>> Please note, today's session is being recorded.
If you have any objections, you may disconnect at this time.
Thank you very much, and on behalf of the National Cancer Institute, I wish to welcome
everyone to the September Advanced Topic - Implementations Science Webinar.
Today, we are delighted to welcome by Doctors Vinson, Sturke, and Gordon, joined by our
own David Chambers to this campfire session.
A brief word about logistics and we'll be off.
The access you're not already on [inaudible] is to keep your phone on mute for the duration
of today's presentation.
As mentioned, this session is being recorded, and muting all lines will help us to avoid
any background noise.
Captions are available for today's session.
You can follow the link to be directed to those captions.
That is available in the chat section on the right-hand side of your screen.
We encourage questions.
They can be submitted at any time using the Q and A feature on the right-hand side of
your screen.
Please type your question in the provided Q and A field and hit submit.
Feel free to submit your questions at any time during the session.
We will be moving through them.
We will start with some prepared questions for our guests.
With that, I will turn it over to David.
>> Thank you, Sara [assumed spelling], as always, and there you see some smiling faces
that you will not be seeing moving over the next hour, but you will -- these are the folks
who you'll be hearing from.
And this is a great opportunity for us to really delve a little bit deeper into ways
in which we can advance global implementation science.
It's part of our campfire slash fire slash fireside chat series, which we started last
year, which has been an opportunity to hear from leaders in the field about topics that
are of increasing interest in areas that we really want to advance within the broader
domain of implementation science or for others engaged in this dissemination and implementation
research or even for others knowledge translation, etcetera.
And so, the campfire chat and of course, even though we're in September, at least in the
D.C. area, it happens to be something like 88 degrees Fahrenheit, which would probably
be about 25 or something Celsius [inaudible] 27.
It is, the way in which we do these things is to try and have as much dialogue, as much
of a chance to hear from and learn from leaders and how they got into the field, what they
think about the particular topic, and how it should be advanced.
But equally important to hear from all of you.
What are the questions that you have?
What are the things that would be helpful to ask our esteemed guests to concentrate
on in the area of global implementation science?
So, as Sara had said, we're going to start out with a few more introductory questions.
We have a number of questions prepared at the same time, we are monitoring that Q and
A box, so that as you start to join the conversation, I'll be relaying the questions that you're
typing in to our various speakers, and we would love to have any and all questions and
comments for the folks to respond to.
So, I am, as you can see here, very happy to be joined by Cindy Vinson, Senior Advisor
for Implementation Science, within our division here at the National Cancer Institute.
Rachel Sturke, who leads implementation science activities for the Fogarty International Center,
and Chris Gordon who has done a lot of wonderful work trying to advance implementation science
in HIV and the interface between HIV and the behavioral health aspects of it.
He is a branch chief within the division of AIDS research at the National Institute of
Mental Health, where I used to work.
I've known each of them for a fair amount of time.
I would love to go into the interesting anecdotes, but we'll save that for footnotes to the session
about how I know them.
So, I just want to say it's wonderful to have each of them with us.
And rather than taking any more time for the intro, I want to dive right in and start with,
and there you see our first lovely campfire.
So, grab your S'mores, grab your hot chocolate, and join us by the fire.
I wanted to start with, first, Cindy, and then Chris, and then Rachel.
For each of you to take a few minutes to talk about what was it that got you into the field
of implementation science.
What, as you saw when you were entering the field, was the state of the science?
And then, maybe we'll stop there, and later we'll get on to your perspectives in turn
about how you've seen the field change.
So, why don't we just start, Cindy and then Chris, and then Rachel.
What was it that inspired you to work in implementation science, and what was the field like when
you first entered it?
Cindy, you want to start us off?
>> Sure, thanks, David.
Appreciate the opportunity to talk about one of my favorite subjects.
How implementation has kind of evolved over time.
I joined the implementation group here at NCI in 2001.
It wasn't called implementation science back then, and I kind of stumbled into it, because
it was a new office that was opening up here at NCI, and at the time it was the Office
of Diffusion, Dissemination, and Implementation.
And I think I kind of came in to this area because I had a background in international
development.
I had worked overseas in a health care center.
And I was tasked as a Peace Corps volunteer at the time with trying to figure out how
to move research into practice, and after working at NCI for a couple of years, understood
that what I thought I was doing in moving research into practice as a healthcare volunteer
was really essentially just making things up based on what I was reading, but not necessarily
doing it in any systematic manner.
So, when this office opened up and there was an opportunity to start helping to develop
the field, I felt really privileged to be one of the first hires in the office.
And when I first started, like I said, this office was brand new, and there were a lot
of scratching heads when we would initially go out to talk to leaders at NCI and around
the country, around why there was even a need for this.
