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Implementation Science: An Essential Tool for Advancing DrPH Practice

By Aubrey Villalobos, DrPH, MPH, MEd; Robin C. Vanderpool, DrPH, MPH; Robert E. Vollinger, Jr., DrPH, MSPH; Antoinette Percy-Laurry, DrPH, MSPH

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Villalobos A, Vanderpool R, Vollinger R, Percy-Laurry A. Implementation science: An essential tool for advancing DrPH practice. HPHR. 2021;35.  

Implementation Science: An Essential Tool for Advancing DrPH Practice

Public Health Practice Implications

This commentary describes how implementation science (IS) complements and adds value to public health decision making, applied research, and practice. The commentary then presents opportunities for integrating IS into public health, with a specific focus on engagement of Doctors of Public Health (DrPHs) in IS research and a call for advanced training in IS for DrPHs.

 

IS can advance public health by improving the translation of research into practice and policy and by addressing health inequities. IS has an increasing focus on incorporating health equity into its frameworks, enhancing community and stakeholder engagement in IS, studying the implementation of multilevel interventions, as well as policy implementation science.

 

IS examines and influences how we move evidence into practice; therefore, it is essential to have practitioners engaged in the field. There is an obvious role for IS to augment foundational DrPH training. Specifically for DrPHs, expertise in IS would elevate leadership and applied research competencies, facilitating evidence-based decision making in policy and practice. In order to achieve this goal, greater awareness of opportunities to build IS capacity and engage in IS research is needed.

Implementation Science and Public Health Practice

Doctors of Public Health (DrPH) are leaders in public health research and practice. We are trained to develop and evaluate policies, programs, and interventions to benefit population health. However, the field often emphasizes best practices and program outcomes, and to a lesser extent, implementation outcomes (Proctor et al., 2011) and the factors that influence them. These are all critical areas of public health practice and are extensively addressed in the field of Implementation Science (IS). DrPH leaders, including practitioners making decisions and implementing interventions in real world settings, would benefit significantly from greater awareness and application of IS.

 

IS facilitates evidence-based, efficient, and equitable public health practice. IS, also referred to as dissemination and implementation research, is the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into routine health care and public health settings to improve impact on population health. The National Institutes of Health (NIH) (2019) defines dissemination research as the scientific study of targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to understand how best to communicate and integrate knowledge and the associated evidence-based interventions. Often, there is a delay in getting research-tested, evidence-based interventions and strategies commonly developed through academic research into the hands of practitioners in the real world. NIH (2019) defines implementation research as the scientific study of the use of strategies to adopt and integrate evidence-based health interventions into clinical and community settings to improve individual outcomes and benefit population health. Efficacious interventions are typically designed and tested under controlled conditions, often without input from practitioners. Even when successful interventions are disseminated to practitioners, there may be challenges with implementing them in a more real-world context and in achieving improved health outcomes. IS enables us to examine the processes and determinants of successful implementation in order to improve practice (Proctor et al., 2009).

Background and Significance

IS can advance public health by improving the translation of research into practice and policy. A 1998 review reported that it takes about 17 years for 14% of original basic science research to be incorporated into practice and benefit patients (Balas, 1998). A follow-up paper from Khan et al. (2021) documented a small improvement of 15 years average to move cancer control research into practice. Translation of evidence into programs in communities for health promotion and disease prevention also suffers from delays and inefficiencies (MacLean, 1996; Nutbeam, 1996). Similarly, there is limited practice-based production of research (Ammerman, Smith, & Calancie, 2014; Green, 2008). Through the dual foci of dissemination and implementation research, IS can help bridge this gap between research to practice and practice to research.

