Asking the right question: implementation research to accelerate national non-communicable disease responses.

Faced by the global growth of non-communicable diseases (NCDs), national governments are finding ways to develop, finance, and respond to protect their people’s health.1 The 2018 United Nations General Assembly high level meeting on NCDs set an agenda from strategy to action.2 Each country faces challenges in implementing NCD policies, programmes, and interventions effectively. This is particularly difficult in countries where there are limited data about NCDs, and where resources are limited. For example, many of the “best buys” in NCDs have not been assessed in low and middle income countries, which are facing an abrupt rise in the burden of these diseases.3 Implementation research provides a useful set of theories, approaches, and tools to turn strategies into implemented programmes. It creates solutions in a wide variety of settings.4 5 6 This article examines ways to identify implementation bottlenecks and opportunities and translate these into questions about policy that can be answered through research.

Many governments have developed national NCD policies and strategies since the World Health Organization’s global action plan was adopted.1 These plans recognise that many NCDs are strongly influenced by social determinants of health and have major social, political, and economic consequences. Each country is concerned whether their NCD plans will achieve ambitious targets. In many instances this requires challenging not only social norms but also business and policy to deal with social determinants of health. Building capacity to work across public and private sectors and overcoming vested interests for the common good are not easy tasks.

There are many barriers to carrying out NCD plans. Overcoming these barriers may require organisational change, new ways of working, and adoption of theoretically derived models. Achieving this involves encouraging the development of leadership through all levels within and across organisations, enabling changes based on data and problem solving, and engaging relevant stakeholders. These approaches highlight the need for data and the use of implementation research.

Role of implementation research

Implementation research can be most useful for identifying the challenges faced by NCD programmes and how to deal with them. Policy makers, managers, healthcare providers, and citizen groups often worry about implementation of NCD strategies. These concerns are not typically framed as answerable questions and are not prioritised using rigorous methods. Implementation research helps to fill these gaps by framing and answering practical questions through scientific methods.

Reviews of national NCD plans and strategies highlight the challenges and opportunities faced by countries from different regions and with different income levels (Australia, Brazil, Indonesia, Kenya, Norway, Turkey). They provide a basis for research questions that can deal with them (see web table on bmj.com).7 8 9 10 11 12 All these national plans describe better ways of identifying and engaging key stakeholders to promote their NCD programmes. Enabling stakeholders to support control of NCD plans is a common approach, either through allocating resources or giving them a larger role in design and implementation. Many plans also cite the need to break down barriers between disciplinary groups and specific health programmes. However, many of these divisions are deeply entrenched across professional societies, funding bodies, and non-governmental organisations. Responding to this requires an increased sophistication in research methods and behaviour change.

Despite the fact that we found no explicit reference to key actors who work against NCD control objectives, we think this is an important problem, particularly in societies where the private sector is weakly regulated. Identifying groups whose interests may oppose NCD control strategies and methods of dealing with them would probably be achieved by conducting a stakeholder analysis. This is a method commonly used in implementation research. In many countries, aggressive marketing of tobacco, alcohol, and unhealthy food is a tough opponent in promotion of positive health messages. Multidisciplinary approaches are often needed. These might include combining spatial analysis with policy and business interventions to consider how “food deserts” or “food swamps” put poor neighbourhoods at risk in Australia.13 Greater focus should be on research and accountability of powerful commercial interests.

Another common thread throughout the plans is the focus on prevention and the need to shift from care models organised around diseases to person centred approaches. Most of the national NCD plans were also concerned with developing the personnel needed to deliver NCD programmes (eg, Indonesia, Kenya, Turkey). They also had similar interests in finding ways to improve the quality of clinical NCD services through frontline providers. The strategies often expressed a need for innovation and better application of information technology. This might include more sophisticated data systems, infrastructure for managing programmes at the population level, as well as for self management across life transitions, and better continuity of care across different types of providers (eg, Australia, Indonesia, Kenya). Implementation research questions relevant to these topics are often concerned with understanding and dealing with the barriers to acceptance and adoption of NCD strategies among those expected to carry them out and those expected to benefit from them.

Stakeholders in an NCD programme may see implementation challenges differently. Politicians, or policy makers in ministries of finance, health, industry, or other sectors related to NCDs, or programme managers, frontline health providers, citizens groups, or the researchers themselves may have different priorities. This diversity of interests and power greatly affects research. To accelerate national NCD action plans, it is important to organise implementation research questions around the concerns of the primary audience, such as national health and finance policy makers or local organisations. None the less, it will also be important to understand and deal with the concerns of each of the main stakeholders if a programme is to succeed, including those whose interests oppose NCD control objectives. One approach would include testing ways in which relevant groups might join the effort (eg, encouraging food outlets to provide healthy food, reducing salt in diets, ensuring affordable and accessible pharmaceuticals for chronic conditions), or assessing ways to restrict damaging products (eg, introducing taxes on cigarettes and alcohol, regulating automobile emissions).