Some people got it, but frequently people thought that our Office of Dissemination,
Diffusion, and Implementation -- I even got that wrong because it's been so long -- they
thought that we were a communication arm of NCI and that it wasn't necessarily a scientific
field that we were working in.
So, I'll stop there.
I think there's more we can learn from Rachel and Chris.
>> Great.
Chris, do you want to go next?
>> Sure.
Thanks everybody for joining us today.
And I'll say this, the hour's going to go quickly and so, for sure, if anybody has any
questions about any of the stuff that we'll touch on today, please reach out to me anytime,
and we can talk in more detail.
So, you know, and I'll be quick and short.
I got into this field because of one, it got me out of the office, and two, it's exciting
intellectually.
And so, I feel that when I talk to people working in the field, so let me touch on the
first part, which is getting out of the office.
I'm a psychologist by training, and so for those of you who aren't implementation scientists
by training, and that's most of us, and so, you know, thinking about problems and trying
to help the public with public health, I started out thinking about individual patients.
And so, as I got working more in the field of HIV treatment and [inaudible] and as we
had HIV treatments available, and that's the lens I'll be talking about my experience,
it got me talking to people in the community.
And it wasn't just providers, it wasn't just hospital administrators, it was community
members and patients.
And so, it really felt like a way to tie things together that our research was really moving
into the field and making a difference.
And so, intellectually, it's exciting because it helps us to answer questions that are really
complicated.
And that's what real life is, and that's what science should adapt to, that the work that
we do doesn't make a difference unless it's put into a context of where people are living
their real lives.
So, that's how I got into it.
>> Great.
Rachel?
>> Yes, sure.
This is, it's really a privilege to be here.
I'm excited to engage in this discussion.
So, I guess I got into this field.
I joined Fogarty's policy division in 2007, and that was sort of just when we, Fogarty,
was coming to terms with the importance of implementation science in the context of global
health and right before we highlighted it as a goal in our strategic plan.
So, I sort of came in right as we were sort of expanding this area of focus.
My training is in global reproductive health.
So, not implementation science, but I had always been really interested in more downstream
research, and really the interface between research and practice and thinking about issues
around context.
I was, studied anthropology as well, and so I was always sort of at that end of the spectrum.
And I think, if you think about implementation science as sort of how you imbed an inspective
intervention into a setting, this can be really complex in the context of a low-income country
health system, where delivery very often can be occurring at the community and school levels,
or in an understaffed or fragile health system setting.
And so, I think over the last 10 years, I think we, as a community, a global health
community, have grown to realize that implementation science is really critical to tackling our
most intractable global health challenges.
And so much so, that some of our board members even talk about implementation science as
the signature science for global health.
So, I think it sort of taps into a personal, professional interest for me, and I have been
sort of riding the wave here at Fogarty as well.
So, I'll stop there.
>> Great.
So, thanks to each of you, and I think each of you now from the brief comments that you
made, it's clear that you've been asked this for a while.
And so I wonder if each of you, and starting with Chris and then, and then Rachel and then
Cindy, could talk a little bit about how you've seen the field change over the years that
you've been working in it.
Chris, can you start us with that?
>> Sure.
Well, one thing for sure is that it's become clear since I've been doing this at NIH for,
oh I'd say, probably 10 to 12 years, really, fostering this area.
For those who are trying to making this a career path, one of the ways I think the field
has changed.
And by the field, I mean all aspects, I mean institutions, I mean NIH itself as an institution.
I think the scientific community, I think it's, whereas five to seven years ago, if
someone was coming in as an early career person, I might have cautioned them about the challenges
of making this a career path.
So, some of you might be familiar with the K mechanism of securing NIH funding for training.
And if someone was coming in that was junior, I would say, boy, it's going to be really
challenging.
Everything takes more time, and you, it might be, you're working with systems and different
settings as opposed to individual patients, but the way it's changed for us now is that
we encourage early career investigators to pursue this as a line of research that they
can make a career in, as Rachel was saying, in many ways, and again, especially in the
area of HIV, AIDS, we have a number prevention and treatment tools and taking them to scale
and learning how to do better effectively and efficiently in a wide variety of settings,
has really become the coin of the realm.
And so, I have now perhaps 15 Ks in my portfolio of work that I oversea, as opposed to a handful.
And so, clearly, I think that collectively is a field, this is an area, that is both
seeing increased attention, and the field is excited to get into this area.
Maybe for some for the same reasons that we cited.
I'll say one other piece about the science that has evolved, and that's the rigor.
I think that as, you know, HIV is a relative newcomer to the field, as opposed to work
in mental health or cancer or heart disease, where implementation science had been an established
field for a longer time, at least in the area of HIV, this science has become more rigorous.