           

Despite the field’s responsibility to advance population health, inequities persist in communities around the globe (Pérez-Stable & Collins, 2019). The recently pronounced inequities in COVID-19 deaths and vaccine access (Ndugga et al., 2021a & 2021b) and civil unrest for racial injustices (Chavez, 2020) have elevated conversations about social and structural determinants of health (SDOH) and systemic racism. We now have broader understanding that multilevel, multi-sectoral interventions are needed to meet the challenges and achieve health equity. Envisioning the future of health disparities research, Pérez-Stable and Collins (2019) noted that “of critical importance, it is not enough to identify factors that contribute to health disparities: intervention science must be applied in full force to seek solutions.” IS adds value to public health in this regard with an increasing focus on leveraging IS models, methods, and strategies to advance health equity (Brownson et al., 2021; Shelton, Adsul, & Oh, 2021), enhancing community/stakeholder engagement in IS (Pinto et al. 2021; Ramanadhan et al., 2018), and studying the implementation of multilevel interventions. Specifically, IS methods can help shift the focus from the inner levels of the social ecological model (individuals and their behavior) to outer levels (SDOH, communities, systems, and policies), and increase the rigor and speed with which we understand and intervene to eliminate health inequities (Chinman et al., 2017). The field is also poised to help us think about how research evidence can be translated into policies, and how those policies can be implemented, enforced, and evaluated, with a particular focus on accounting for and addressing SDOH to advance health equity (Emmons & Chambers, 2021).

 

IS complements public health decision making, applied research, and practice (Bauer et al., 2015). Many of the theories, models, and frameworks used in IS will be familiar to public health trainees, while others should certainly be better integrated in teaching and practice (Tabak et al. 2012; Nilsen, 2015). IS tests implementation strategies (Leeman et al., 2017) and provides guidance for adapting interventions to different contexts (Chambers & Norton, 2016). For example, IS can inform how we document and implement lessons learned about controlling transmission and optimizing treatments across waves of the COVID-19 pandemic (Chambers, 2020) and inform approaches to rolling out and scaling up vaccinations (Galaviz et al., 2020). IS researchers are developing pragmatic measures and methods for implementation and effectiveness (i.e., process and outcome) evaluation (e.g., Proctor et al., 2011). Often, we struggle to sustain and scale effective interventions; importantly, IS generates evidence to aid in this regard as well (Walugembe et al., 2019; Shelton, Cooper, & Stirman, 2018). Human papillomavirus vaccination and colorectal cancer screening are two examples of interventions that have been brought to scale with the help of IS. Some IS focuses on mis-implementation, which includes ending effective or continuing ineffective programs (Allen et al. 2020). Further, the field is increasingly investigating de-implementation of practices that are found to be ineffective, harmful, or inferior to newer evidence-based practices (Norton & Chambers, 2020). Finally, IS encourages attention to cost-effectiveness analyses, which helps leaders make more informed decisions about allocation of scarce public health resources. This is particularly relevant to global health and implementation of programs in low and middle-income countries (Ridde, 2016; Yapa & Bärnighausen, 2018) whose resources are more limited and whose implementation contexts require greater attention to maximize the value of investments and have the greatest impact on population health.

 

IS intersects with several disciplines that are more commonly included in public health training programs. In particular, health communication can be thought of as both part of dissemination science and considered an implementation strategy to improve intervention and policy implementation (Manojlovich et al., 2015). IS and community-based participatory research (CBPR) are also related and mutually enhancing, as described by two DrPHs, Wallerstein & Duran (2010). However, IS adds value by incorporating theories and methods that may be less familiar to those trained in public health. These include organizational theories (Birken et al., 2017), political science (Nilsen et al., 2013), economic theories (Vicki et al., 2020), human centered design (Chen & Neta, 2020), and clinical quality improvement science (Mitchell & Chambers, 2017), among others. As an example, Purtle, another DrPH, is leading policy implementation research related to urban health disparities and mental health (e.g., Purtle et al., 2021; Purtle et al., 2020).