Turning implementation problems into answerable questions

Researchers can work with key stakeholders to help translate implementation challenges into answerable research questions. Together with decision makers they can encourage mature communication that focuses on responding to the needs of decision makers. Researchers are often able to combine research evidence to identify how interventions have worked elsewhere. This is useful for providing alternatives or benchmarks in discussions with decision makers. Local knowledge can be obtained by joint meetings to discuss programme and research concerns, or through more structured approaches, such as planned discussion between policy makers and researchers.14 For example, “reverse research days” can be held where programme implementers present their challenges to researchers. Researchers then respond by trying to turn the problems into research questions, based on data that that can be obtained. Another approach is to embed researchers in ministries of health. Some innovative approaches have involved “implementer led research,” where the principal investigator on a research project is an implementer, while the researcher serves as a co-investigator.15 16 Other strategies involve setting up research units in ministries of health to commission or conduct research seen as relevant to the government, or having staff exchanges between government and universities.

One recent example is the Kenya NCD symposium that focused on research for actionable policies.17 Key stakeholders from government, civil society, business, and academia met for two days to consider whether the implementation research conducted in Kenya supported the government’s NCD strategy.8 If it did not, they considered how the country might better use health research to inform policy and practice. Top research priorities included an assessment of how current strategies were working; how to generate communication messages based on evidence; assessment of the human resources, financial, and infrastructural capacity to deliver NCD programmes; and how to develop systematic ways of using data and fill research gaps.17

What should programmes examine?

There is no shortage of implementation research questions that can be asked in forging an NCD agenda. It is helpful to have a systematic approach to prioritise the order and importance of the implementation research. Numerous theories and frameworks provide useful ways of understanding what factors affect outcomes, of evaluating policies and programmes, or ways of translating research into practice.18 One approach is to examine the continuum of implementation concerns (table 1). This approach begins by asking scoping questions about the context, key stakeholders, NCD conditions, or interventions that can affect the introduction of NCD programmes. One such review of NCD programmes was conducted in Turkey to identify challenges that required investigation and action.19 Systematically examining NCD challenges for the set of “implementation outcome variables” can also be very helpful.4 14 As shown in table 1, this requires assessment of implementation barriers and opportunities through a series of questions. These start from acceptability to adoption, relevance, feasibility, fidelity, adaptation, cost, coverage, effectiveness, and sustainability, as well as questions about the future course of implementation. Different stakeholders may be interested in particular outcomes. For example, Ministries of Finance often want to know about cost effectiveness of an intervention to justify paying for it. The effectiveness of NCD strategies may be reduced through one or more of the outcome variables. This is not necessarily a linear process, though some implementation outcomes are more pressing at different times during the introduction of a strategy. As noted in the six national NCD plans reviewed, many had initial questions about the acceptance and adoption of interventions, and strategies to provide them. Over time there is likely to be growing interest in questions about feasibility, fidelity, coverage, cost, and effectiveness. For longer term outcomes it is critical to deal with questions of sustainability from the start, so that strategies are not designed to be merely short term.20

Table 1

Continuum of implementation research questions for programme delivery of non-communicable diseases (NCDs)

