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Lost in translation: key lessons from conducting dissemination and implementation science in Zambia

Implementation Science Communications volume 5, Article number: 121 (2024) Cite this article

Abstract

Background

As the field of implementation science continues to grow, its key concepts are being transferred into new contexts globally, such as Low and Middle Income Countries (LMICs), and its use is constantly being reexamined and expanded. Theoretical and methodological positions commonly used in implementation research and practice have great utility in our work but in many cases are at odds with LMIC contexts. As a team of implementation scientists based in Zambia, we offer this commentary as a critical self-reflection on what has worked and what could limit us from fully utilizing the field’s promise for addressing health problems with contextual understanding.

Main body

We used a ‘premortem,’ an approach used to generate potential alternatives from failed assumptions about a particular phenomenon, as a way to reflect on our experiences conducting implementation research and practice. By utilizing prospectively imagined hindsights, we were able to reflect on the past, present and possible future of the field in Zambia. Six key challenges identified were: (i) epistemic injustices; (ii) simplified conceptualizations of evidence-informed interventions; (iii) limited theorization of the complexity of low-resource contexts and it impacts on implementation; (iv) persistent lags in transforming research into practice; (v) limited focus on strategic dissemination of implementation science knowledge and (vi) existing training and capacity building initiatives’ failure to engage a broad range of actors including practitioners through diverse learning models.

Conclusion

Implementation science offers great promise in addressing many health problems in Zambia. Through this commentary, we hope to spur discussions on how implementation scientists can reimagine the future of the field by contemplating on lessons from our experiences in LMIC settings.

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Background

The application of implementation science (IS) in solving health challenges has grown significantly in Africa over the past 10 years [1]. Yet, many research traditions and activities at the intersection of knowledge generation and practice, such as monitoring, evaluation and learning, have recognized the relationship between evidence and action and have been applied widely on the continent [2]. The growth of the field can be attributed to investments in capacity building initiatives such as short- and long-term training targeted towards different cadres of professionals [3, 4], development of communities of practices that promote knowledge exchange [5], funding for implementation science projects [6] and growth of local centres of excellence which prioritize implementation research [7]. Ultimately, this growth is linked to the field’s capacity to generate different forms of information that enhance effective implementation of evidence-based interventions [8]. Implementation science encourages the use of systematic approaches to generate implementation evidence [9] aimed at reducing the occurrence of “know-do” gaps as secondary research-to-practice gaps as well as practice-to-research gaps [10]. Different types of studies that have been proposed as being relevant for the accumulation of scientific knowledge for the field of implementation science include evaluation of implementation strategies, theory driven analyses of implementation processes and determinants of implementation outcomes as well as development and validation of measures relevant to dissemination and implementation science [9, 11]. However, one of the key challenges that implementation scientists in LMICs face in our application of implementation science approaches is that while the field continues to progress rapidly, predominant theories, models and frameworks, implementation strategies and measures are often at odds with our contexts—i.e. low-resource settings in Africa [12]. Though there have been some efforts to adapt key implementation science concepts to low-resource settings [13], the foundations of the field continue to be based predominantly on work that is conducted in high-income settings [14]. For instance, current prevailing taxonomies used for implementation strategies such as Expert Recommendations for Implementing Change (ERIC) were developed based on expert opinions from high-resource settings [15].

In their commentary critically appraising implementation science through a decolonial lens, Bartels et al. called for an interrogation of the foci, methods and approaches of the field as it moves into low-resource settings through various recommendations including decentralized knowledge creation [14]. As former recipients and now leaders of different implementation science capacity building initiatives who live and work in Zambia, we provide this commentary based on our experiences in: (i) providing training to graduate students, pre- and post-doctoral fellows, frontline implementers, and other health professionals to conduct implementation research [16]; (ii) implementation support to practitioners working in different organizations in health and non-health settings in the region; and (iii) implementation practitioners applying the evidence we have generated in our programmes. We reflect on the transportability and adaptability of the key concepts of the field from Western settings into low-resource settings such as ours [9].