 

If IS is dedicated to studying how we get evidence into practice, it is essential to have practitioners engaged in the field. Yet, opportunities for enhancing practitioner engagement remain (Hursting & Chambers, 2021; Lobb & Colditz, 2013). IS has clear relevance to public health competencies (Council on Linkages Between Academia and Public Health Practice, 2014) and accreditation criteria for educational institutions (Council on Education for Public Health [CEPH], 2016), yet is not explicitly mentioned. CEPH’s accreditation criteria were amended in 2016 in part due to calls from the field for schools of public health to better prepare graduates for the challenges of contemporary practice (Foster, King, & Bender, 2018). There is an obvious role for IS to augment three foundational DrPH competency domains of: data and analysis; leadership, management, and governance; and policy and programs (CEPH, 2016). Specifically, expertise in IS would elevate leadership and applied research competence, facilitating evidence-based decision making in policy and practice. To achieve this, however, greater awareness is needed of opportunities to engage in IS.

Opportunities in Integrating Implementation Science and Public Health

The IS field has expanded significantly over the past two decades, thanks in large part to the national leadership of the NIH, and the National Cancer Institute (NCI) in particular, who recognized the benefit of not only communicating research findings, but of studying how to better facilitate translation of research to practice (Glasgow et al., 2012). We, the four authors, are DrPH leaders working to advance the IS field in the Division of Cancer Control and Population Sciences at NCI. We bring DrPH and public health practitioner perspectives to both research and translation efforts at the federal level. From this vantage point, we see opportunities to increase practitioner engagement in IS and expand IS training in public health curricula to enhance the impact of the 10 essential public health services, which now center on equity (Krisberg, 2020).

 

DrPHs are national leaders in public health research and practice “who use advanced research expertise to perform and evaluate evidence-based public health practice using advocacy, communication, community-cultural orientation, critical analysis, leadership, and management skills as well as professionalism and ethics” (Calhoun et al., 2012, p. 25). Practitioner engagement in dissemination and implementation research would improve the relevance of findings and facilitate their adoption in practice. IS researchers should engage practitioners in refinement of the many models, theories, frameworks, strategies, and measures being used. Practitioners, given their engagement with communities, have a unique perspective on implementation context, feasibility, adaptation, and inequities. As public health leaders and decision makers, DrPHs can also make important contributions to the science of implementation related to cost analyses and perspectives on return on investment. Further, practitioners play an integral role in studying policy implementation, as they are often in the position of determining how to implement and enforce policies. Practitioner awareness of and engagement in IS will facilitate application of findings in practice by answering common questions about what to implement, how, when, where, or with whom.

 

To increase practitioner engagement in IS, adequate training in IS concepts is needed to build capacity. Utilizing IS approaches will equip future practitioners to integrate interventions well, focusing on cost-effectiveness, efficiency, and equity. Over 30 years ago, the former Institute of Medicine (1988) recommended that “research in schools of public health should range from basic research in fields related to public health, through applied research and development, to program evaluation and implementation research.” Brownson et al. (2006) called for schools of public health to increase commitments to translation and dissemination by offering curricula and training to students and faculty including teaching methods to design interventions for dissemination, develop new communication methods for dissemination, and lead in conducting research in translation and dissemination. Green (2008) reiterated that students should receive training in practice-based and participatory research methods, and in the application and adaptation of evidence in practice in order to bridge the research-practice chasm. Albers, Metz, and Burke (2020) began to articulate a more formal role that could be filled by public health trainees—implementation support practitioners, whose primary function is to help facilitate translation of evidence into practice. Yet, most practitioners report that their only IS training is not received during their schooling, but rather once they are already practicing in the field (Schultes et al., 2021).

 

Estabrooks, Brownson, and Pronk (2018) articulated the synergies between IS and public health. They encouraged practitioners to develop their capacity in nine key overlapping competencies (Figure 1) previously identified by Tabak et al. (2017).

