate rigorous impact evaluation methodologies into operations and implementation research, particularly when operating in a LMIC context. Past research suggests that international collaborations can inform efforts to identify solutions to the US health challenges in two major ways. First, the evaluation of major differences in health policy, context, and the effect of health policies on health and behavioral outcomes can inform future policies in the USA as well as LMICs. Second, study of health policy factors and outcomes within a given country likely underestimates the effect of policies because of the restricted range of policies within any given country. International comparisons can provide a better sense of multi-level effects within various contexts. The programs and activities summarized above are promising beginnings, but there are many remaining opportunities for behavioral and social sciences to address global health needs. The examples in this column are illustrative but not inclusive of all NIH global health initiatives. Global health is one of NIH Director Francis Collins’s five primary areas of focus [9], so new and continued opportunities for global health research are likely.

Building cancer control capacity: a mixed-method evaluation of the Research to Reality (R2R) Mentorship Program.

In 2011, the National Cancer Institute launched the Research to Reality (R2R) Pilot Mentorship Program to enhance mentees’ core evidence-based public health (EBPH) competencies. In this article, we describe the program and its evaluation results and the program’s ability to improve participants’ EBPH competencies and appropriateness of program components. Program evaluation consisted of a pre/post program competency questionnaire and interviews with mentees, mentors, mentees’ supervisors, and program staff. Mentees reported the same or higher rating in every competency at end of the program, with average increase of 0.6 points on a 4-point scale; the greatest improvements were seen in policy development/program planning. Mentorship programs are a promising strategy to develop EBPH competencies, provide guidance, and disseminate and adapt evidence-based interventions within real-world context.