A key feature of our work is that we are often adapting key IS concepts [17]. According to Rogers’ diffusion of innovation theory, adapting and reinvention occurs when changes or modifications are made to an innovation following its adoption alongside the processes by which the innovation is changed by its adopters [18] as they struggle to give the innovation meaning [17]. In our case, this is caused by a variety of factors. First, there are pragmatic considerations related to research and practice in a complex and dynamic health system in Zambia. The Zambian health system is fragile characterized by the frequent need to translate evidence generated from high-income settings, regular shifts in key implementation actors and funding bodies, fragmented implementation of interventions due to a large numbers of actors, internal organizational features and unstable funding and funding continuity shaped heavily by global political forces as well as the sociocultural context [6, 19]. Secondly, the collection of empirical data is often hampered by more antiquated data collection systems, which require more innovative strategies when dealing with implementation outcomes and measures. As is the case with all implementation contexts, this highlights that evidence is not the only consideration that informs the decisions to adopt and continue implementing effective interventions. Decision-making is often influenced by politics, interests and resources, organizational readiness and individual capacities to use the evidence [20,21,22]. Thirdly, health systems in many African countries are significantly impacted by frequent and overlapping external shocks, such as pandemics, financial crises, changes in governance and policy arrangements, climate change and natural disasters challenging the idea of “routine practice” [23, 24]. In such cases, the use of implementation science approaches can significantly improve efficient use of scant resources for better outcomes such as enhanced coverage and quality of health services. Despite these challenges, we are still interested in generating theoretically informed findings grounded in and extending the implementation science literature [25]. We acknowledge that there has been a catalytic nucleus of impactful implementation science that has emerged from Zambia and from other African countries being led by African institutions. As such, we believe that the field can grow further by learning from implementation science projects done in low-resource settings where constant adaptation of key concepts is a defining feature [10, 26, 27].

We conducted a critical assessment using a premortem approach similar to Beidas et al’s example from US-based implementation scientists to examine the promises and pitfalls of the field [27]. Premortems use prospective hindsights which imagine future failures and generate potential explanations for why they occur as a way of putting in place measures that can reduce the likelihood of those failures occurring [27, 28]. The guiding prompt used in the discussions was: “There has been a significant growth in the application of implementation science in low-resource settings such as ours. We are in the year 2027 and a recent article on the state of the field suggests that despite the availability of implementation evidence on processes, strategies and methods, the adoption and translation of this evidence into practice in Africa remains poor. Looking at where we are now, what do you think we have done/are doing right to apply the key concepts of IS and contribute to the growth of the field? What do you think we are doing/went wrong and why?” Additionally, we used secondary data collected as part of a needs assessment exercise for the establishment of the Implementation Science Centre for the Advancement of Practice and Training at the University of Zambia between August and October 2023. The needs assessment involved a stakeholder workshop and a survey which was focused on understanding local actors’ experiences with conducting implementation science, their knowledge and skills as well as the barriers and facilitators to conducting implementation research. The results from the assessment were summarized into higher order themes from which we extracted data relevant to the themes that arose during the premortem.

Main body

The proceeding section explores the main themes that arose during the premortem and reflect what we have achieved so far alongside the challenges we believe will slow down the progress of applying implementation science concepts in settings like Zambia. By utilizing prospective hindsights, we had an opportunity to take a critical stance that permits a reimagination of what implementation science is and could be in Zambia and similar LMIC settings [29, 30].

Theme 1: Our efforts to challenge epistemic injustices did not diversify the field

Implementation science’s call for the use of systematic methods to guide the transformation of intentions to address societal challenges into concrete actions through the use of Theories, Models, Frameworks and Approaches (TMFs) has been useful in creating a shared language needed for advancing the field [31]. We have been applying TMFs in various ways including: to understand determinants of implementation [32], guide implementation [6, 16, 33, 34], evaluate implementation outcomes and processes [35] or to test implementation strategies [36]. Drawing from our research and practice experience, we have been able to apply these TMFs to develop local framings of implementation challenges that are common in our context.

