Theories, Models, Frameworks:A Practical ApplicationRajesh Vedanthan, MD MPHDirector, Section for Global HealthAssociate Professor, Departments of Population Health and MedicineNYU Grossman School of Medicine

I receive financial support from the following company or companies related to the products listed below. These relationships may lead to bias in my presentation.

Disclosures

Entity Type(s) of relationship(s)

Product name(s)

Relevant disease(s) or condition(s)

NONE

K01TW009218R01HL125487R56HL150036U01HL114200

U01HL138636U01HL142099 R01MH118075R21HL14047414SFRN20490315

Knowledge-Practice (Know-Do) Gap

3

Implementation research

• Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and public health

• It includes the study of influences on healthcare professional and organizational behaviour.

• (Eccles/Mittman, 2006)

4

Research Pipeline

5

Dissemination

Scale Up

Scale Out

Suggested criteria for a good theory:

@PilvikkiA / GACD ISRTS 2019

1. Clarity of theoretical concepts2. Clarity of relationships between constructs3. Measurability4. Testability5. Being explanatory (statistically or logically)6. Describing causality7. Achieving parsimony8. Generalisability9. Having an evidence base

Michie S, West R, Campbell R, et al. An ABC of behaviourchange theories. London: Silverback Publishing, 2014.

Theories, Models, Frameworks—Why?

7https://impsciuw.org/research/frameworks/

Implementation Research

Vedanthan (2011) MSJM

PI (Kenya): Constantine Akwanalo, MMedCo-I (USA): Rajesh Vedanthan, MD MPH; Tim Mercer, MD MPH;

Sonak Pastakia, PhD; Gerald Bloomfield, MD MPH; Jonathan Dick, MD

Strengthening Referral Networks for Management of Hypertension

Across the Health System

Implementation Research

Vedanthan (2011) MSJM

Mercer et al. (2019) Trials

Referral Networks

TertiaryNational Referral Hospital

(MTRH)

SecondarySub-County and County Hospitals

PrimaryHealth Centers and Dispensaries

Implementation Research

Vedanthan (2011) MSJM

Analyze Determinants• Context, Agency, Structure

Daivadanam et al. PLoS One 2019

Implementation Research Frameworks—PRECEDE-PROCEED

14Green and Kreuter (1999)

Process Model—PRECEDE-Proceed

Mercer et al. Forthcoming

Process Map – Task Map

Pathak et al. Forthcoming

Implementation Research

Vedanthan (2011) MSJM

Intervention/Strategy Selection• Patient-focused• Provider-focused• Education• Feedback/Reminders• Patient safety• Organizational change• Economic strategies• Policy/Regulation• Multifaceted

DESIGN THINKINGDesigner's sensibility and methods to match:

• Desirability (people’s needs)

• Feasibility (social, political, technological, cultural)

• Viability (economic, sustainable, scalable)

Designer’s Sensibility:Integrative Thinking

ANALYTICAL THINKING

Deductive reasoning

Inductive reasoning

INTUITIVE + IMAGINATIVE THINKING

Abductivereasoning

INTEGRATIVE THINKING

Reduces spillage by over 80%!

BaselineAssessment

STRENGTHS—Design Process

Design Parameters(Study Protocol)

Scalable InterventionModel

Community Engagement

Design Capacity Building

Parallel Health System Development

Design Inputs Design Outputs

Prot

otyp

e #1

Prot

otyp

e #2

Prot

otyp

e #3Do you like this idea?

Is it a good fitfor your community?

Did the prototypeseem effective

in facilitating referrals?Overall Positive Feedback:

• Improved referral experience• Encouraged referral adherence via peer counseling• Facilitated communication between clinicians• Reinforced referral practices

Persistent Challenges:• Some barriers not directly addressed• Integration of Health IT tools across clinics

Pillsbury et al. (2020) CUGH

STRENGTHS

Implementation Research

Vedanthan (2011) MSJM

STRENGTHS: Cluster RCT

The PRagmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) wheel

Kirsty Loudon et al. BMJ 2015;350:bmj .h2147

Pragmatic vs. Explanatory

Pragmatic vs. Traditional

30Krist, et al. (2012) Imp Sci

Pragmatic vs. Traditional

31

Implementation Research

Vedanthan (2011) MSJM

Implementation pipeline- Mittman & Curran 2012

Hybrid – Type 1Test intervention,

gather information on implementation

Hybrid – Type 2Test intervention,

Test implementation strategy

Hybrid – Type 3Test implementation

strategy, gather effectiveness data

Process evaluation

NYU School of Medicine36

Process EvaluationThe Saunders Framework

STRENGTHS Process Evaluation – Methods

NYU School of Medicine37

Process Evaluation Component Data Collection Method

Objective Structured Clinical Examinations (OSCEs)

Implementation Research

Vedanthan (2011) MSJM

THANK YOU