Opportunities and Priorities for Dissemination and Implementation Research at the National Cancer Institute

February 14, 2024

Information

Speaker: Gila Neta, PhD, MPP

Wednesday, November 17, 2021

ID11307

To CiteDCA Citation Guide

00:02<v ->We're very delighted to have Gila Neta,</v>
00:07who is a Program Director for Implementation Science
00:12in the Office of the Director
00:13in the Division of Cancer Control and Population Sciences
00:17at the National Cancer Institute.
00:20And Gila has actually been a leader
00:23in stimulating implementation science approaches
00:28to cancer prevention at the NCI for,
00:32I'm not sure how many years, 10 or even 15 years.
00:35And encouraging research in this area, and fixing concepts
00:41and theories of how to approach this sort of work,
00:45and yeah, we just look to her for, in terms of cancer
00:52and implementation science, she is the top person.
00:57So we're thrilled to have her here today.
01:00And we just found out that NCI and NIH people
01:04are allowed to travel, but we weren't able to arrange that
01:08in time for today.
01:09So maybe we'll have her back another time
01:11where we can meet with her in person.
01:13But I just wanted to give a little more information
01:15about her background before turning this over to her.
01:19This talk is sponsored by the Center for Methods
01:22and Implementation and Prevention Science
01:25here at the Yale School of Public Health
01:27and it's co-sponsored
01:28by the Department of Chronic Disease Epidemiology,
01:31led by Judy Liman, the chair, and also by the Yale Scholars
01:36in Implementation Science Career Development Program,
01:39our K12 program, which is actually funded by NHLBI,
01:44but I think there are a number of people involved
01:46who also are interested in cancer prevention and control,
01:50and implementation science perspectives for that.
01:54So Gila is the NCI Scientific lead
01:59for funding announcements
02:00and dissemination implementation research and health,
02:04and assists with research and training activities
02:06related to implementation science across the division.
02:10And she has a secondary appointment within the Epidemiology
02:13and Genomics Research Program
02:15and the Center for Global Health.
02:17And something I know about Gila
02:19that isn't in her biography is, I think she,
02:21you can correct me if I'm wrong, PhD Epidemiologist.
02:25So you came to implementation science through epidemiology,
02:29which is interesting and not the most common path.
02:34Most people come to implementation science
02:36through social sciences,
02:38so it's nice to have a PhD epidemiologist
02:42leading implementation science at NCI.
02:46Dr. Neta's programmatic and research interests
02:49within implementation science include training,
02:52portfolio analysis, the use of the PRECIS criteria
02:56in evaluating pragmatic trials.
02:58Is that the correct pronunciation?
03:01<v ->Yeah, PRECIS.</v>
03:03<v ->PRECIS.</v>
03:03Okay.
03:04I did take French.
03:07And that's something we actually covered in the course
03:09I'm offering this semester on advanced methods
03:12for implementation and prevention science.
03:14Shared decision-making and cancer screening,
03:16economic evaluation, de-implementation,
03:19which we were just discussing on an earlier call
03:23and the use of standardized measurement and reporting.
03:26Dr. Neta's co-chair of the NIH-sponsored Annual Conference
03:30on the Science of Dissemination and Implementation,
03:33which many of us have participated in for many years
03:35and had a very nice representation
03:38from the Yale School of Public Health
03:40and the Yale Medical School.
03:41She also leads the NIH D&I working group,
03:45a trans-NIH initiative providing leadership and vision
03:49for implementation science across the NIH.
03:52Today she'll be talking about opportunities and priorities
03:56for dissemination and implementation research
03:58at the National Cancer Institute.
04:00So Dr. Neta, I'm pleased to turn the mic
04:03and screen over to you.
04:04We're really looking forward to your talk today.
04:07<v ->Great, thank you so much, Donna.</v>
04:09And I should clarify that I don't lead
04:13the NCI Implementation Science.
04:15David Chambers is definitely our fearless leader,
04:17although he does primarily come from mental health.
04:20But I would say NCI as our team,
04:23I'm on a large implementation science team
04:26and we are seen as leaders across the NIH,
04:28which is great because I have fantastic colleagues
04:31and we are truly an interdisciplinary team.
04:33So I do think, Donna, what you said is correct,
04:35that I'm the lead epidemiologist in implementation science
04:39at NCI, in part, 'cause I'm the only epidemiologist
04:44in implementation science.
04:45But it might be worth mentioning how I came to this
04:48as I was, I did my postdoc in radiation epidemiology
04:52and the questions that were most interesting to me
04:54at that time, and that was when papers were coming out
04:57about excess deaths due to unnecessary CT scans.
05:02And so I was really interested in the question
05:04of how do we de-implement, how do we de-implement
05:06this practice of unnecessary CT scans
05:09while I was doing my epidemiologic research
05:12on the risk of thyroid cancer associated
05:16with medical diagnostic radiation.
05:20But what I was really sort of passionate about,
05:22were asking those bigger questions.
05:24So now I'm working with this very transdisciplinary team
05:27at NCI and we consist of health services, researchers,
05:33anthropologists, psychologists.
05:37So it's just a fantastic, MBAs, MPAs.
05:41So, fantastic Team.
05:45One question I wanted to ask before we share the slides,
05:49just to get a sense, and I don't know if it's easy
05:52for people to raise their hands.
05:55I believe raising your hand is an ability,
06:00I'm curious.
06:01<v Donna>If you go down to reactions</v>
06:02and you click on reactions,
06:04and then you'll see raise hand under reactions.
06:08<v ->So I would love it if folks could raise their hand</v>
06:10if you are an epidemiologist.
06:14I'm just curious to get a sense.
06:17Okay, great.
06:18Oh, that's great.
06:19It's even summarizing how many,
06:22so we've got some epidemiologists in the group.
06:25Can I see a show of hands of how many folks
06:28have actually submitted a grant in implementation science?