However, the rich plurality and complexity of our context is lost by the push to make sure our findings fit neatly into existing TMFs whose origins are from clinical settings and systems in the global north [37]. This has led to the occurrence of epistemic injustices of varied forms. Epistemic injustices refer to unfair, unjust and avoidable differences experienced by scientists such as ourselves which limit our capacity for participation in scientific inquiry that could provide alternative possibilities to address implementation challenges in our context [30, 38, 39]. This results in the exclusion of specific voices and institutional structures from the generation of knowledge that can push the field forward [40] by reducing avenues to disrupt and question implementation science assumptions that have been accepted as the norm [29, 41]. For instance, the selection and application of TMFs tend to be based on convenience and previous exposure, therefore specific theoretical positions become seen as default positions [27, 42]. This has led to an exclusion and delegitimization of orientations that challenge them as inferior as well as a failure to acknowledge their blind spots and limitations of particular theoretical lenses [29, 43]. An assessment of implementation scientists’ use of TMFs found that very few of us are using them to critically engage with implementation science theory; only 18.4% stated having used them to understand disciplinary and philosophical foundations of the field, 52.8% to make a cumulative contribution to theory building and 33.9% for disciplinary approval (i.e. making choices that are aligned to the leading voices or groups who are considered as credible within the field of implementation science) [42].

Our use of TMFs is value laden and influenced by varied factors such as power relations in research partnerships with institutions in high-income settings, limited resources that inhibit us from delving deeper into implementation science questions, poor basic service delivery infrastructure, underdeveloped health system building blocks that are often taken for granted in TMFs from the global north, and short-term timelines and changing priorities of funders [44]. For instance, Implementation science funding from the Special Program for Research and Training in Tropical Diseases is primarily directed to diseases of poverty which limits the possibility of exploring other community identified research priorities. Further, our studies are usually nested in larger projects whose focus may not be primarily to understand implementation. This leaves very limited room for exploration resulting in more prescriptive use of the TMFs and, even when adaptations are made, they can end up being surface level. As TMFs form part of the “implementation science canon,” we are placed in a position where we have to balance between upholding the canon or challenging it based on our work and lived realities [45]. Abimbola et al. have mapped out how these contextual conditions contribute to credibility deficits and interpretative marginalization as they fail to recognize our role in meaningfully contributing to the field [46].

Drawing from critical theories such as Africana critical theory (i.e. philosophical approach drawing on the work of continental and diasporan African thinkers/thinkers from marginalized communities to critique systems of domination and support emancipatory efforts) [29, 43], we echo the call for a more theoretically informative implementation science [25, 47, 48], as this would facilitate the application of multidimensional and multiperspectival approaches to examine our experiences with key concepts [43]. For this to be possible, implementation scientists must be epistemically open, drawing from different theories and methodologies from across multiple disciplines even those that seem incompatible. Theories then become heuristic and discursive weapons to understand the social world in which implementation is occurring [43]. Gustafson et al. provides a good example of using indigenous knowledge to enhance an implementation process framework to enhance equitable implementation [49]. This critical standpoint requires a self-reflexive position where we are constantly reexamining the philosophical foundations, methods, positions and presumptions that inform our practices so that we can meaningfully contribute to the field [30, 43]. Additionally, this epistemic reflexivity will simultaneously stimulate work based on our training while also pointing out where gaps lay in existing TMFs, thereby giving us room to resist dominant assumptions that may not fully describe our contexts and experiences [29, 43, 50].

In the same vein, epistemic reflexivity creates an opportunity to question who is allowed to generate “implementation science knowledge” and why this is limited to only a small segment of the field while other voices are underrepresented in the process [50,51,52]. This raises the question: whose knowledge matters? Ongoing efforts to map groups, centers and individuals working in implementation science in Africa and building local communities of practices may enhance consensus building on what implementation science priorities are relevant for the continent. Such networks can enhance solidarity and learning, create space for mutual knowledge exchange, and foster development of contextually relevant theoretical and methodological innovations [53]. In the past few years, we have seen the growth of implementation science-specific forums in Africa (e.g., Adolescent HIV Prevention and Treatment Implementation Science Alliance annual forum or the annual HLB SIMPLE Alliance meetings focused on implementation strategies for HIV-NCD integration) or inclusion of designated tracks in regional public health conferences (e.g., the International Conference on Health in Africa, CPHIA) that show there is a growing interest in the application of the key concepts.