And developing the theory and the methods is just as important as sort of, quote unquote,
making a difference in terms of public health.
So, it's not just simply enough to implement interventions in places where they haven't
been done before.
That's important to do, of course, and so, you know, if we haven't done good self-HIV
testing in Tanzania, it's terrific to want to do it there, but it also has to advance
the science as a whole.
And so, advancing the theory, methods, and measurement in implementation science and
the rigor has been increasing.
I'll stop there.
>> Yes, thanks.
Rachel, can you pick up on that too?
How have you seen, over the, you talked about how 2007 was sort of a starting point for
you.
Can you talk a little bit about over the last decade, how you've seen the field change?
>> Yes, sure.
So, right, so as I mentioned, in our 2008 strategic plan advancing and supporting implementation
plans was a goal.
I would say that, at that time and I think for many years after, it sort of felt like
a bit of an uphill battle here at NIH and certainly within Fogarty, in terms of credibility,
or sort of valuing implementation science as a credible science.
So, I think it took a very long time for us to evolve to a place where it really is a
critical priority that we value in each of our programs.
I think there are also, sort of, structural challenges 10 years ago and even sooner, where
we, there weren't a lot of funding opportunities that were explicitly targeted at implementation
science, which I think is indicative of the fact that it wasn't necessarily valued here
institutionally as a, sort of, credible science fully.
I think we also didn't have, for example, a stand-alone review committee of people who
were able and capacitated to understand and review implementation science itself.
So, I think that there have been changes that sort of incentivized the research.
I think that the fact that there is now a journal that focuses on implementation science,
it is critical, because you need a place to publish your work if you're going to advance
in science.
And so, those are all things that I think that have helped move the field forward.
I do think that the capacity in low-income country settings is lagging, and I think there
are ways that some of the opportunities that are made available here at NIH are more challenging
to tap into from a low-income country setting.
For example, so I think there's more work and targeted work to be done around building
a critical mass of researchers in low-income countries who can mentor each other and collaborate
and, sort of, build the science there.
But I do think that that's happening and there are more targeted training opportunities,
and so it's a slow road, but I think that we're moving in the right direction.
So, I'll stop there, I could go on, but I'll stop.
>> Thanks for that.
Cindy?
Same question, how have you seen the field change over the years?
>> So, thank you.
I agree with both Rachel and Chris on how the field has evolved over time.
One of the things that I've noticed since the early stages, you know, back in the 2001
era, when we first launched the funding opportunities and dissemination and implementation research,
the quality of the applications coming in has significantly changed and improved.
I know, originally, a lot of the applications that were coming in were really trying to
understand adaptation and how to move an evidence-based intervention from one population to another,
or from one setting to another.
I think the questions that are being asked in implementation science have matured.
We're looking more at understanding the system-level issues, looking at context and complexity.
The study designs that we're using have evolved over time.
And, you know, I think also the resources that we have, when we started out in this
area, people kind of figured that we were just going to be able to move research into
practice naturally, that it was going to occur without any incentives.
But now, we do have, you know, as Rachel and Chris have talked about, a great recognition
at NIH, that implementation science is important.
The blue-ribbon panel from NCI that came out of the moon shop, one of our areas, focuses
on implementation science, which is amazing to me to see that be a focus across NCI.
The [inaudible] section and the trainings that have been put into place, and also the
collaboration across NIH, the fact that there are more institutes that are involved in the
funding opportunities that have their own funding opportunities in dissemination implementation
research.
But there's also a number of training opportunities that are available, both nationally, but also
include international components.
So our international training institute for dissemination and implementation research
and health, and open to international applicants, and we've seen international applications
for that training institute really grow, and the qualifications of the international applicants
to compete with U.S. applicants to improve.
And we've also, while we don't see a significant number of international applicants yet being
successful, is the big trans-NIH dissemination and implementation funding opportunities,
we have seen applicants that have been successful from low and middle income countries.
And, Solvina Irosee [assumed spelling] from Argentina is an example of a person who is
a trainee from Tigre who was able to successfully compete for an RO1 at NIH, which 10 years
ago, I don't think would have been possible.
>> Great.
Thanks so much, and where you left off, Cindy, I think is the perfect place for us to continue.
Each of you has talked a little bit more generally about the field, and of course, the point
of this particular campfire chat is to focus a bit more on the global space.
I do, before getting to the next question, want to encourage, and I'm already seeing,
thank you for the first person who submitted a question, but encourage more of you to submit
questions, comments as well, and we'll pick those up.
But before we get to those, just want to ask each of you whether there are specific priority
areas in global implementation science that you would like to see the field undertake?