06:36<v Donna>You have to lower your hand and then re-raise it.</v>
06:39<v ->Yeah, no, I see people lower.</v>
06:41Okay, now lower your hands.
06:42And maybe last question is,
06:50or two, a two-part question, raise your hand if you are new
06:56to implementation science.
07:06Okay, great.
07:07So a significant portion of you,
07:11I'm glad that I anticipated that an introduction
07:15to what implementation science is would be helpful
07:19in addition to describing funding opportunities,
07:23resources, and priorities.
07:25<v Donna>It will be helpful, Dr. Neta.</v>
07:27<v ->Great.</v>
07:28Okay, great.
07:29So with that then, William,
07:31if you don't mind sharing my slides
07:35and as Donna mentioned the title, the official title
07:39of my talk is "Opportunities and Priorities
07:41for Dissemination and Implementation Research
07:43at the National Cancer Institute".
07:46Summarizing that as implementation science
07:48fits cleaner on the slide, but also what I'm going to share
07:52with you, I do sit on the implementation science team,
07:56but we do use dissemination and implementation research
07:59and health sometimes interchangeably
08:01with implementation science.
08:03And as I'll describe a little bit later in my talk
08:06for the purposes of our funding opportunities,
08:09we do think of implementation science
08:11as those two different component parts.
08:14So I'll explain a little bit about that later.
08:17But basically, on the next slide, I just wanna summarize
08:22what I'm hoping to do over the next 50 minutes with you
08:26or 49 minutes with you, which is give you
08:30a brief background on what is implementation science
08:33and why should we care.
08:35Then do what Donna asked me to do,
08:37which is talk about opportunities and priorities
08:39in implementation science at NCI.
08:41So I'm really hoping to wet your appetite in this field
08:44and then hoping that you will reach out to me
08:46or any folks on my team
08:48to take advantage of these opportunities
08:51and where our priorities may align with yours.
08:54Great to explore ways to collaborate
08:59and synergize those efforts.
09:02And then finally, how can you learn more?
09:04So on the next slide, just starting with
09:08what is implementation science and why we should care?
09:12So first wanted to start with just simple definitions
09:15on the next slide, which is distinguishing the difference
09:19between implementation science from implementation practice.
09:23And I think in my,
09:24I guess it's a little more than eight years
09:27that I've been a program director on the team
09:29and speaking with PIs,
09:31I've realized sometimes this distinction
09:34is not always clear upfront.
09:36So implementation practice is simply using interventions
09:39in healthcare and public health settings.
09:41And perhaps, I shouldn't say simply
09:43because that's complicated as well,
09:45but implementation science is focused on studying the use
09:49of those interventions in healthcare
09:51and public health settings and specifically studying methods
09:55and strategies to promote the uptake, the adoption,
09:58and integration of that evidence into practice.
10:03So why should we care about studying those things?
10:06Why do we need to focus on those methods and strategies?
10:09So on the next slide, I highlight an example
10:11that shouldn't come as a surprise to anyone.
10:14I think COVID has really highlighted the importance
10:17of thinking about implementation.
10:19It's not enough to just think about what intervention.
10:22So we saw with COVID that it wasn't enough
10:26to just come up with a vaccine.
10:28While that was phenomenal and I mean just an amazing feat
10:33of science that we had these highly effective vaccines.
10:37As you see on the next slide, and as you well remember,
10:41the rollout was slow and complicated.
10:45Anxiety was growing, shots were slow to reach arms
10:48as those final steps of ensuring vaccine delivery
10:51were left to beleaguered states.
10:54And I think on the next slide,
10:56you'll see that Dr. Ashish Jha, who's now dean
10:59of the Brown University School of Public Health
11:02really nicely articulated the problem.
11:04And that was that the federal government saw their role
11:07as getting vaccines to the states
11:10without considering what support states would need
11:12to get vaccines to the people.
11:14And this type of problem, as you all know,
11:16is not unique to COVID-19.
11:20So on the next slide, you'll see that the promise
11:22of any effective innovation that our science delivers
11:26can only be fully realized through its use
11:28by a range of stakeholders and attending to a range
11:32of different types of barriers held by those stakeholders.
11:35So while the vaccine was highly desired,
11:37there was still a significant portion,
11:39and continues to be a significant portion of the population,
11:42who continues to refuse to take it.
11:44So how do we deliver our innovations most effectively?
11:50Is it, A, not thinking about implementation?
11:53B, thinking about implementation with a plan
11:55informed by intuition?
11:57Or C, having a plan informed
11:59by empirical evidence, the signs of implementation?
12:03So too often we don't focus on thinking about
12:05and generating the necessary evidence
12:07to inform implementation.
12:10And on the next slide, I think this won't be new to you,
12:14but what this slide illustrates is what happens
12:16if we don't also focus on implementation.
12:19And Donna's center highlights this as well, noting this gap.
12:23But what this displays to give you the story
12:27behind that 17 year gap, these are findings of a study
12:31from 2000 by Andrew Balas and Sue Boren
12:34that asked the question, let's assume that the end product
12:37of our research is simply a high-impact publication,
12:40an RCT on the effectiveness of an innovation.
12:43What happens next if we're not thinking about implementation
12:46and not attending to it?
12:48So what you see in the middle of the slide
12:50is the rough publication pathway from publication
12:53of our original research to implementation,
12:56which they defined in this paper as 50% uptake.
13:00So on the left side of the slide you see all the ways
13:02we lose valuable evidence and on the right side
13:05it estimates about how long it takes
13:07to get through each one of these steps.
13:10And on the next slide, you see the punchline
13:12that it takes 17 years for only 14%
13:16of original research to benefit patients.
13:19So it shouldn't be the case that so little
13:20takes so long and that's the time
13:22to reach just half of the people who could benefit.
13:25We need to do a better job.