Figure 1. Nine overlapping competencies between public health practice and implementation science (Tabak et al., 2017)

  1. Communicate Research Findings
  2. Improve Practice Partnerships
  3. Make Research More Relevant
  4. Strengthen Communication Skills
  5. Consider and Enhance Fit
  6. Develop Research Methods and Measures
  7. Build Capacity for Research
  8. Ensure Research is Meaningful
  9. Understand Multilevel Context

Ramaswamy et al. (2019) called for the incorporation of IS into Master of Public Health (MPH) curricula and we argue that IS education is even more important for DrPH trainees given their trajectory toward applied research and leadership in developing and implementing programs and policies. Boyce et al. (2019) highlighted the inadequate dissemination and implementation research workforce to address the many complex challenges we face in public health, namely health inequities. Advanced IS training in DrPH programs could directly respond to this need. Davis and D’Lima (2020) identified 41 dissemination and implementation capacity-building initiatives in the peer-reviewed literature but concluded that more training is needed to reach a broader audience, including practitioners. Table 1 lists a selective sampling of capacity-building resources led or funded by the NIH or partner agencies, but opportunities remain for universities to develop and offer more IS training through new or existing DrPH courses.

Table 1. Select Capacity-Building Resources in Implementation Science

Training and resources for researchers

National Cancer Institute’s Implementation Science website includes funding opportunities, sample grants, and other resources. For example:

The Consortium for Cancer Implementation Science (CCIS) is an annual working meeting that focuses on cancer control priorities, cross collaboration, and innovative solutions in IS.

Washington University in St. Louis’ Implementation Research Institute provides two years of training in mental health IS for 10 new fellows each year.

Washington University in St. Louis’ Institute for Implementation Science Scholars is an innovative two-year program that places a strong emphasis on mentoring, applying competencies and curriculum specifically focused on chronic disease disparities, and working with a diverse set of partners.

The University of North Carolina’s Implementation Science Exchange is a free, online source for those interested in resources to help design, acquire funding for, execute and disseminate IS research projects. They find (or create) resources, tools, websites, guides, toolkits, and sample grant applications to help support researchers in the field of IS, particularly those new to research or new to the field itself.

The D&I Models Webtool is an interactive, online resource designed to help researchers and practitioners navigate dissemination and implementation models through planning, selecting, combining, adapting, using, and linking to measures.

Additional electronic tools are described here: Ford, B., Rabin, B., Morrato, E. H., & Glasgow, R. E. (2018). Online Resources for Dissemination and Implementation Science: Meeting Demand and Lessons Learned. J Clin Transl Sci. 2(5), 259–266. https://doi.org/10.1017/cts.2018.337

Training and resources for practitioners

NCI’s Implementation Science at a Glance provides a succinct overview of the rapidly evolving field. This workbook was written by members of the NCI IS team and reviewed by public health practitioners and implementation researchers. Through summaries of key theories, methods, and models, the guide shows how the use of IS can support the effective adoption of evidence-based interventions. Case studies illustrate how practitioners are successfully applying IS in their cancer control programs.

NCI’s Evidence-Based Cancer Control Programs website is a searchable database of evidence-based cancer control programs and is designed to efficiently disseminate program materials to program planners and public health practitioners.

NCI-funded Implementation Science Centers in Cancer Control (ISC3) Program supports the rapid development, testing, and refinement of innovative approaches to implement a range of evidence-based cancer control interventions. Centers all feature “implementation laboratories” involving clinical and community practice sites that will engage in implementation research across the cancer control continuum to advance methods in studying implementation and develop and validate reliable measures of key IS constructs.

The Consortium for Cancer Implementation Science (CCIS) is an annual working meeting that focuses on cancer control priorities, cross collaboration, and innovative solutions in IS. Practitioner engagement in this consortium is encouraged.

Putting Public Health Evidence in Action Training, created by the Cancer Prevention and Control Research Network (CPCRN), supports community program planners and health educators in developing skills in using evidence-based approaches and learning about new tools for planning and evaluating community health interventions. It is a self-paced curriculum with activities and tools.