We've got over a hundred attendees who, I'm sure, would love to hear the [inaudible] perspective
on just some of the high priority areas that you would see.
Why don't we start with Rachel on that, and then go to Cindy and then Chris?
>> Okay.
Great.
I sort of mentioned this, and this is not a sort of priority area for someone looking
to apply, but I just want to emphasize I think, we really feel that there is a huge lack of
capacity.
So, I think building capacity in low and middle income countries to engage in implementation
science is really critical to global health.
And I think some of the feedback that we've gotten, when we've engaged in some of the
training, is who can mentor me?
After I leave the training, who can I reach out to to be mentored?
So, I think the whole area of capacity building is really important.
For the whole field, but I think especially critical for the low and middle income country
setting.
I think the other area that I think would be useful and really critical for global health
is to think about how and whether existing implementation science framework can be effectively
adapted and used to do implementation science in low and middle income country settings.
And I think if you look in the literature, there aren't a lot of examples.
And so, I think of those frameworks being adapted and used for work in low and middle
income countries.
And so I think focused work on that, and sort of trying to pull out and trying to use and
experiment with some of those frameworks is important, I think.
>> Great.
Cindy?
Thoughts for areas, for priority areas that you'd like to see the field focus on?
>> Well, I don't have specific research questions that I think are important to be addressed
for international.
I think that they can be developed in any country.
But I do agree with Rachel.
There's a huge interest in training of implementation scientists internationally.
I feel like we're constantly being asked to provide training in different avenues and
in different ways to groups around the world.
I think one of the challenges is training is not sufficient if there isn't funding,
and I don't know that the international funding is solely the purview of NIH.
I think trying to find ways to partner with organizations outside of NIH to support implementation
science, is an area that needs to be further examined, because I think that there's a pathway,
I don't know that internationally everybody's going to qualify for an NIH grant, but I think
that there's ways to build capacity through other funding mechanisms so that investigators
can build up towards an NIH grant.
Similarly with Rachel, partnering or mentor, you know,, having developing mentoring relationships
with implementation scientists in the U.S. and abroad, that can help develop the skill
set so that folks can gain expertise in implementation science, so that they can qualify for different
types of grants is going to be really important.
>> Great.
Chris, do you want to join in?
>> Yes, I'm thinking how best to use this time, you know, because we have standing FOAs
that really iterate a variety of priority areas.
Maybe a useful way to start is just to emphasize, you know, we've been really encouraging on
this call and talking about the growth of the field, but I think it's also worth acknowledging,
you know, in the international space, especially, the pie is not going to grow in terms of funding.
And I might speculate within NIH, but also with some of our international partners that
we work with, like USAIV and CDC and [inaudible].
And so, the work is going to have to be more targeted, even at a time when we're wanting
to do more.
And so I'll talk about a couple of research domains that I think that maybe, cross disease
areas, that are particularly important internationally because what's striking is, as many of you
know who work globally, is the variability of resources across country, across region,
even within, within country.
And so, two concepts that I think are critical to think about -- one is the differentiated
care.
And there was a time when maybe that was known more as task shifting, but I think that the
whole concept internationally for implementation science is about flexibility and tailoring
models of care to meet the needs of providers and patients and community members and in
places where resources may be limited.
And that could be tailoring care to adolescents that takes into account migration that takes
into account, you know, in country tumultuousness.
So, I'll just say that one area that we're increasingly trying to foster, which frankly
we could learn a lot domestically, I actually have found that the research internationally
that we have [inaudible] because of the nature of those systems to be a bit more flexible
has allowed for some really interesting, creative, innovative work in terms of alternative models
for care.
The second major domain that I'll just touch on is that, and I think that this for a variety
of reasons, we wind up being a bit siloed.
And so, NIH institutes are sort of set up by disease and this is a scientific area that
crosses diseases.
And I think that we need to do better collectively as a field to think about how to do science
as it relates more to comorbidities.
Because it's often the same people, the same patients, that we're trying to help, and in
the international space that we work in it can be trying to deal with someone's HIV prevention
or treatment needs at the same time that we're trying to address their TB needs and their
substance use and their alcohol and their mental health needs and screening for heart
problems or worrying about diabetes.
And so I think that -- if there's no, it's a bit of a ramble, but in short, the science,
I think it would be terrific if it could adapt to the nature of the needs in the field, which
is not to necessarily just look at one problem at a time, but to have the capacity scientifically
to advance the methods to look at multiple problems at the same time, and multiple resiliencies.
>> Right.
Thank you, and so with the change in the campfire picture, I think it's a great opportunity
to pick up on some of the questions that we're starting to see from the group.
There's one that's specifically focused on training, and so here's the question.