13:28And on the next slide, just wanted to mention,
13:31Balas and Boren looked at a range
13:32of healthcare interventions,
13:34but specifically for cancer control,
13:36this time lag is not much better,
13:38as you can see from this recent review.
13:43So on the next slide,
13:44and as you saw with the COVID-19 vaccine example,
13:47the problem really goes beyond the strength
13:49of the evidence for effectiveness.
13:51An intervention is going to be only as good as how
13:54and whether it is adopted by the different systems
13:56within different communities and that we can identify
13:59the relevant practitioners who can then be trained
14:02to deliver the intervention.
14:04But we can't stop with training and education.
14:07I've often seen a lot of applications
14:09that are simply focused on training,
14:11thinking education will be enough, but we have a history
14:13and we know this, that training is not enough,
14:15because we have a history of training providers
14:17where there isn't then a way to come back from that training
14:20and incorporate the intervention into routine practice.
14:23So we need to think about the barriers to doing that,
14:26attending to those, and making sure we also consider
14:29the needed supports to ensure that delivery and integration.
14:33And we need to make sure that once those trained providers
14:36are able to deliver the intervention
14:38and have the needed supports,
14:40that they can also reach all those people
14:42who could potentially benefit from it.
14:45So on the next slide,
14:46and I don't believe this is the next slide,
14:49the next slide is, even one more,
14:53even if we get halfway there at each of these steps,
14:56not accounting for issues with access, adherence, dosage,
14:59and maintenance, we are down to just a fraction
15:02of the benefit that we thought we were going to have
15:03with that promising intervention.
15:06And we need to make sure that we don't assume these steps
15:08are going to happen by themselves.
15:12So how can we accelerate the time it takes
15:14for our evidence to be implemented?
15:16On the next slide, you can see here,
15:19on the left side, you see effective interventions
15:22such as vaccines, technologies, and treatments.
15:25On the right side of the slide, you see our goal
15:27to decrease the burden of disease or cancer.
15:30And in the middle, you see some reasons why there's a gap
15:33from the intervention to its intended effect.
15:35It's that challenge of implementation.
15:37So interventions are often underused and overused
15:41and this has been highlighted during the COVID pandemic,
15:43of course, but as similarly true as those of you
15:45in chronic diseases, it being known this is also true
15:48for cancer control measures
15:50and other chronic disease measures.
15:53And some reasons for that implementation gap
15:55include insufficient training, infrastructure, governance,
15:58and policies to provide the needed supports
16:01to deliver interventions.
16:03On the next slide,
16:04you can see that through implementation science
16:08we can understand those implementation barriers,
16:11and develop, and importantly develop and test,
16:14strategies to overcome those barriers.
16:17So on the final slide, on the next slide,
16:20final slide of this picture, if you advance one more,
16:26how do we know if those strategies are working?
16:30As you will find out, here we go.
16:33Those strategies should improve the feasibility
16:36and acceptability of an intervention.
16:39Ensure delivery is cost-effective
16:41and can reach as many people as possible, ensure fidelity
16:45so that the intervention works as it's intended,
16:47that we can see high rates of uptake
16:50and sustain the intervention over time.
16:52So these are really critical outcomes that we seek
16:55to advance through implementation science
16:57and that our strategies are intended to improve,
17:00to ensure that we can promote the adoption and integration
17:04of interventions into practice
17:07by developing and testing strategies
17:09to advance these implementation outcomes,
17:12and generating evidence on these strategies
17:14which can improve our ability to ultimately decrease
17:17the burden of cancer
17:18through effective data-driven implementation.
17:22On the next slide, I just wanted to give you an example
17:24of what this looks like in practice.
17:27And I realize many of you may be interested
17:30in global health.
17:31So I pulled two examples of studies that NCI funded
17:35and that's the example of testing a strategy,
17:39a general strategy, of task shifting to address the barrier
17:43of limited access to cancer control intervention.
17:45So task shifting is a broad strategy to enhance access
17:50through decentralization of care,
17:52and we funded these two studies to test specific types
17:55of task-shifting strategies to increase the uptake
17:58of different cancer control interventions
18:00in two LMIC countries.
18:03So interestingly both found a threefold increase in uptake
18:07with these two different approaches,
18:09suggesting that this strategy of task-shifting
18:12can be broadly effective to address a range
18:14of global cancer control implementation challenges.
18:20So on the next slide, I just wanna clarify
18:22that task shifting is one example,
18:25but there are a whole host of implementation strategies
18:28that have been identified, and tested, and developed,
18:31and studied in the literature,
18:33you see these nine categories,
18:36but these categories were actually grouping,
18:39I think it was about 73 different strategies
18:42that through a systematic review had been identified.
18:48And this paper from Byron Powell et al. in 2015
18:54talks about those 73 strategies
18:56and these different categories.
18:59But just to give you a sense of what these things are,
19:01these include things like strategies to educate
19:03and train practitioners, as I've mentioned,
19:06as well as strategies to ensure that those practitioners
19:09can incorporate the intervention into the workflow
19:13and integrate it into community settings,
19:15providing that interactive or technical assistance,
19:20strategies to support fidelity,
19:23and other supports for clinicians.
19:26Also at the front end,
19:27really ensuring stakeholder buy-in, building relationships
19:31among stakeholders as needed, engaging consumers,
19:35and importantly, financial strategies,
19:39as well as thinking about whether there might be a need
19:41to change the infrastructure to deliver the intervention.
19:45So how would you select these range of strategies?
19:48And in your research proposals, in particular,
19:50it will be really dependent on what barriers
19:55you are seeking to overcome,
19:57what resources you are able to leverage,
19:59and the critical implementers or other stakeholders
20:02who you are seeking to affect.
20:07So on the next slide you'll see in terms of thinking
20:11about who those stakeholders are in implementation science,
20:15we recognize that intervention and innovation delivery
20:19is really context-dependent
20:21and there are a range of multilevel factors
20:23that can influence that.
20:25And so on the next slide,
20:28engaging stakeholders at all of these levels.