Relevant questions	Examples
Implementation
What are the main implementation challenges? For which stakeholder (eg, target populations, healthcare providers, managers, policy makers)?	What do policy makers see as the main reason why NCD programmes are not effective?
	What barriers need to be overcome for policy makers to allocate sufficient resources for NCD control?
	What are the opportunities for public-private partnerships to deal with NCD problems?
	Why do healthcare providers not follow clinical guidelines for detection and management of hypertension?
What are the key contextual factors for an NCD condition, target population, or the intervention that might affect implementation?	What are women’s perceptions of the importance of cervical cancer, and the barriers to seeking screening and follow-up?
	How do we deal with hypertension in low resource settings when cancer and HIV appear more critical chronic disease threats?
Which are the main organisations that affect implementation of the intervention? How do they facilitate or impede implementation?	How can physician organisations be better engaged to promote NCD control?
	How influential is the tobacco industry among key decision makers in opposing tobacco taxation or other measures such as crop diversification away from tobacco? Are there strategies that can be used to limit their influence?
Implementation outcomes
Acceptability: How agreeable do implementers (eg, managers and providers) and target populations find the intervention? How important is the health problem or intervention to them?	How well do food producers and consumers accept lower salt formulations in food, or having publicised targets for reduced salt intake?
Adoption: To what degree are key stakeholders (eg, managers, healthcare providers, target populations) deciding to try out the new intervention?	How willing are doctors, nurses, and primary care providers in our country to spend time on counselling and referral for physical activity as part of primary care? What are the constraints preventing patients increasing physical activity, where appropriate?
Relevance: How strongly do implementers or target populations believe that the intervention is relevant for their setting?	To what degree do policy makers and the public believe that reducing sugar sweetened beverages is important?
Feasibility: How well can an NCD intervention be carried out by an implementing organisation or by the target population?	To what degree do people believe that they should use a clean fuel cookstove in their home to reduce exposure to air pollution?
Fidelity: To what degree is the intervention implemented as designed (eg, with appropriate staff, training, intensity, and consistency of delivery)?	How well can healthcare workers follow recommendations for blood pressure screening and treatment in our country?
Adaptation: To what degree does the intervention, and how it is delivered, change based on learning from implementation?	What is a culturally acceptable way for the media and an educational campaign to support increased levels of physical activity across a community
Cost: How much does the intervention cost? Across settings? Can costs be reduced without harming implementation?	How many resources are needed to implement the priority NCD control strategies nationally?
	What resources are allocated by the public and private sector for priority NCDs?
	What is the cost of providing screening, counselling, and medication for populations needing glycaemic control for diabetes, or hypertension control for cardiovascular disease, in our country?
Coverage: Are populations who are eligible to benefit from the intervention actually receiving it? Why not? How can a programme be scaled up?	How can all girls aged 9-13 in our country be reached to receive two doses of human papillomavirus vaccine?
Sustainability: How sustainable is the intervention (eg, organisationally, socially, financially, politically, technologically)?	What are the human resources, social, political, and financial requirements needed to implement the national NCD programme?
	How do you maintain political and social support for NCD programmes?
Implementation effects
Effectiveness: How effective is an NCD intervention (or its components) in reducing exposure to risk factors? Morbidity and mortality? Across settings? What is reducing its effectiveness?	How effective are local efforts to reduce alcohol consumption, such as through minimum age requirements, limiting retail outlets, or through mass media campaigns?
	What is preventing efforts from being more successful?
Cost effectiveness: How cost effective is the NCD intervention (or its components)? Across sites?	What is the cost effectiveness of using mobile phone based tobacco cessation services for all those who want to quit?
Future course: What is the likely (or possible) course of future intervention?	What will be the likely effect on morbidity and mortality rates in our country with the current programme implementation of smoking prevention and cessation? How might that change with improvement of the programme?
	How would public-private partnerships alter the course of progress on cardiovascular health?

From research question to conduct

Once the research questions and methods are well formulated, it is necessary to ensure that what is planned is likely to serve the intended purposes of the research. One way is to check whether the research has the desired characteristics that will promote its application (box 1). Another is to ensure that those commissioning the research, the programme implementers, the researchers, and, in many cases, the intended beneficiaries, have mutually agreed expectations and consider potentially unintended consequences.

Is the research question relevant to the primary audience of the research (eg, national policy maker)?

Is there potential for application of results?

Is it timely to the needs of the decision maker, and when decisions need to be made?

Is the research itself acceptable (to policy makers, but also to implementers, beneficiaries)?

Is the research feasible given the time, financial, and personnel constraints?

Is the research ethically acceptable?

Concluding thoughts

Implementation research provides an opportunity to include key stakeholders in identifying main barriers to implementation of NCD action plans. The pragmatism and rigour of implementation science that is tailored and targeted to real world concerns is compelling. Systematically dealing with questions about NCD programmes serves the immediate purpose of advancing NCD action plans. The broad and multifaceted dimensions of NCD prevention, management, and treatment require us to consider a broader range of people involved in health and social services, including government and non-state personnel. This will challenge us to think in new ways about how NCD strategies will be funded and implemented beyond more traditional disease specific programmes. Answers to questions of political leadership and accountability are also needed and are particularly important as healthcare is increasingly politicised. Yet the type of problem solving at the heart of implementation research also builds capacity in NCD programmes. Implementation research fosters reflexivity and learning organisations that can continuously improve through informed decision making, increased accountability, and greater involvement and empowerment of key stakeholders.

Non-communicable disease (NCD) programmes can be more effective if they identify barriers to implementation

A systematic approach to identifying researchable questions based on these barriers is a critical step

Policy makers, programme managers, frontline health workers, patients, and people at risk of NCDs have different priorities that are worth researching

Implementation research should be fit for purpose to meet the needs of those asking the question, and should balance trade offs between timeliness, costs, and the strength and type of evidence needed to answer the question