Developing an Implementation Research Program for Quality and Equity: Exploring the Context, Adaptation, and Measurement Challenges of Maternal and Child Health Implementation Research in Rural Nepal

Abstract

Implementation research is an emerging multidisciplinary field of study that aims to facilitate the adoption of evidence-based practices and programming to reduce the wide gap between what we know and what we deliver in real-world settings. This gap exists globally, but is particularly deadly in resource-limited areas due to ineffective healthcare and research systems. Here, I present a developing an implementation research program embedded within a growing public-private healthcare system in rural Nepal and discuss the challenges of adaptation and measurement within this framework.

I ground this discussion in the context of maternal and child health and present a quasi-experimental study of the impact of surgical obstetric care expansion on institutional birth, which informed the development of a hybrid (type I) effectiveness-implementation research study on group antenatal care. The adaptation of this intervention during the trial presented significant challenges, and a key lesson that reflection on the dynamics between research and practice may facilitate stronger implementation climates, particularly with respect to hybrid trials. Finally, in developing the data capacity to measure effectiveness, we confronted a dearth of methodological approaches to measure child mortality in our small population. I thus present an argument for under-two mortality as a more reliable and relevant measure than the typical under-five mortality indicator; and in our experience, one that can be feasibly measured through census-based methods. Through iterative adaptation of these methods, we have arrived at a continuous surveillance approach to measure this and other population health indicators prospectively in real-time.

Together these pieces represent progress towards the key building blocks of (1) contextual research, (2) mutually adaptive research and implementation approaches, and (3) robust and dynamic measurement systems for this nascent implementation research program.