20:31So thinking beyond that relationship between a provider
20:33and a consumer, but also taking into account
20:37the organization in which that provider is working,
20:39the community in which that organization exists,
20:42and what higher-level policies may be needed
20:45to put in place in order for those things to be possible.
20:51And when we've historically ignored these levels,
20:53we often leave out populations
20:55who don't have as good access to care.
20:57So this is really critical in thinking about equity as well.
21:00How do we best get organizational change?
21:02How do we best get communities and states
21:04to support implementation of these interventions?
21:08And so it is particularly important to engage stakeholders
21:10at all of these levels to build the evidence base
21:13to support implementation at each of these levels.
21:17So on the next slide, I had mentioned earlier
21:21the distinction, how we define implementation science,
21:25and the component parts of implementation science.
21:29So this is how we think of it at NCI
21:32and these definitions come from
21:33our trans-NIH funding opportunities,
21:36which I'll talk about in a few slides.
21:38But we see implementation science broadly
21:40as bridging the gap between research, and practice,
21:42and policy by building a knowledge base
21:45on how evidence can be most effectively communicated
21:48and integrated into practice.
21:50And so for the purposes of our funding announcements,
21:53we break it down into these two different components
21:56where dissemination research is the study
21:58of the targeted distribution of information
22:01and how best to spread or sustain knowledge and evidence.
22:04Whereas implementation research is focused on
22:06what strategies can best facilitate the adoption
22:10and integration of evidence into a given practice.
22:14So on the next slide, I just wanna break down
22:16a little bit further.
22:17The goal of dissemination research is really to understand
22:20how, when, by whom, and under what circumstances
22:23evidence most effectively spreads focusing on all the stages
22:27of evidence from its creation to its reception.
22:30And these are important steps that we often jump over.
22:34So in the next slide,
22:37focusing more on the implementation research
22:40and what we try to draw contrast from what you typically see
22:44in effectiveness trials, which tend to focus on the what,
22:47what intervention can improve health outcomes?
22:50And most studies assume that if we focus on the what
22:53we will get the answers that we need,
22:55what do we need to do for the these individuals
22:58in this population to improve a range of health outcomes?
23:01But we often jump over, through doing this,
23:04we jump over this important middle
23:06which is seen on the next slide.
23:08And that's the question of how,
23:11how can we ensure those interventions are delivered?
23:14So what are those implementation strategies
23:17that will support our ability
23:19to deliver those interventions?
23:21And you can see here in the implementation outcomes
23:23that I had mentioned earlier,
23:25those outcomes that those strategies
23:27are intended to improve.
23:29And so how do we know those strategies are working,
23:32in implementation science we're really focused on
23:34understanding what strategies, what methods
23:37can improve implementation
23:43and focusing on the implementation of something
23:46that is evidence-based.
23:47So for those of you who are thinking about implementation,
23:52it's very important that this really is the science
23:54of implementing evidence.
23:57It's also increasingly I brought up de-implementation.
24:01We're also interested in thinking about
24:03where it may not be an evidence-based intervention,
24:05but something is being implemented
24:07that is not evidence-based, then you would flip it,
24:09and it would be implementation strategies
24:12to reduce the use of those things.
24:16Just wanted to mention that as an aside
24:18because that is something
24:19that we are also very interested in.
24:22So by focusing here we see this knock on benefit
24:25of improving service outcomes and health outcomes.
24:30So, on the next slide,
24:33just reiterating what we mean by those strategies,
24:36it's really developing and testing,
24:38here are a range of strategies that have been studied
24:42but focusing again on that question of what are the barriers
24:45that you're observing for your evidence-based intervention
24:48or innovation, whatever it is that you're trying
24:50to implement, understanding why it's not being implemented
24:55or perhaps in some cases, you see in certain places
24:58it's being implemented very well
24:59and you wanna understand why that might be,
25:03and then trying to overcome those barriers.
25:06So on the next couple slides I just wanna mention
25:10that in implementation science,
25:13a lot of this work really hinges on theories, frameworks,
25:15and models.
25:16So I'm gonna review just a few.
25:18And the reason why these are valuable
25:20and as an epidemiologist, I was not trained in theories,
25:23frameworks, and models, but I've come to appreciate,
25:25I mean we learned about DAGs, the directed acyclic graphs
25:28because we need some sort of basis to inform
25:32what variables we include in our regression models.
25:37But as Donna mentioned,
25:39this is also very much a social sciences,
25:41behavioral science, and implementation science
25:44is truly a transdisciplinary science,
25:46and I think epidemiologists are a real asset for the field.
25:51But in terms of thinking about,
25:53in terms of developing measurement methods,
25:56but in terms of understanding what are those barriers,
25:58I think that that's where social and behavioral scientists
26:01can really help us.
26:03Through these theories and frameworks
26:05is understanding what are those drivers.
26:08So here you see one of the oldest theories in the field,
26:12Roger's Diffusion of Innovations theory,
26:14which actually comes from agronomy.
26:16And in fact, because implementation science
26:18and health is a relatively new field,
26:21a lot of our theories, and frameworks, and methods
26:24are borrowed from other fields.
26:26And so in this case, what Everett Rogers highlighted
26:30was that what influences our ability to adopt and deliver
26:38is not just the characteristics of the intervention itself
26:41but also the organizational characteristics,
26:44the environmental context.
26:45And those are the types of things that can influence
26:49or impede our ability to adopt and implement something.
26:53So on the next slide, this is the consolidated framework
26:57for implementation research.
26:59Those of you who are less new to the field
27:02I'm sure are very familiar with this.
27:04But this was actually developed in 2009
27:07from Laura Dan Schroeder at the VA and colleagues
27:11where they identified a range of constructs of categories,
27:17which you can see are similar
27:18to what Everett Rogers laid out.
27:20There's the inner setting, and the outer setting,
27:22as well as the intervention characteristics.
