Friday, April 29, 2016

The Tangled Pair: Implementation Science and Service Delivery in Chiapas, Mexico

Rose Molina, MD
Fellow in Global Women’s Health, The Connors Center for Women’s Health and Gender Biology, Brigham and Women's Hospital

Rose Molina (Global Women's Health Fellow) and
Carolina Menchu (Professional Midwife) in
Laguna del Cofre, Chiapas
As part of my Global Women’s Health Fellowship, I have collaborated with Partners In  Health/Compañeros En Salud (CES) in Chiapas, Mexico in implementing and evaluating the impact of a rural maternity center in providing peripartum care for women with low-risk pregnancies. I traveled to Chiapas for 2 weeks in March as part of this ongoing collaboration over the course of my two-year fellowship. As I reflect on this project, I have realized that there are several challenges in the relationship between service delivery and implementation science. However, overcoming these challenges is essential for both teams to achieve their ultimate goal in improving health outcomes and being able to demonstrate impact in our context in Chiapas.

Implementation science has been defined as “the study of methods…to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions” with the intent “to investigate and address major bottlenecks (e.g. social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact.” Along with adaptive trial designs, implementation science has become a buzzword in global health research. It occupies a space on the continuum of monitoring and evaluation (M+E) for internal organizational needs and rigorous research for knowledge generation. Purpose, funders, and resources determine its location on this continuum.

OB ultrasound course in Jaltenango, Chiapas
Global health work encompasses many levels of direct patient care, program analysis, and policy change. One of the central goals in global health work is to demonstrate the impact of interventions and scale up the successful ones in a sustainable way. This is where implementation science is needed. Decision-makers and funders need high-quality data to decide what programs to fund for scale-up. Questions that need to be addressed are 1) What types of data are needed to influence health policy makers and funders to improve health systems? 2) How should meaningful impact be defined for a given intervention? The purpose of implementation science research is to measure the impact of how a program or intervention is designed and carried out. This requires close collaboration between the research team and the team designing and implementing the program, as each informs the other. Good implementation science is iterative, reflecting and evolving with program development. One example of how we applied a research lens to program development was the process of integrating respectful maternity care into existing best practices and developing systems to evaluate these new indicators in our rural maternity center.

Despite the need for implementation science research, little or no infrastructure exists for this purpose in many resource-limited settings. Limited mentorship from personnel experienced with this type of research is another challenge. Furthermore, where limited funding exists, resource allocation may place research priorities further toward monitoring and evaluation on the continuum, which may have implications for generalizability and potential for scale-up.

Maternity center in Revolucio'n, Chiapas
While I was in Chiapas for this recent trip, I had the opportunity to participate in both the service delivery and research teams. With regard to clinical teaching and supervision, an OB/GYN resident and I led a basic obstetric ultrasound course for the general physicians in CES. We performed approximately 35-40 ultrasounds on pregnant women in 4 communities, and we saw the physicians’ skills improve in a short period of time. With regard to research, I helped develop M+E indicators and research protocols that evolve with the changing scope of the project. As I continue to work on this project in Chiapas, my goal is to ground my research in ongoing clinical activities, which can then provide continuous iteration in how the research can best adapt to the clinical reality of the maternity center. This experience continues to shape how I understand implementation science research within an organization dedicated to providing excellence in primary care in a challenging, marginalized environment. Lessons learned from this experience have been invaluable in further developing my career in global health research.

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