Though there has been a steady rise in implementation research articles from Africa, there is still a significant under representation of authors from LMICs in public health scholarship published in high impact factor journals generally [54], as well as in implementation science in particular [55]. As Aane-Binfoh et al. point out, the likelihood that authors from low-resource settings publish in such journals is shaped by factors such as low submission rates, overemphasis on articles using specific measurement approaches, concerns over quality of the research and writing we conduct, and cost considerations (i.e. article processing fees and language editing services) [44, 56]. Further, many African implementers and researchers do not have funded protected time to write and disseminate the knowledge they generate. Moreover, key journals and conferences such as the Annual Dissemination and Implementation Science Conference, and other knowledge sharing platforms are held primarily in high-income settings. Investments in the continent’s publication infrastructure with peer review processes and conferences that respect Afrocentric knowledge will provide outlets from many of the region’s implementation scientists to share their knowledge including the publication of key texts that can be used in African Academies [51]. In our experience, documenting our work can be challenging, and, therefore, an expansion of such platforms would promote more knowledge sharing in the field. This could include documentation through traditional avenues such as journal as well as Afrocentric ways of expanding knowledge such as storytelling and building participatory knowledge infrastructures [57, 58].

Theme 2: We have not fully expanded our conceptualizations of evidence-informed interventions to LMIC practice settings

Evidence, whether it is related to etiology and burden of societal challenges, effectiveness of interventions or evidence of implementation within specific contexts, is the foundation of dissemination and implementation science [9]. Interventions that have been proven efficacious and effective are commonly referred to as evidence-based interventions, evidence-based practices of interest or “The Thing” [59,60,61]. The nature of the interventions include: programs, practices, principles, procedures, products, pills and policies which target changes to behaviors, outcomes or environments [59, 62]. Locally generated evidence from Zambia and other African settings has been used for stakeholder health priority setting, to guide improvements in quality of care, to inform resource mobilization, and to introduce evidence-based practices in diverse program settings throughout Africa, such as integrated disease management in Zambia [63,64,65]. Implementation science approaches have been instrumental in the identification of gaps in evidence use, evidence dissemination and adaptation and tailoring of interventions drawn from different settings into African health systems [66, 67]. This has been made possible through TMFs such as MADI, ADAPT-ITT, the Adaptome model and FRAME for tracking adaptations to interventions [68,69,70,71]. Finally, the emergence of new knowledge translation platforms has encouraged the dissemination and use of evidence in the design of policies and programmes, such as the West African Health Organisation [63, 72].

We apply a critical lens to examine assumptions about evidence or “implementation science knowledge” when transported to low-resource settings. The first assumption is that knowledge is objective, consistent and reproducible across multiple settings. Evidence is not neutral, it has history based on the context from which it is derived which determines transferability and success in other contexts [73]. Given the power dynamics at play in low-resource settings, it is common for institutions and agencies based in high income settings to dictate which interventions ought to be implemented even when transferability has been shown to be difficult to achieve and especially when an intervention may be life-saving and impactful but expensive [73]. Further, evidence is also shaped by corporate interests, failed regulations and the commercialization of academia [74, 75]. Guidelines and criteria that help in the adoption of new interventions are often based on well-functioning systems with adequate resources and good absorptive capacity which is not always characteristic of our implementing systems. Scientists from our contexts are scarcely involved in decision surrounding what needs to be implemented which further weakens the alignment of selected interventions to the context [46].

The second assumption is that the know-do gap—which arises from the difference between scientific facts and practices—can be separated analytically and practically [73]. Based on our experiences, the delineation between implementation research and implementation practice is often not possible as we wear hats both as implementers and researchers simultaneously depending on what needs doing, whether it is research or scaling up the knowledge produced. While this also occurs in high-income settings, it occurs far more frequently in low-income settings where human resources for health are comparatively scarce and opportunities to comfortably occupy a narrow professional niche are relatively fewer. Removing the frequent false distinction between who is a knowledge user and knowledge producer, and more deliberate inclusion of implementers in the knowledge generation process, can allow us to tap into a more transformative use of implementation science [45].