27:24And I realize this graph is a little bit confusing
27:26so I'm gonna take a moment to walk through it
27:28'cause I actually think it's popular for a reason.
27:32I think they really do a great job of describing the range
27:36of constructs that can influence our ability to implement.
27:41And a few things that they add
27:44to what Everett Rogers had posited,
27:46as you see on the left side of the slide,
27:49the intervention as unadapted.
27:52And so we think of interventions
27:53as having their core components
27:55and that's what you need to ensure fidelity.
27:58But there's also an adaptable periphery
28:01and on the left side, you see it doesn't quite fit.
28:03There's some white space there.
28:06But this bottom part that they added
28:07is this critical iterative process of planning,
28:12of engaging stakeholders, of implementing and iterating,
28:17of assessing your ability to implement
28:20and testing those strategies.
28:22The hope is that you can get to the right side of the slide
28:25where now you have an adapted intervention
28:28that fits much better into the context
28:31in which it is delivered.
28:32Understanding that both that inner and outer context
28:36are critical.
28:37And what's really nice is there's a whole website
28:39for CFIR that describes all of these constructs
28:43and they're also SIRC,
28:47the Society for Implementation Research Collaboration,
28:50they've created, unfortunately it's behind a paywall,
28:54but there are a whole host of measures
28:56that have been developed, validated,
28:59and tested to measure these constructs as well.
29:02So I think that's one reason
29:03why this is very popular framework.
29:05You don't have to invent these things from scratch.
29:08There are existing tools to measure these constructs
29:11to understand what those barriers are
29:13and perhaps what their relative weights are
29:16to help you decide on
29:17where you can most appropriately intervene.
29:20So on the next slide, last, oh
29:27and I wanted to mention also the re-aim framework,
29:30which is another popular framework in the field.
29:33It's often been used as an evaluation framework,
29:35but I think it nicely highlights what are the key questions
29:37in implementation science.
29:39So beyond the effectiveness,
29:41how do I know my intervention is effective?
29:44It's also focusing on
29:45how do I develop organizational support
29:47to deliver my intervention, the implementation,
29:50how do I ensure the intervention is delivered properly
29:54and that maintenance, how do I incorporate the intervention
29:57so it is delivered over the long term?
30:00And finally, how do I reach the targeted population?
30:02So re-aim is another framework in the field
30:06that was developed for the field
30:08and also has a website with extensive guidance
30:12on the use of this framework and measures.
30:15So on the next slide, I wanted to move now
30:21to what opportunities and priorities
30:24in implementation science at NCI.
30:27So first starting with the trans-NIH funding opportunities
30:31that NCI leads on the next slide.
30:35And so these are called the Dissemination
30:37and Implementation Research in Health,
30:40PAR, that's program announcement with review.
30:43So that R is that dedicated study section.
30:46If folks were here at the very beginning of the call
30:49when Melinda and I were talking about review committees.
30:52So applications submitted to these funding opportunities
30:56which do include 22 institute centers
30:59and offices across the NIH
31:01participate in these funding opportunities.
31:04I believe I can share with you that while they will,
31:07the current versions that are published expire in May, 2022,
31:11you can expect that those will be renewed.
31:14So those will continue.
31:16And to date, we've funded well over 300 grants
31:19across the NIH just in the last decade
31:23through these funding opportunities.
31:25And that review committee I mentioned,
31:27it used to be called DIRH, our Center for Scientific Review
31:32at the NIH recently went through a process
31:36of reviewing the study sections
31:38and coming up with new study sections
31:40or revising somewhat how the study sections are
31:43to stay up to date with the science.
31:45And this is a process CSR goes through periodically.
31:48So now DIRH has become SIHH,
31:52which stands for the Science of Implementation
31:54in Health and Healthcare.
31:56There are an additional four review committees
31:59that were newly created that have overlapping interest
32:03with implementation science,
32:05which basically means just additional expertise.
32:08So if you submit through these funding opportunities,
32:11but for some reason, it is not assigned to SIHH,
32:15there can be a few reasons why that might happen.
32:17Feel free to reach out to me
32:18and we can talk about that another time.
32:22But all of these committees should have the capacity
32:26to review implementation science grants.
32:28And just also as a side note, for those of you familiar
32:31with the review committee, SIHH is almost entirely
32:34the same members as DIRH, the chair is the same.
32:37So it has been a pretty seamless transition.
32:41On the next slide, for those of you unfamiliar
32:46with these funding opportunities, I did want to highlight
32:49what the purpose of these are,
32:51which is to support innovative approaches to identifying,
32:55understanding, and developing strategies
32:58for overcoming barriers to the adoption, adaptation,
33:02integration, scale-up, and sustainability
33:04of evidence-based interventions.
33:06And I had mentioned earlier
33:08also an interest in de-implementation.
33:10So conversely, as we recognize there's a benefit
33:14in understanding circumstances that create a need to stop
33:17or reduce the use of interventions that are ineffective,
33:20unproven, low value, or harmful.
33:23And these funding opportunities,
33:24in addition to studying those strategies to implement
33:27or de-implement, we also seek studies that advance methods
33:33in our field as well as measures.
33:37So on the next slide, I just wanted to give you
33:40some example research questions
33:42from the funding opportunities, but I do encourage you
33:44to take a look at these funding opportunities
33:47and take a look again after, at the end of February
33:52when we hope that they will be reissued.
33:54So you can see slightly updated version of these,
33:57but essentially, these are focused on understanding
34:01what factors influence the creation, packaging, transmission
34:04and reception of valid health research knowledge.
34:07That's the dissemination research questions
34:10as well as understanding how do we adapt our interventions
34:13to best fit within specific contexts or settings,
34:17what strategies best support uptake in sustainability,
34:20also strategies to ensure scale-up and sustainability.
34:25And then finally, that de-implementation question.