The CPCRN Scholars program (launched in 2021) is an educational and training program that strives to educate students, postdoctoral fellows, junior faculty, practitioners, and other health professionals in dissemination and implementation science focused on cancer prevention and control and health equity. Enrollees are provided with a curriculum related to IS, webinar and group interactions, and opportunities to engage in mentored projects.

The D&I Models Webtool is an interactive, online resource designed to help researchers and practitioners navigate dissemination and implementation models through planning, selecting, combining, adapting, using, and linking to measures.

 

Conclusion

IS is essential for advancing the impact of public health by reducing research translation time, improving equity through multilevel, multi-sector interventions, and integrating strengths from multiple disciplines. Practitioner engagement is vital to accomplish this. Therefore, we need more engagement in the science and its application, and we must build greater capacity among DrPH students and alumni to prepare them to address the complex contemporary challenges facing them in practice.

Disclaimer

The opinions expressed by the authors are their own and the research presented in this paper should not be interpreted as representing the official viewpoint of the U.S. Department of Health and Human Services, the National Institutes of Health, or the National Cancer Institute.

How DrPH Training Informed This Work

 The authors have a combined 25 years since completing their DrPHs and decades-long careers in public health research and practice. Our professional backgrounds and career trajectories mirror the rich diversity and multi-disciplinary nature of the field. Our collective expertise is broad, as expected of DrPHs, covering implementation science, social and behavioral science, cancer prevention and control, tobacco prevention and control, breastfeeding, policy, community engagement, clinical quality improvement, and health equity. Throughout our careers, we have served in community organizations, clinical practices and hospitals, academia, and federal agencies. The DrPH-related skills in leadership and practice exercised and enhanced through these professional experiences informed the perspective presented on the gaps and opportunities for a melding of implementation science and public health practice.

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About the Authors

Aubrey Van Kirk Villalobos, DrPH, MPH, MEd

Aubrey Van Kirk Villalobos is a Health Scientist with the Implementation Science (IS) Team in the Office of the Director in the Division of Cancer Control and Population Sciences (DCCPS) at the National Cancer Institute (NCI). She leads a number of efforts to advance the involvement of practitioners in IS to enhance the integration of evidence-based guidelines, programs, and policies for cancer control in public health and clinical practice. Prior to joining the NCI, Dr. Villalobos served as director of cancer control and health equity at the George Washington University (GW) Cancer Center.

Robin C. Vanderpool, DrPH, MPH

Robin C. Vanderpool is Chief of the Health Communication and Informatics Research Branch at the NCI in Rockville, MD. She graduated with her DrPH, concentrating in Health Behavior, in 2006 from the University of Kentucky College of Public Health. She has published and presented extensively in cancer prevention and control, rural health, and health communication.

Robert E. Vollinger, Jr., DrPH, MSPH

Robert E. Vollinger, Jr. is a Program Director in the Tobacco Control Research Branch at the NCI. He leads an extensive portfolio of tobacco prevention and control policy research with a current emphasis on tobacco control policies to promote health equity. He has led numerous large research initiatives to inform state and community tobacco control policies and programs. His research has focused on policies to reduce exposure to secondhand smoke, particularly in multi-unit housing. He is committed to engaging a diverse array of community partners in the research, with a focus on community-based participatory research, and to working collaboratively to ensure that research findings are proactively disseminated and implemented as broadly as possible.

Antoinette Percy-Laurry, DrPH, MSPH

Antoinette Percy-Laurry is a Health Scientist Administrator at the National Institute on Minority Health and Health Disparities within the National Institutes of Health. She leads projects related to the planning, development, implementation, and evaluation of intervention and social-behavioral research to improve minority health and reduce health disparities. She previously worked at the NCI as Lead Public Health Advisor in IS in the DCCPS.