Evaluating implementation of the World Health Organization's Strategic Approach to strengthening sexual and reproductive health policies and programs to address unintended pregnancy and unsafe abortion.

BACKGROUND: We conducted a process evaluation to assess how the World Health Organization's (WHO) Strategic Approach to strengthening sexual and reproductive health policies and programs ("the SA") was used in 15 countries that requested WHO's technical support in addressing unintended pregnancy and unsafe abortion. The SA is a three-stage planning, policy, and program implementation process. We used the social ecological model (SEM) to analyze the contextual factors that influenced SA implementation. METHODS: We used a two-phased sequential approach to data collection and analysis. In Phase A, we conducted a document and literature review and synthesized data thematically. In Phase B, we conducted interviews with stakeholders who used the SA in the countries of interest. We used a qualitative method triangulation technique to analyze and combine data from both phases to understand how the SA was implemented in each country. RESULTS: Data from 145 documents and 19 interviews described the SA process and activities in each country. All 15 countries completed Stage 1 activities. The activities of Stage 1 determined activities in subsequent stages and varied across countries. Following Stage 1, some countries focused on reforming policies to improve access to sexual and reproductive health (SRH) services whereas others focused on improving provider-level capacity to enhance SRH service quality and improving community-level SRH education. We identified factors across SEM levels that affected SA implementation, including individual- and community-level perceptions of using the SA and the recommendations that emerged from its use, organizational capacity to conduct SA activities, and how well these activities aligned with the existing political climate. Stakeholders perceived SA implementation to be country-driven and systematic in bringing attention to important SRH issues in their countries. CONCLUSION: We identified key success factors for influencing the individual, organization, and system change required for implementing the SA. These include sustaining stakeholder engagement for all SA stages, monitoring and reporting on activities, and leveraging activities and outputs from each SA stage to obtain technical and financial support for subsequent stages. Results may be used to optimize ongoing implementation efforts to improve access to and the quality of SRH services.

Navigating barriers: two-year follow up on recommendations to improve the use of maternal health guidelines in Kosovo.

BACKGROUND: Although there are a growing number of initiatives aimed at supporting guideline implementation in resource-constrained settings, few studies assess progress on achieving next steps and goals after the initial activities are completed and the initial funding period has ended. The aim of the current study was to conduct a qualitative process evaluation of progress, barriers, facilitators, and proposed solutions to operationalize nine recommendations to prepare Kosovo to implement the 2012 World Health Organization (WHO) prevention and treatment of postpartum haemorrhage guideline. METHODS/DESIGN: In 2012, we co-created nine recommendations designed to support implementing the WHO's guideline on the prevention and treatment of postpartum haemorrhage in Kosovo. The current study uses a realist evaluation approach to assess activities and progress two years after the recommendations were developed. The study involved conducting qualitative focus groups and one-on-one interviews with participants from the first meeting to evaluate the activities and progress on the nine recommendations. RESULTS: Forty-three participants provided insights into the barriers and opportunities experienced to date and proposed future directions. Although progress has been made towards implementation of a number of the recommendations, scaling up has been limited by barriers, such as lack of awareness, limited resources, and evaluation challenges. Participants proposed addressing these barriers by building within- and between-country partnerships to facilitate guideline implementation. In addition, participants reported less progress on implementing recommendations related to broader cultural changes, which indicates a need for specific and actionable recommendations to operationalize implementation efforts. CONCLUSIONS: In the two years since the initial meeting, there has been mixed progress on the recommendations. Based on participant feedback, we refined the recommendations so that they can be operationalized by health care system stakeholders in Kosovo to further support implementation efforts. It is beneficial to share these lessons learned throughout the implementation process to inform next steps in Kosovo and offer ideas for use in other settings.

Longitudinal evaluation of a course to build core competencies in implementation practice.