The third assumption is that the implementation of evidence is based on a series of rational decisions for which scientific evidence has the greatest bearing [73]. In contrast, implementation processes are often characterized by bounded rationality where actors are limited in their capacity to prioritize and interpret evidence due to uncertainty, low levels of confidence in their knowledge of existing gaps or ambiguity arising from multiple interpretations of a problem [76]. This limits the amount of evidence that they can assess and choose from and the breadth of gaps they can solve before delegating responsibility to others [76, 77]. Consequently, evidence becomes only one consideration when choosing interventions alongside politics, values, available resources, stakeholder knowledge and expertise, as well as the sociocultural and economic environment [59, 78]. While these factors are certainly relevant globally, existing implementation science frameworks consider these elements but give insufficient attention to their primacy in implementation contexts such as ours. For us, evidence informed interventions are quite complex because they are comprised on multiple components acting at different levels of the health system whilst their implementation is occurring in complex adaptive systems [79]. Further, due to the large number of partners and the focus of multisectoral collaboration and other forms of joined up policy making, interventions often require action across different implementing systems requiring cross-system strategies [80]. Though there has been a recognition of the need to consider complexity and a nonlinear approach when thinking of interventions, more needs to be done in areas such as the identification of strategies for cross-system interventions that are typical in Zambia.

There is limited emphasis and guidance in many training programmes on pragmatic approaches to adapt evidence on interventions and implementation strategies for practices in LMICs [10]. Adaptive methodologies and their use remains minimal despite their promise of promoting implementation of an intervention in a way that can be transferrable across real world settings. We have failed to identify rigorous yet understandable approaches for the clear, step-wise adaptation of evidence-based interventions, incorporating new contextual knowledge in the adaption process. The TMFs used for adaptation approach the process from a high-level of abstraction, meaning that they lack clear, methodical and practical guidance on incorporating contextual knowledge into adaptation processes. Similarly, we lack simple ways of costing implementation strategies and accounting for other implementation research practice costs when developing evidence packets to advocate for evidence-based interventions. We can, therefore, be less convincing when trying to demonstrate the feasibility of our interventions, which often results in continued implementation of lower value care.

Theme 3: We continued to use simplified depictions of our context

Context is a key element in determining whether implementation efforts are going to succeed or fail by examining how it interacts with strategies, mechanism and outcomes [81]. The capacity to conduct robust contextual assessment has been recognized as a key competency for any implementation scientist [82, 83]. Yet, context remains a poorly described and highly contested concept in implementation science [19]. We agree with Pfandenhauer’s assertion that this is the result of the positivist history of the field which views phenomena from the position that there is only one objective reality which can be understood by studying the constituent elements of a system [19]. Given the myriad factors that influence implementation effectiveness, it is important to assess evidence-informed interventions within their historical context, unpacking the tensions between the interventions and the cultural, social, political, economic, scientific, aesthetic, religious, and institutional settings where it is meant to be delivered [43]. In addition, social forces also shape mechanisms and structure the delivery, receipt, and operationalization of evidence [29]. For too long, having intimate contextual knowledge of community and practice settings in LMICs—a prerequisite not only for effective implementation, but also for correcting epistemological injustices—has been undervalued by the field and lacking among implementation scientists from the global north. Therefore, implementation scientists should be required to develop deep understanding of the contexts in which they are working, developed through immersion into communities and practice in the systems in which they intend to intervene through equitable collaboration with implementers with experiential knowledge. As former colonized regions, the legacy of colonialism and imperialism add a spatial and temporal dimension to our understanding of context where the past, present and future overlap [45, 84, 85]. Implementation science methods and approaches are well suited to develop historical and contemporary understanding of context that can help guide the selection of appropriate strategies for correcting health inequities rooted in historical injustices and helping realize future locally defined goals [45]. Insights drawn from other disciplines can complement implementation science approaches and lend explanatory power to understanding context. Anthropology and history, in particular, are useful disciplines in this regard as they are relevant to implementation science and have a rich African academic tradition [86,87,88].

Theories, models, frameworks, approaches and taxonomies are often not suited to assess the realities of conducting implementation science locally as they fail to account for complexity of conducting implementation science in low-resource settings including whose interests and values implementation efforts serve [19, 41]. Modifications to frameworks such as CFIR and the health equity implementation framework have come closer to how we think about our context by thinking about the political economies in which we operate [13, 89, 90]. Often times, the interests and values of patient, clients, and their communities can be left out of the design, implementation, and evaluation of interventions, which may be more aligned with the priorities of foreign donors or national governments. We have used Participatory Action Research and the application of community health system lenses to bring their voices to the centre while linking them to formal primary health care systems [6, 91]. Further, these lenses have helped us question the deeper social, political, historical, economic and health system-forces that shape the implementation of interventions [6, 92].