Are there specific training opportunities in implementation sciences for individuals
with considerable years of experience in the other fields of population health, for example,
at the genealogy and others?
Any of you want to jump in and just talk a little bit about the training opportunities
that you might recommend for folks?
>> David, [inaudible] do you mind if I step in?
>> No, please.
Jump on in.
>> Okay, so I think that that's a great question.
And, you know, the training institute that we hold at NIH, it's a trans-NIH training
institute on dissemination and implementation research and health, and it is open to junior,
mid, and senior level investigators.
And it's been really nice to show and to incorporate all levels of investigators here because,
you know, having a senior level investigator participate that does not have any experience
in implementation science but is moving into the field, they benefit from leaving experts
in dissemination and implementation and also provide an opportunity to mentor some of the
junior investigators.
We've had cancer center senior investigators that have participated.
We've had editors of journals that have participated, and I think that they have found it very valuable.
But the challenge is that we only can train, in that training institute, you know, around
50 people a year.
So, trying to develop other training opportunities that go beyond the training institute is a
thing we need to think about.
>> Okay.
>> David, can I jump --
>> Yes, please, Rachel.
Go ahead.
>> I was just going to say, I think that Cindy, I agree completely.
And I think the issue there is that there's only so many spaces in that training institute,
which is a fabulous opportunity.
I was just going to say, building on that, I think there are increasingly short courses
that are attached to academic programs.
So for example, the University of Washington hosts a short course every August, and it's
a two-week course.
They sort of change it every year, but it often is two weeks.
And again, that training course usually has a thematic focus, but that shifts, and I think
they're, they accept people who are very seasoned researchers and people who are very junior.
So, again, that same diversity you see in the [inaudible].
And I think there are increasingly opportunities similar to that.
And one thought is that, we're sort of trying to compile a landscape of what's out there,
which is continually evolving.
But I think we'll see that there will be short courses sort of sprouting up.
And I do know as well though, there are some courses that are also being established in
low and middle income country universities, for example, the University of [inaudible]
in South Africa has an implementation science track, and they do a training course that's
a full semester.
And for example, we're working with them to do a short training for a group that we're
hosting.
So, that's not a terribly specific answer, but I think there may be an opportunity for
us to share resources around what's out there right now.
>> Thanks, Rachel.
Chris, anything to add on that?
>> Yes, I, yes, thanks, David.
And I think I'll compliment those very good suggestions just by adding that, so if I think
about the places that are at the National Institute of Mental Health in the HIV/AIDS
space for example, is funding people right now to do implementation science.
And you can use a resource like NIH for porter to find those places, but I think of all the
centers for AIDS research that [inaudible] funds.
Virtually in every major city in the U.S. that's been affected by HIV and the NIH made
centers that we fund, then the many are the ones that were funded in this place.
I just think I'll add that the training opportunities that are more informal, that are going to
require more leg-work on the part of people who are trying to increase their work in this
space, which is just to try and take advantage of your local resources.
And I'm still of the mind that some of the most critical training that you can do is
by doing and by working with people who are doing the science in places that you want
to work.
And of course, as I started at the outset, I'm happy to help match-make, if you will,
with people who are doing work in an area that you're interested who might be willing
or able to work with you.
And that's whether you're mid-career, senior, or early career.
There's a real growing network of folks who are working in this domain.
You can certainly meet them at the dissemination implementation conference that NIH hosts now.
But increasingly, what I've seen is that, you know, if you go, and again, sorry that
I'm tilting towards HIV, but at the international AIDS society meetings, there's now an entire
tract devoted to implementation science.
And so, I think whatever area you're working at, you're going to find people who are doing
where you're at, I think.
And so, those ongoing partnerships, I think, are critical, especially since it takes so
long to form these partnerships globally.
It's hard to start from scratch.
It really is.
And just sort of saying, okay, I want to do something somewhere in this domain.
And so really taking advantage of people who are working in those areas already, both scientifically
and literally the place that they're working.
>> Great.
Thanks.
But I want to ask a follow-up question, because I think each of you has talked about it.
I think you didn't, I'm seeing one of the comments from Anna, recognizes that there're
even additional training opportunities like the implementation research institute that
NIH funds, which is an R25, focusing primarily on mental health and substance abuse and some
work that NHLBI [inaudible] is also funded, focusing on heart-lung-blood and implementation
science in low and middle income countries, but I wanted to mention because a lot of the
emphasis of our training efforts that we've been engaged in have been these, sort of one
time or potentially a couple of years of mentor training, but then not necessarily something
that follows.
If you have any ideas for types of ongoing mentoring or training that you think might
be needed to further build capacity, are there things that the field should be thinking about
to provide additional support beyond some of these time-limited training programs or
some of the existing resources?