34:29So on the next slide I just wanted to very briefly mention
34:33that there are, on our website,
34:37which I'll show you at the end,
34:39we do have examples of sample grant applications
34:42that have been successfully funded through these.
34:45And this is one of the most popular websites on our website
34:54because it's nice, not only do you have the abstract
34:58which anyone can access in reporter,
34:59but we had about a dozen investigators
35:03generously agree to have their full application,
35:06the research strategy, and specific aims
35:09also made available publicly.
35:11So you can see here and on the next slide
35:13a range of sample grants that are available
35:18and that really are spanning a range of different topics
35:22from healthcare, public health, sustainability,
35:28de-implementation, both in global and domestic settings.
35:34So on the next slide, in terms of priorities,
35:37just generally, I would like to mention for those of you
35:40who aren't aware, well, NCI is the one institute at NIH
35:45that has a separate congressional line item since,
35:49and our director is a presidential appointee.
35:54And so because of that we do submit each year an annual plan
35:58and budget proposal to Congress that needs to be approved.
36:01And so for this fiscal year that just ended,
36:06implementation science was recognized as a key priority area
36:10by the NCI.
36:13And on the next slide, you can see,
36:15and I think this really launched interest
36:17across the divisions and centers within the NCI
36:22and so our NCI Center for Global Health,
36:26they recently hired a new director
36:30and released this new strategic plan for the next four years
36:34where implementation science was also highlighted
36:37as a key priority area.
36:39So on the next slide, I just wanted to mention this,
36:43this is a real opportunity as we are thinking across the NIH
36:47and NCI of the importance of addressing inequities.
36:51And here the simple graph from the WHO really highlights
36:55how those global inequities in cancer control.
36:59And so on the next slide you can see, oh,
37:04and so just as an aside, this was a systematic review
37:09not just in cancer but across a range of health issues
37:12focusing on studies that have been published
37:17on implementing health interventions in LMICs.
37:19And these weren't implementation studies necessarily,
37:22these were just all studies in literature
37:25where they were looking at health interventions in LMICs.
37:28And what was interesting about this review
37:32is that relatively few, painfully few, only 14 studies,
37:38if you look at that smallest circle at the bottom,
37:40actually measured implementation outcomes.
37:43So really we saw this as a huge missed opportunity
37:48to be studying implementation in the context
37:51of global cancer control.
37:54And so on the next slide you can see that
37:59the Center for Global Health
38:01has issued two funding opportunities.
38:04One is a Notice of Special Interest for Dissemination
38:07and Implementation Science in Low Resource Environments.
38:12And those are, NOSIs are Notices of Special Interests
38:18that are tied to an existing funding opportunity.
38:21So in this case, these are tied to those dissemination
38:24and implementation research
38:25and health program announcements.
38:28And then most recently, the Center for Global Health
38:32issued a UO1 Clinical Trial Optional, Implementation Science
38:38for Cancer Control in People Living with HIV
38:41in Low and Middle-Income Countries.
38:43So given that Center for Global Health,
38:47one of their main strategic goals
38:48is to advance implementation science and cancer control
38:52in Low and Middle-Income countries,
38:54I would stay tuned for additional funding opportunities
38:58that may come out.
39:00And I'm happy to talk about any of these as well.
39:04So on the next slide I wanted to mention
39:07in addition to global and global is a part of this,
39:11the NCI launched a consortium
39:14for cancer implementation science
39:16and I remember one of your colleagues,
39:18Steve Bernstein was at that initial launch meeting.
39:23And so this was a consortium of implementation scientists
39:26and cancer control researchers identifying
39:29key areas that the field could really advance
39:35and we could all benefit from advancing those areas.
39:38So you can see here the CCIS development of public goods
39:44on the bottom left of the slide.
39:47And on the next slide, you can see examples
39:51of what those different areas were.
39:55So one was focused on enhancing community participation
39:59and more broadly, stakeholder engagement.
40:02One is focused on advancing economic evaluation
40:06and really understanding not just the cost-effectiveness
40:09of the intervention but the cost of the strategies
40:12and how do we measure those costs.
40:14And there are relatively few good measures for that.
40:19In fact, none to date have been validated measures
40:23of implementation costs.
40:24So there's been a thriving community of economists,
40:29healthcare, health service researchers,
40:31and implementation scientists working together
40:33to try to develop guidance for the field on doing that.
40:36Also a focus on policy implementation science
40:40and context and equity.
40:42And as you can see in the small print,
40:43additional areas that were identified as key priorities
40:48where those public goods are forthcoming.
40:51So if you were to click on those pluses
40:53by each of those four areas I mentioned,
40:57on the next slide you can see for example
41:00with the economics and costs group, there is a link
41:05to a new collection of papers that was just published
41:09in BMC, and it's a collection
41:12because it's not only in one journal
41:14but it's across several BMC journals.
41:16So implementation science
41:17and implementation science communications.
41:21And these are a series of papers that are providing
41:23that guidance I had mentioned around measuring cost
41:26in implementation science.
41:28On the next slide you can see resources for stakeholder
41:33and community engagement.
41:34There's a whole list on the next,
41:41I think somebody is not on mute,
41:43but I'm almost done.
41:51The next slide.
41:53<v Donna>Gila, can you mute everybody?</v>
42:05<v ->Oh, I see Amaka joined who I know from Aortic.</v>
42:12So on the next slide, that community engagement
42:16and stakeholder engagement, if you go one more, William,
42:20you'll see that that group created this phenomenal resource
42:26on stakeholder, and community engagement literature,
42:30and best practices and measures of doing that.
42:32So on the next slide, you can see
42:36what are the contents of that resource.
42:39Key readings focused on health equity
42:42and community engagement in implementation science,
42:44the rationale for doing it,
42:46frameworks for doing it, and assessing, and measuring it.
42:51And so that's a really rich guide
42:54if you're interested in focusing on that aspect.
