Implementation science research (ISR) has been around for a decade and is still considered a relatively new field of science, as is evident by recent trends in funders starting to request applications for and require ISR framework to grants for impact. But what exactly is implementation science research? Think about the following comparative example.
Let’s assume the standard of care in a given cancer center is that every patient who walks into a clinic has a cell phone. If the clinic staff sends the patient a text message relaying results, confirming appointments, and/or asking that person to return in two weeks, the patient likely will and has the means to do so.
Now, let’s change the scenario and place the setting in a low-resourced setting in Africa. Not every individual in Africa has a cell phone or may share a cell phone number with non-intimate contacts, causing confidentiality issues. Additionally, a patient might live eight hours away from a clinic or they may have had to spend a considerable sum of money just to get transportation to the clinic. So, the system that is taken for granted in the United States is simply not the best or most appropriate solution for the low-resourced setting. Healthcare systems must be adapted to the local context, and implementation science research provides the tools to implement and measure that adaptation to prove impact.
Gugulethu Tshabalala, BBR Project Coordinator of Bio-Behavioral Research in the Perinatal HIV Research Unit of Chris Hani Baragwanath Academic Hospital, in South Africa, explains it best by describing the challenge of using Paps smears for women in Africa. But in this setting, as described by Miss Tshabalala, education and awareness are the major gap, not necessarily technology.
“We (healthcare providers) usually do it for those who request we do a pap smear,” she says. “People don’t like that even when we tell them the procedure, that procedurally we have to do a Pap smear on them. They will tell you, ‘I will come back...’ and all those things because they become skeptical. Some of them have this thing that (cancer) is for white people and not for us black people. That’s the other part that people believe, that these things (cancer) are not for us. They don’t affect Black people. That’s another challenge, but we have education and you know if you can really explain, (you can) convince them.”
ASCP has supported implementation of cancer diagnostic solutions in Africa since 2015 with a core program of telepathology. But not every site in Africa where ASCP worked was ready for telepathology. ASCP had to assess, find gaps, and then plan its implementation that was specific to the challenge of the local context. Often, this is straight forward. However, sometimes the gaps identified are complex and require testing and data to make sure the implementation is appropriate. In response to this, in 2019, ASCP became part of the Coalition for Research in Global Oncology (CIRGO), a group of global oncology organizations that work collaboratively to improve the coordination of cancer care systems in low- and middle-income countries, particularly in Africa.
As a first step, CIRGO announced in December of 2020 it would award $480,000 in capacity building grants, funded by the Bristol Myers Squibb Company, to support eight implementation science research projects in Africa. Each project received a $60,000 grant to develop country-specific initiatives focusing on early detection of breast cancer, cancer data quality, improving rural access to cancer testing and diagnostic services and strengthening cancer registries. Each grant recipient was assigned an expert liaison to provide assistance throughout the project.
The mission of CIRGO is to identify knowledge gaps across the spectrum, not just in diagnostics, and find solutions to fix those gaps. The initial round of grant recipients reflected that mission, and included organizations focusing on multiple areas of care, including pathology, surgery, primary care, and cancer registry organizations. According to a May 2020 article in the International Journal of Health Policy and Management, “Implementation research offers the approach needed to understand the variability of health outcomes from implementation strategies in different settings and why interventions were successful in some countries and failed in others. When mastered and embedded into a policy and implementation framework, the application of implementation research by countries can provide policy-makers and implementers with the knowledge necessary to work towards universal health coverage (UHC) with the effectiveness, efficiency, sustainability, and fidelity needed to achieve sustainable positive health outcomes for all.”1
“Surgery is an essential treatment modality of cancer. With limited access to surgical oncologists, implementation of innovative training models is highly needed to ensure trainees receive surgical oncology skills and improve surgical outcomes of cancer patients,” says Godfrey Sama Philipo, MD, MPH, clinical research coordinator at Muhimbili University of Health and Allied Sciences (MUHAS), and a grant recipient. “With support from CIRGO, a laboratory-based training will be implemented in MUHAS Tanzania.”
Prior to the recognition of the importance of implementation impact data that is afforded by the implementation research model, funders would provide resources for an organization to do a project and simply require them to provide a report. With implementation science research, there is now a hard science to show why things worked or didn’t work. Additionally, implementation science research is conducted by the people living within that country, and who will most benefit from the outcomes, rather than by researchers from outside of the community or country. “Healthcare researchers working in cancer within Africa assess their own situation,” says ASCP Chief Medical Officer Dan A. Milner, Jr., MD, MSc(Epi), MBA, FASCP. “They then identify the gaps they found in order to develop new solutions that will work in the local context and can then be replicated in other locations.”
With its background of conducting its own implementation research for global health projects, connecting and collaborating with CIRGO was a natural fit for ASCP. “There is a need to fill in these (knowledge) gaps, and you have to start somewhere,” Dr. Milner explains. “The program fits a niche, in terms of the amount of grant money provided. These are gateway grants for people to conduct the initial work and then go on to apply for larger funding.” ASCP, he adds, has the background and experience necessary to assist smaller organizations.
“ASCP stepped in and volunteered, as an organization, to serve as the fiscal agent for CIRGO, which does not have 501c3 (charitable) status,” Dr. Milner notes. “ASCP does have 501c3 status so we could receive the grant funding and collect data because we already have that formal channel for our own projects.”
For the 2021 application cycle for awards to be funding in 2022, CIRGO received more than 110 applications, the vast majority of which were focused, single-country research questions in Africa. In the 2020 cycle, CIRGO only received 16 applications. With this major increase in interest and need by the applicants on the ground who are capable of recognizing the major gaps in their own systems, it is hoped that the funding community will see the value of filling these gaps and improving patient outcomes and increase their fiscal support.