Any guidance that you would give for gaps that we can fill for the longer term?
Why don't we start with Rachel, and then Chris, and then Cindy?
>> Sure.
And this is interesting, I was thinking about this as Chris was talking just now.
But I think here at Fogarty, we do focus more than half of our portfolio on training, not
in implementation science specifically only, but across the board in global health.
And I think we think often about the difference between long-term training and short-term
training, and they sort of function very differently.
So I think I would agree with you, David, that there is a need for longer-term training
opportunities and support.
I think you're training different people when you train them in a long-term implementation
science track to get a terminal degree, whether it be a master's or a PhD, I think you're
training an implementation science methodologist.
And I think we're seeing more of those programs, not tons of them, but more of them popping
up, both in the U.S. and in other countries, sort of in the global space.
I think when you're engaging in the shorter-term training, I think often those are folks who
are, who might be well-seasoned researchers in a specific disease area.
And again, I think what you're doing there is trying to expand their skill-set to be
able to engage in implementation science.
They may not ever end up being an expert, but so I think there's a need to balance those,
and I think we're lagging a little bit on the long-term training opportunities.
I certainly at Fogarty, we have programs that span many disease areas from HIV to environmental
health.
And in most of our programs, our funding announcements implementation science prioritized as one
of many different methodologies that we would encourage people to use.
That said, that's not a specific, targeted, long-term training funding opportunity, but
the platform of the D43, which is what we use, is essentially, I think, is needed to
support implementation science in the global space.
I think the other, I think we do have to make sort of more deliberate efforts at thinking
about mentoring and how to support that, whether it's with funding or with sort of some infrastructure.
And we have been doing some thinking about that here, but it's, I think we need to be
quite creative, because it's very hard to link an implementation scientist from perhaps
the U.S. with someone abroad without some kind of incentive and system set up to support
that relationship-building.
But I think that's really needed as well.
>> Okay, Chris, thoughts?
>> Boy, that's a tough one.
I'll be brief, and defer to Cindy to see if she has anything wise to say here, but from
my observation working internationally for a few years now, just like in the U.S. sort
of had to be some major structural change.
I mean we're talking about an evolution of this science and an appreciation for it.
But the incentives to get into this field in low and middle income countries is weak
in the sense that, you know, there's a lot of incentive to become a physician or to become
a physician scientist or, you know, and work in biomedical sciences, which, which still
are seen, you know.
It may be evolving a bit here domestically and in other spaces, but in many of these
places, the institutions are going have to change.
There's only a hand-full of sort of advanced training programs in the U.S. now for training.
And so I think if there's one thing that we could do as a field outside of the bits that
we could do to sort-of train individuals is to, sort of, train if you will, or do closer
work with deciders in institutions in low and middle income countries, whether they're
health ministers or they're staffers or policy makers or those who are responsible for, you
know, deans of schools of health in international settings.
And so, if I'm thinking about trying, you know, I have a long-view for how to seed training
for 15 or 20 years down the road, I think we're going to have to change structures or
else we're going to be seeding a bunch of folks in places where there's real disincentive
to work in this field.
>> Thanks, Chris.
Cindy?
>> Yes.
I echo Rachel in this thinking, you know, that we need to have systems in place to train
mentors and kind of embed this.
You know, when I'm thinking about long-term, I'm always challenged with, it's always easy
for us to do the work and to reach out and do the training, but it's not necessarily
as effective in the long-term.
So, you know, Sara and I are frequently tapped along with our Center for Global Health here
at NCI to go and do training in implementation science, but we're trying to find mechanisms
and ways to do these trainings where it's not an NCI or an NIH roadshow.
So, working with other agencies like the Global Alliance for Chronic Disease, or ministries
of health in other countries, where they have already shown support for this.
I think back a number of years ago, Argentina reached out and wanted NCI to do training
in implementation science for their country.
And we pushed back a bit, wanting them to do their own training with us just supporting
them.
And it turned out, I think, to be a nice model where the ministry of health in Argentina
actually put funding behind it.
They funded the training, but they also developed a funding opportunity in implementation science
for investigators in Argentina to apply for.
So it wasn't just training for training's sake.
There was an opportunity for them to apply it and to get funding for their research concept.
Of course, the challenge is it's not a one and done.
Ministries of health change, and you can work one off with the ministry of health, but if
the ministry of health personnel change, the commitment to this might change as well.
So, I don't know that I have a specific answer of how to incorporate training in low and
middle income countries to grow the field in low and middle income countries, but I
think there are a number of ways that we can kind of reach out and see this.
But like, Chris, it's going to be like an ongoing process, and we, you know, I think
there's a lot that can be learned between low and middle income countries and sharing
experiences in implementation science, and what they're studying, going across chronic
disease and then also taking lessons learned from low and middle income countries and implementation
science programs and projects -- taking them back to the U.S.