Reporting guidelines and other normative guides that are used to report implementation science projects ask us to describe our context. STARI, for instance, asks users to describe “the context in which the intervention is implemented (consider social, economic, policy, healthcare, organizational barriers and facilitators that might influence implementation elsewhere)” [93]. Whereas TiDIeR asks one to “describe the type(s) of location(s) where the intervention occurred including any infrastructure and relevant features” [94]. Hopefully, the growing availability of these guidelines will increase the ease of reporting contextual characteristics even with the challenges that are associated with embedding complexity theory in assessments to understand phenomena prospectively [95].

Theme 4: We did not reduce the chasm between implementation research and practice

A decolonial turn in implementation science means that more knowledge will be generated through research that must be extended pragmatically to address health and other inequities within the realm of practice [29]. Despite being equipped with the capacities to work in a broad range of areas and with different partners, we have not escaped the secondary research to practice gap faced in in translating the implementation evidence that we generated [26]. This gap could be the result of misalignment between the evidence we generate, and the practice needs and limited capacity to implement, scale, and sustain interventions among practitioners. Building capacity in implementation practice targeted towards a broad range of actors may lead to knowledge attainment and increased perceived ability to implement evidence [96]. Examples of content areas identified by Reszel et al. that can be covered include; identifying and applying TMFs, developing relational and coordination skills, taking a process approach to implementation and learning implementation steps and skills [97]. The gap may be further closed by capturing and specifying LMIC-derived practice domains and implementation strategies, further studying how practitioners access, apply, and synthesize evidence in LMIC settings, and reorienting the field to optimize our understanding of these methods and processes.

We recognize though that there has been a significant growth in the field in terms of introducing interventions outside of the narrow clinical settings from which it originated to even non-health settings, which could be due to the field’s inclusion of a broader range of practitioners such as anthropologists [98]. Yet we cannot reflect on implementation practice without a discussion of funding and resources within low-resource settings. Funding for implementation science like other fields of global health remains concentrated in high-income countries [44]. Though frameworks like the stages of implementation completion and the quality implementation framework have been useful in guiding the roll out of new interventions [99], they often have limited utility in LMIC settings. Often, when launching a new implementation science project, our initial considerations usually begin by first addressing implementation readiness for adoption, often by putting in place the necessary health system building blocks for implementation. It is not uncommon, then, to work in areas where basic service delivery infrastructure is completely absent. Initial costs to establish the right capacities and infrastructure for the EBI may leave limited resources to critically explore implementation effectiveness questions. We cannot always utilize dedicated measurement-oriented methodologies, which have been accepted as the gold standard of evidence, as we often must balance these research costs against health system strengthening costs, resulting in knowledge that may be graded as less rigorous. Nonetheless, in Zambia data from SmartCare and other nationalized electronic health systems have been harnessed to make generalizable insights about implementation innovations. Further, projects are usually implemented over short periods of time, with a focus on short-term rather than long-term outcomes, which limits our capacity for examining the myriad implementation and contextual problems that are rife in our context [40]. Cumulatively, this results in a unique lag in the knowledge production among implementation scientists working here. Though there have been calls for accelerated generation of implementation science knowledge in response to a rapidly shifting world [56], we believe that a slower and more deliberate approach may be more ideal to unpack the complexity that characterizes our setting and more suitable for a practice-driven approach to implementation science [37].