BACKGROUND: Few training opportunities are available for implementation practitioners; we designed the Practicing Knowledge Translation (PKT) to address this gap. The goal of PKT is to train practitioners to use evidence and apply implementation science in healthcare settings. The aim of this study was to describe PKT and evaluate participant use of implementation science theories, models, and frameworks (TMFs), knowledge, self-efficacy, and satisfaction and feedback on the course. METHODS: PKT was delivered to implementation practitioners between September 2015 and February 2016 through a 3-day workshop, 11 webinars. We assessed PKT using an uncontrolled before and after study design, using convergent parallel mixed methods. The primary outcome was use of TMFs in implementation projects. Secondary outcomes were knowledge and self-efficacy across six core competencies, factors related to each of the outcomes, and satisfaction with the course. Participants completed online surveys and semi-structured interviews at baseline, 3, 6, and 12 months. RESULTS: Participants (n = 15) reported an increase in their use of implementation TMFs (mean = 2.11; estimate = 2.11; standard error (SE) = 0.4; p = 0.03). There was a significant increase in participants' knowledge of developing an evidence-informed, theory-driven program (ETP) (estimate = 4.10; SE = 0.37; p = 0.002); evidence implementation (estimate = 2.68; SE = 0.42; p < 0.001); evaluation (estimate = 4.43; SE = 0.36; p < 0.001); sustainability, scale, and spread (estimate = 2.55; SE = 0.34; p < 0.001); and context assessment (estimate = 3.86; SE = 0.32; p < 0.001). There was a significant increase in participants' self-efficacy in developing an ETP (estimate = 3.81; SE = 0.34; p < 0.001); implementation (estimate = 3.01; SE = 0.36; p < 0.001); evaluation (estimate = 3.83; SE = 0.39; p = 0.002); sustainability, scale, and spread (estimate = 3.06; SE = 0.46; p = 0.003); and context assessment (estimate = 4.05; SE = 0.38; p = 0.016). CONCLUSION: Process and outcome measures collected indicated that PKT participants increased use of, knowledge of, self-efficacy in KT. Our findings highlight the importance of longitudinal evaluations of training initiatives to inform how to build capacity for implementers.

Evaluation of the "Foundations in Knowledge Translation" training initiative: preparing end users to practice KT.

BACKGROUND: Current knowledge translation (KT) training initiatives are primarily focused on preparing researchers to conduct KT research rather than on teaching KT practice to end users. Furthermore, training initiatives that focus on KT practice have not been rigorously evaluated and have focused on assessing short-term outcomes and participant satisfaction only. Thus, there is a need for longitudinal training evaluations that assess the sustainability of training outcomes and contextual factors that may influence outcomes. METHODS: We evaluated the KT training initiative "Foundations in KT" using a mixed-methods longitudinal design. "Foundations in KT" provided training in KT practice and included three tailored in-person workshops, coaching, and an online platform for training materials and knowledge exchange. Two cohorts were included in the study (62 participants, including 46 "Foundations in KT" participants from 16 project teams and 16 decision-maker partners). Participants completed self-report questionnaires, focus groups, and interviews at baseline and at 6, 12, 18, and 24 months after the first workshop. RESULTS: Participant-level outcomes include survey results which indicated that participants' self-efficacy in evidence-based practice (F(1,8.9) = 23.7, p = 0.001, n = 45), KT activities (F(1,23.9) = 43.2, p < 0.001, n = 45), and using evidence to inform practice increased over time (F(1,11.0) = 6.0, p = 0.03, n = 45). Interviews and focus groups illustrated that participants' understanding of and confidence in using KT increased from baseline to 24 months after the workshop. Interviews and focus groups suggested that the training initiative helped participants achieve their KT project objectives, plan their projects, and solve problems over time. Contextual factors include teams with high self-reported organizational capacity and commitment to implement at the start of their project had buy-in from upper management that resulted in secured funding and resources for their project. Training initiative outcomes include participants who applied the KT knowledge and skills they learned to other projects by sharing their knowledge informally with coworkers. Sustained spread of KT practice was observed with five teams at 24 months. CONCLUSIONS: We completed a longitudinal evaluation of a KT training initiative. Positive participant outcomes were sustained until 24 months after the initial workshop. Given the emphasis on implementing evidence and the need to train implementers, these findings are promising for future KT training.

Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity.

BACKGROUND: Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO's Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael's Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these. METHODS: We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers). RESULTS: Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators. CONCLUSION: This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.