>> Okay, thanks.
So I want to pick up on another question that someone had submitted.
And while the question is specific to cancer control, I maybe like to use the prerogative
to make it a little more general, and that's to say that within low and middle income countries,
there's, some of the planning does not necessarily always address the use of evidence-based practices
or programs which may not be available in those particular countries.
And the question asks is adapting evidence-based practices from the U.S., say in the broad
areas of prevention and early detection, appropriate?
And so how do each of you think about the evidence-base, where it was generated in a
particular country that wasn't an LMIC country, and how you'd think about adapting existing
programs, versus needing to develop the new ones in the international sites where you're
working?
Anyone just want to give your thoughts on that?
Anyone want to start?
>> This is Rachel.
I'm happy to briefly start.
I think that, and maybe David, I'm twisting this a, or expanding your question a little
bit, to think about adapting evidence-based interventions or programs from one country
to another, and just some experiences we've had with some of our work in sub-Sahara Africa,
for example, around the prevention of mother to child transmission of HIV.
And I think we saw in the context of some work that we did with a network, that there
are huge challenges at the country level, in terms of decision makers being comfortable
using evidence from another country to adopt a policy that would then influence programs.
And so I think there's a tension among the group that we were working with, around having
to do the work in every single setting and the fact that implementation science is so
context specific, and sort of how do you sort of step away from that to scale something
so that you don't have to redo the research that's been done.
So, I think, I think it's a really complicated question, but I think I would say it is appropriate,
I think you just have to, it's complicated, and I think if you're a researcher looking
to inform a program, I think, thinking about who that program, programmatic stakeholder
is, and whether they're going to be willing to accept evidence from another context, and/or
a decision-maker, whether it's a ministry of health person or not.
Again, I think there's more of a softer question that's around the process and the realities
of using evidence from somewhere else.
So, from a scientific level, I think I would support it in all of its complexity, but I
think whether that works and functions at an operational level, I think is sometimes
challenging.
>> Thanks.
Chris or Cindy, anything to add on this idea of adaptation of evidence practices that were
generated elsewhere?
>> David, this has been so -- I get that, not just from low and middle income countries,
but from other populations from other populations in the U.S. Context is one of the critical
components in implementation science, and I agree, it's a challenge to try and take
interventions from one population, where, if it's tested in the U.S., and apply it to
another country, whether it's, you know, American Indian, Native American populations or sub-Saharan
African populations.
I think you do have to take context into consideration, but there's also different ways of doing studies
that allow you to test the evidence, you know, you can use a hyper design to see if you're
able to get the same impact and hopefully get some buy-in that way, but I do know that
it's a challenge because context does matter.
>> Yes, Chris, anything to add?
>> Yes, the little that I'll add is just that in some cases, I mean, it may be as fundamental
as the, you know, in the case of, you know, psychiatric treatment in Uganda, that they
might not have, you know, state-of-the-science medications on formulary available.
And so, the best answer that I can give, I think, to this question is that it depends,
you know, in some cases, some adaptation and some testing the ways you need to evolve an
intervention in order to be appropriate for particular contexts is important.
I would also emphasize that you have to document, I mean, part of the sciences, the science
of adaptation and how was it the changes were made and using what framework in order, so
that the actual adaptation process itself may be transferable.
And so, again, if someone is trying to do this work in another similar setting, they
don't have to redo the adaptation process.
I mean, as much as possible, much like the basic science that we foster at NIH, we're
trying to make the science that respond in this area transferable or generalizable whenever
possible.
>> Great.
Thank you.
So, recognizing that we only have a few more minutes left and we do often have attendees.
There you can see there's some more, or the, at least, part of the s'more construction
of the s'more and the constituent parts of the marshmallow.
However we can only imagine the chalk in the graham cracker elsewhere.
Anyway, [laughter] wanted to, since we have a number of folks on the line who are at earlier
stages in their career, I wonder if each of you could just briefly comment on advice that
you have for earlier investigators who are contemplating a career focusing on global
implementation science?
Maybe we'll start with Cindy and then Chris and then Rachel.
>> I think that the advice that I would give early career investigators is that I think
it's a great field to be moving into.
There's a lot of opportunities for engaging in training.
It doesn't have to be travel intensive.
There's a lot more trainings that are being provided, as was mentioned previously, in
conjunction with conferences.
The International Society for Behavior Medicine frequently has trainings.
The Global Alliance for Chronic Disease has trainings, and various organizations have
it.
But there are also, there are also programs in academic institutions that can give you
a very firm foundation in implementation science, and there are some that have a very specific
focus internationally, like the University of Washington program.