Theme 5: We did not disseminate our findings strategically

Despite generating implementation science knowledge, the rate at which we are disseminating it and its subsequent translation into practice in LMICs remains very low. In most cases, knowledge translation efforts are left until the end of the projects and are often badly underfunded by donors if funded at all, with limited considerations of how evidence-informed interventions will be sustained [37]. The lack of alignment between the needs of users of knowledge and those who generate evidence could be bridged through more thoughtful knowledge translation and dissemination approaches [100]. However, dissemination research has developed at a much slower rate when compared to implementation research. For every dissemination science article published, there are approximately 25 implementation science articles [11]. This shows a clear need for using dissemination science to open up the field such that more people are familiar with the work that we do and the different types of evidence that we generate. Otherwise, we run the risk of not optimizing the value of our work for policy and practice [40]. Transformative participation through the engagement of different public parties, including; interested citizens and those who are skeptical about our work, communities, policymakers, implementers, funding agencies and other implementation scientists can ensure more effective dissemination [101]. For instance. Citizen panels have been used in Uganda to enhance evidence-based policy making and community treatment observatories have been used in different countries across Africa to enhance HIV service delivery [63, 102]. Learning health systems (LHS) provide an opportunity through which transformative participation of different actors can be realized. LHS rely on meaningful collaborative partnerships amongst stakeholders (including the engagement of communities and the general public who are often left out) in a learning community who are involved in the execution of the entire cycle from design to implementation and delivery of interventions [103]. This reduces the lag between the generation and uptake of the implementation science knowledge while ensuring the information is relevant. Shared activities during the course of implementation can be thought of as windows of opportunity through which information tailored to specific audiences can be disseminated through user friendly tools [26]. In addition, IS training can be more strategic by incorporating approaches to training facilitation that empowers communities, researchers, policymakers and practitioners in LMICs to engage and utilize research findings [56].

Theme 6: We did not open the field of implementation science up to enough new voices through robust training

There has been a significant growth of opportunities for training and capacity building in implementation science across the continent. Universities in Anglophone, Francophone and Lusophone speaking countries in Africa are running different programmes to provide training [4]. At the University of Zambia, we have been providing training for graduate students and short term training to different implementing organizations across the country since 2015 through funding from of the Special Program for Research and Training in Tropical Diseases (TDR) and the NIH (through the ZENITH and UVP-2 Programmes) [16]. Over 35 Fellows have graduated from Masters programmes while more PhD and Masters students are currently in training. Nevertheless, to realize robust and resilient health systems, a further critical mass of professionals equipped to conduct dissemination and implementation science are needed.

Capacities at individual, team and institutional level remains insufficient to adequately match the research and practice needs within the African continent. Training models are often short-term, do not provide hands on or longitudinal-mentored experiences, are focused largely on masters-level training without sufficient opportunities for dedicated doctoral and post-doctoral training, and, are, thus, not suited to building deep implementation science expertise and to sustaining trainees’ interests in the field long-term. Curricula, textbooks and other learning resources used in capacity building programmes are not exhaustive, are often Euro/American centric and use delivery methods that do not critically engage with the nature of local contexts. Moreover, while self-study and on-the-job experience are the most common forms of knowledge and skills acquisition for implementation scientists, opportunities to structure, strengthen, and scale these learning modalities are still insufficient [83]. Technological advances could be leveraged to enhance learning experiences and make them more widely available, particularly to busy front-line implementers and practitioners.

There is a need to make training initiatives more contextually grounded and practical using practicum experiences alongside coursework to build core IS competencies as a way of improving our capacities at different levels [82, 83, 104]. The jargon and language of the field which is too often needlessly complex should be taught using instruction models that balance between practical and theoretical components to make the teaching more acceptable, accessible, and effective [51]. There is a need for more cross-institutional training whereby trainees from academia can be embedded within industry, government, non-profit and non-governmental organizations while persons in those organizations can be placed in academic institutions. During training, mentors assigned to trainees should have a deep understanding of the context and the underlying mechanisms that determine what aspects of the interventions work or don’t work, and how and why that may be the case [105]. Whenever possible, trainees should be drawn from practice settings themselves and mentors selected who have deep and nuanced understanding of implementation context gleaned from immersion and work in such settings.

Practitioners and communities tend to be left out of the sciences because capacity building initiatives tend to be based in academic institutions which tend to internally focus more on researchers than anyone else. Approaches such as learning health systems and citizen science can help build stronger partnerships between different actors involved in implementation, who can promote active learning of implementation science knowledge (e.g. between clinical teams and academic partners or between communities and non-governmental organizations) [106]. Information flow in such a system is bidirectional between those generating new knowledge and those generating new insights in practice from the translation of this knowledge [107, 108]. To maximize this synergy, implementers can be trained in programme as well as implementation science to apply insights from the field in the settings where they practice. A recent example from Ghana is a good illustration of how comprehensive IS training can be rolled out to engage a broad range of actors [109]. Their model had three phases; an initial engagement of relevant programme implementers and implementation science community to identify participants, a competency building phase to roll out resources and facilitate proposal development, and hands-on practical guidance to execute funded proposals while integrating them into existing programmes [109].