42:58On the next slide,
43:01this gets to the policy implementation science
43:03and I did see that there may be several of you
43:08or many of you who are really interested
43:10in advancing policy implementation science.
43:13And so there was this recent commentary
43:17addressing that in particular
43:20as a way to address social determinants of health.
43:22We also had Karen Emmonds from Harvard come and work with us
43:28over the last two years to really build out this area.
43:31And one of the things that she did
43:34was help curate this fantastic series of webinars.
43:38I think there were six in total, here are four of them,
43:41they've all been archived.
43:42So something that you may be interested in exploring.
43:49And so those are just some of the key priority areas
43:52that I wanted to mention.
43:54But then finally, where can you learn more?
43:58So on the next slide, and the next slide after that.
44:04So in addition to those policy webinars,
44:07we do have a whole host of webinars,
44:09two different webinar series.
44:11All of these webinars are archived.
44:13Some of those include, from years past,
44:17a focus on different methodologies, measurement,
44:22the use of frameworks.
44:23And upcoming our next webinar at the end of November
44:28is focused again on economic evaluation
44:31because of that recent publication of those collection
44:34of papers which continues to grow.
44:36Right now we have two published in that collection,
44:39two forthcoming any day now, and an additional six
44:45that are forthcoming in the coming months.
44:49And so in addition to the webinars, I did wanna mention
44:52for those of you new to implementation science
44:55and hopefully, I've convinced you
44:57that you may wanna learn more, on the next slide,
45:01you can see that NCI has been hosting a training institute
45:05in implementation science.
45:08And here you can see the main modules
45:10for this training institute.
45:12It historically had been an institute
45:15where initially was a residential program,
45:18five-day intensive residential program.
45:21Then we moved to a hybrid model
45:23where we would do three months online
45:26where people could just integrate it
45:28into their everyday lives but then a two-person
45:31in day meeting.
45:33And now with COVID, it's been completely virtual
45:36but also it has been a highly competitive program
45:40and we've wanted to be able to train more people
45:43than we can necessarily accommodate at our NCI offices.
45:47So we have made it open-access
45:49and all the modules now are available
45:51as well as the readings.
45:53The one thing that you don't get from the open-access
45:57and during those three months of the online
46:02you get feedback from faculty on your proposal.
46:07So it's really an opportunity to develop a proposal
46:10through this training program.
46:13But thankfully you have a whole team at NCI
46:17and program directors across the NCI and NIH
46:21who can help you as you're developing your proposal.
46:24So I would encourage you as you are developing proposals
46:28for implementation science or if you are
46:31and when you are to reach out
46:32to program staff often and early.
46:35So on the next slide, I did just wanna mention
46:38at least for NCI, on the next slide,
46:42we do have a pretty user-friendly search function
46:47where you can look through at the division of cancer control
46:51and population sciences grant opportunities,
46:54we have a filter where implementation science
46:56is one of those filters.
46:58So in addition to the funding opportunities I mentioned,
47:01you can see which other funding opportunities might exist
47:05that could align with the specific topics
47:07that you're focused on.
47:08We do have one for example,
47:10that's specifically on de-implementation in cancer screening
47:14for the overuse of screening.
47:16And lastly, on the last slide, I just wanted to leave you
47:21with a link to our team's website and to remind you
47:23that I am just one of a fantastic group of folks at the NCI
47:29on the implementation science team.
47:31You can see there in the back left is David Chambers,
47:36our director for implementation science,
47:39as well as Wynne Norton, April Oh, Cindy Vincent
47:43who are other critical members of our team.
47:49So thanks, I hope that was helpful.
47:51And I was hoping we'd have at least 10 minutes
47:53for questions.
47:54So I hope, Donna, we can use some of that time
47:57for questions if folks have questions.
48:03<v ->Yeah, so perfect timing</v>
48:08and it's great to see the overview
48:12and it's so interesting that some of the slides
48:15that you have shown, I also show in my class
48:18and I'm guessing Luke Davis
48:19who teaches our implementation science course here
48:23probably uses some of these slides.
48:24So there's so much common knowledge
48:26and kind of perspective that I think we all share.
48:29I see that Luke Davis has his hand up.
48:31He is an implementation scientist focusing primarily
48:36on HIV and tuberculosis,
48:39particularly from the global health perspective.
48:41And he's an associate faculty member of our center.
48:45So Luke, what are your questions and comments?
48:49<v ->Thank you, Donna, and thank you Gila for a great talk.</v>
48:52Donna's right, I really do enjoy your slides
48:54and a lot of the materials that you, and David,
48:56and others have put together, they've been very helpful
48:58in setting up our implementation science course
49:00here at Yale.
49:02As Donna mentioned,
49:03I'm primarily a global health researcher,
49:04but I wanted to ask you a general question
49:06about grant strategy 'cause this is something
49:08that's come up in my own work
49:09and also in talking with other colleagues here at Yale
49:12who are interested in putting in proposals
49:14and I think the issue that arises
49:17is that often one of the most common critiques, I think,
49:20of any type of grant is that there's an interdependence
49:22of the aims and in implementation science,
49:24I think it's very common
49:26that you may be thinking of adapting
49:28or scaling-up intervention or an implementation strategy
49:32in a new setting
49:33and you don't yet have the intervention adapted.
49:37And so often maybe aim one might be to adapt it
49:40and aim two might be to evaluate it.
49:41And that leads commonly to a critique
49:43that the two aims are interdependent.
49:45And I'm just curious how you would respond to that
49:48from an implementation science perspective.
49:50And then more practically when you're in that type
49:52of situation, are you better off, say, pursuing an R21
49:55and doing the adaptation in one grant,
49:59and then pursuing the evaluation in another.
50:01Thanks so much.
50:02Really enjoyed your talk.
50:04<v ->Very important question, Luke.</v>
50:07<v ->Yes, excellent question</v>
50:08and not the first time I've been asked.
50:11Yeah, no, it's a great question.