So, it's an area where there's a lot of support for people moving into the field now, which
is nice to see as the field has evolved.
>> Great.
Thanks.
Other thoughts.
>> Yes, just real quickly.
I would encourage anyone that's getting into this area to think about diversifying their
portfolio in a sense, because you know, so often, say somebody gets into their specialty.
Didn't start out as implementation scientist, started out with, you know, how do we deal
with uptake of preps, pre-exposure prophylaxis, for HIV prevention.
And so they want to focus on that because they were an infectious disease specialists,
and they want to get this up to scale, perhaps in a certain country, but that you know, prep
happens to be the tool that they're working on now that's exciting and they want to advance.
But diversifying their portfolio really means that you're, you know, that the same skills
you'll develop in working with, say, providers and setting in context will be transferable
to other prevention tools.
And so, you may be able to apply to other institutes down the road and sort of not become
sort of prep-centric, if you will.
And be able to apply the skills in a way that can maintain a career independent of what
the particular tool is that you're working on at the time.
>> And I would just say, do it.
We need you.
Right?
I would encourage an early career investigator to go into global implementation science.
I think one of the things I would advise would be to engage where you can, where there are
conferences, engage potential mentors as best you can.
I think there is strong support to sort of grow, pull people in and grow this field.
So, I think you would have success, and I think just as Cindy was saying, just to engage
in the training opportunities that are out there, and they're in various places.
And so depending on where you live, that they may not be such a heavy lift.
>> Thanks for saying that, Rachel.
I didn't mean to be so pessimistic at various points during this.
I mean, this is an exciting area, and what a world of opportunity that there is to, again,
really make a difference and bring some science to places that really need it.
And so I'm happy to talk to anybody at any time and be even more encouraging.
>> Awesome.
We like encouragement.
And that so to that end, there is a question, and I wonder if any of you wants to take it
on.
So, open to the first person who wants to jump in.
What do clinicians working in direct patient care need to know and understand about implementation
science?
And any thoughts about how we can get them this information?
So, how would you engage clinicians?
>> I saw that question come up, there's no, I mean, it's the same as when I started out
in psychology.
And there are many psychologists who, you know, aren't terribly [inaudible].
And it's just encouraging those in direct patient care to be consumers of the science
at the outset.
And there's no easy way to do that either, but that's the sort of basic place to start,
is just to appreciate that there is a science here to get in to.
And then, you know, frankly, partnering with researchers in their area is another way to,
you know, even if they're not scientists investigators themselves, being a part of that operation,
I think, is a great learning tool.
>> Uh huh.
>> I would just add to what Chris just said.
I think there are some ways that funders or that NIH is trying to support that sort of
bridge between the researcher and the folks that use, or might be using, the research
evidence.
And I think there are different examples of how that's being done.
One of the them, and it's very slow, but [inaudible] these platforms where we bring together researchers
who are funded by NIH along with the program implementers, whether they're clinicians and
policy makers to sort of create a space to support that, that dialogue so that the clinician
would understand more about the implementation science evidence and the implementation science
approach in general.
I also think some of our funding opportunities here at NIH do ask a researcher to come in
with either a program implementer, whether that's a clinician again or a decision maker,
and that's a way to encourage researchers to really, to span that bridge and really
make that connection at the start of their research.
>> Yes, and I think each of you have made the point throughout your comments about the
need for partnerships, and we recognize that no matter how good science, you know, how
robust a specific study may be, if it isn't demanded by people who are going to apply
those results, use those programs, then it's like that tree falling in the woods that nobody
even has heard or seen.
And so the idea of understanding the demand side and understanding what is driving clinical
practice and what are the both, you know, strengths, leverage points, but also limitations
of any clinician, and how can we better meet those needs is a key part of implementation
science.
So even just getting more people understanding that at the end of the day, we're trying to
make it easier to deliver the best possible care, and we need everyone involved in that
effort.
I think, you know, would be a helpful message to pass along.
So, we're not right at the top of the hour.
I want to very much thank Rachel and Chris and Cindy for sharing their wisdom with us,
and want to thank all of you for your great questions and comments, and for tuning in
with us.
I'm going to turn it over to Sara to close things out.
>> Great, thank you so much, David.
And with that I'm also going to take a moment to thank David for his time [inaudible] and
just a few quick close-out reminders.
Though your feedback is important to us, we encourage you to complete our online evaluation.
A link to the survey will open in a new window once this session is ended.
An archive of the saved session should be made available shortly on our website, and
we hope to see you at our next session in October, which will be part two of this global
implementation science discussion.
Registration details will be shared in the coming weeks.
Thank you again for joining us today.
You may disconnect at this time.
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