In addition, implementation support practitioners ( i.e. professionals who are not directly involved in service delivery or management but work closely with program staff to effectively deliver, scale and sustain evidence based interventions) can facilitate learning across systems and translation of evidence but they are not commonly utilized in many low-resource settings due to minimal funding and poor definition of their roles [110, 111]. Complementary investments in operational research and programme science can help implementation support practitioners get the most “research out of practice” to spark further implementation science inquiry [112]. In Zambia, programme science approaches have been used to meaningfully engage frontline implementers and community-based organizations in understanding the effects of programme innovations on the reach of HIV prevention services among marginalized key populations. Finally, funding investments towards implementation scientists can facilitate their retention in African institutions [113, 114].

Conclusion

Implementation science generates knowledge that has the capacity to aid in the transformation of health and health systems. Applying a critical lens to evaluate the current state and potential future of the field elucidates some areas for further investment. As a team of authors conducting implementation science within a diverse range of settings in Zambia, we have identified potential failures on which we can all reflect upon. Our reflections build upon previous work and we hope it provides additional insights that can propel the field forward, particularly for those in LMIC settings [27]. The key themes identified in the commentary challenge us to consider the local conditions and social cultural foundations of our work. It also asks us to attend to the histories of our contexts across time and space using a broad range of theoretical positions, methodologies, and complementary disciplines, including Afrocentric ones, to examine implementation [45], while also being reflexive of ourselves and the politics that shape our contexts and impact implementation efforts [104]. It calls for more, not less, global collaboration and solidarity, but in ways that appropriately value deep contextual understanding gleaned through immersion in practice settings and equitable partnership among individuals, communities, healthcare providers, implementing organizations, and health systems from the global north and south alike. We hope that this commentary will spur more discussions on how insights from implementation researchers and practitioners in Africa and other low-resource settings are making meaningful progress and can push the field forward. To that end, there is an urgent need to catalog and specify LMIC-derived implementation strategies, develop implementation measures responsive to LMIC practice settings, create foundational frameworks that acknowledge the centrality of health system building blocks and their strengthening to implementation science in LMICs, and to train the next generation of LMIC implementations scientists in all of the above. We are hopeful about the future of implementation science in LMICs because we have seen the transformative change that it can bring about for improved outcomes, including global health equity across several sectors such as health, early childhood education, and social protection.

Data availability

Data sharing is not applicable in this article.

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Acknowledgements

We would like to acknowledge Ramya Kumar, Tinanganji Banda and Mungabo Choongo for their feedback on the paper.

Funding

There was no funding for this article.

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Authors and Affiliations

  1. Implementation Science Centre for Advancing Practice and Training (IMPACT), University of Zambia, Lusaka, Zambia

    Patricia Maritim, Margarate Nzala Munakampe, Mweete Nglazi, Wilbroad Mutale & Hikabasa Halwindi

  2. Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia

    Patricia Maritim, Margarate Nzala Munakampe, Chris Mweemba, Adam Silumbwe, Joseph Mumba Zulu & Wilbroad Mutale

  3. Implementation Science Department, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia

    Kombatende Sikombe & Michael Herce

  4. Ministry of Health, Lusaka, Zambia

    Wilson Mbewe

  5. Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia

    Choolwe Jacobs

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  1. Patricia Maritim
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Contributions

PM and HH conceptualized the study and led the data collection. All authors took part in the premortem data generation exercise. PM, MNM, MN, WM and HH analysed and interpreted the data. PM drafted the initial manuscript. CM, KS, WM, CJ, AS, JMZ & MH contributed to drafting the revised manuscript drafts. All authors reviewed and approved the final manuscript.

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Correspondence to Patricia Maritim.

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Maritim, P., Munakampe, M.N., Nglazi, M. et al. Lost in translation: key lessons from conducting dissemination and implementation science in Zambia. Implement Sci Commun 5, 121 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s43058-024-00663-z

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s43058-024-00663-z

Implementation Science Communications

ISSN: 2662-2211