50:13I guess the first thing,
50:15well, there's several first reactions I have to that
50:18and one is, I think that one of the struggles is making sure
50:24for each aim they have to have their own hypothesis.
50:29They are each individual scientific aim.
50:31So is it enough to just say you wanna adapt
50:34the intervention in your aim?
50:35I think part of it is understanding
50:37what are the most effective ways
50:39and you may hypothesize an effective way to adapt it.
50:42So the use of different methods to do that
50:45I think could be the focus.
50:47But I think what we've seen more in terms of the challenge
50:52of that interdependence has been where the first aim
50:55is trying to understand the barriers
50:58and you don't know then whether those barriers will be ones
51:02that can be overcome for example,
51:04or how that would influence your strategy.
51:07So I think we often encourage investigators
51:11to already have a clear sense
51:13or already have a reasonably clear sense
51:16of what the likely barriers might be.
51:18But also given that implementation sciences really focused
51:21on understanding context,
51:23we understand that that's also a significant aspect
51:27of the study.
51:28So I think, if you go through those sample grants,
51:33you'll see that, I think this is a nuanced challenge
51:38because many of our grants that aim one, it does have to do
51:41with adaptation or understanding barriers and context.
51:44And I think part of it is how it is framed,
51:47and how you can justify that this is needed,
51:52and it will not, I think it's needed
51:56because it's needed to make sure that you're tailoring
52:01those strategies, that they are attentive.
52:04But it's true that the more
52:06you can have some preliminary evidence on the feasibility
52:10and acceptability of those strategies,
52:13and some preliminary evidence on those barriers
52:15would be critical.
52:16And I think that gets to your second question
52:18of whether you go for the R21 or the R01.
52:22I can't tell you how much preliminary evidence you need.
52:25That is a tough one.
52:27The answer is always, it depends,
52:30but I think for a particular study,
52:32and I think that those are the conversations
52:34that presumably program directors,
52:36program officers can help you figure out
52:41as you're developing those aims pages.
52:47<v Donna>Great.</v>
52:48<v ->I hope that's helpful.</v>
52:49Yeah, glad to talk more about that offline.
52:50<v Luke>Yeah.</v>
52:51Great.
52:52Thank you.
52:53<v ->Does anybody else in our audience have a question</v>
52:57or comment they'd like to make?
53:01Okay, well, Gila, I was wondering,
53:06I'm kind of interested and I keep encouraging colleagues
53:09that I work with to think about integrated approaches
53:13to health promotion that might, let's say for example,
53:17there's the PEN guidelines from WHO
53:21for chronic disease prevention and control.
53:24And it addresses the controllable cancers,
53:27it addresses cardiometabolic diseases,
53:30and I think it includes mental health disorders that have,
53:34all of which have well-known evidence-based interventions
53:38that probably need to be adapted to different contexts.
53:41By the way, I should mention,
53:42we do have quite a bit of global reach in our center
53:45and there's people on this call from, at least from Nigeria
53:49I can see, and also from Mexico.
53:52So anyway, but then we have the problem with NIH
53:56that a proposal has to be cancer
53:59or it has to be mental health
54:01or it has to be cardiovascular disease
54:04when really probably the most sustainable,
54:07when once somebody's in a center
54:09or once a community health worker
54:10is going to somebody's home,
54:12why would they only focus on HPV vaccination
54:16or taking a TB test,
54:19it just isn't really the best thing for public health.
54:21And how do you suggest that we address that
54:24in terms of developing interventions
54:27that are really integrated?
54:31<v ->That's a visionary question.</v>
54:34I think it's the next horizon and I can say,
54:37I know this is an area
54:38that David Chambers has been really pushing this concept of
54:42how do we best bundle our margins?
54:44And I think that's really critical,
54:46especially, in global contexts, but oh yeah,
54:51and I see that perhaps some of your tighter alum
54:58can speak to that as well.
55:01But no, I think absolutely that is really critical
55:04and I think that is an area
55:06that we are hoping to see advance.
55:10<v ->But right now it isn't really an option.</v>
55:13Do you agree?
55:14For example, I'm a methodologist, so I work in cancer,
55:18but I also work on HIV AIDS, and other areas,
55:22and we're involved in implementation science work
55:25in ending the AIDS epidemic domestically.
55:27And we have a core, a technical support core,
55:31for implementation science methods across the range
55:34of qualitative, quantitative, and health economics.
55:37Anyway, when we had our renewal, they wanted an innovation.
55:41And so I suggested maybe thinking about integration
55:45of HIV prevention and control with say some other issues
55:52that people are facing.
55:53And so because this particular core, and overall project,
55:58and consortium is funded by NIMH and NIAD,
56:02they said we could only integrate with substance abuse
56:05and mental health.
56:07<v ->Well, actually-</v>
56:08<v ->Not in diabetes or obesity or cancer screening,</v>
56:11that was like off the table.
56:14<v ->Well, that is one challenge</v>
56:16sometimes people bring up depending on the institute.
56:18But you said the Center for Global Health
56:21recently released as you know the U01
56:24that's focused on cancer control
56:25and populations living with HIV.
56:27And so there, I think that opportunity,
56:31that funding announcement, I think bundling is identified
56:35as one of the key questions there
56:37and how do you integrate it with HIV care,
56:40how can you cancer control of HIV care.
56:43<v ->Yeah.</v>
56:47Great.
56:50So any other comments?
56:53We're a minute away from the hour.
56:57Okay.
56:58Well, thank you all for tuning in
57:01and continuing with your work in implementation science
57:05here at Yale and elsewhere.
57:06And thank you, Dr. Neta, for such an interesting
57:09and informative talk.
57:11So have a great rest of your day everybody.
57:14<v ->Thank you for inviting me</v>
57:15and thank you to William for advancing my slides.
57:16<v Luke>Bye.</v>
57:19<v Donna>Bye-bye.</v>
57:20<v Gila>Thanks, bye.</v>