Example 1: In Vietnam

In Vietnam, after the introduction of user charges in 1989, several provincial health insurance schemes were developed. In these schemes, industrial workers, constituting a minority of the population, were in principle insured on a compulsory basis, while other citizens (including farmers in the rural areas), could join on a voluntary basis. However, less than 2% of the rural target population was enrolled in the voluntary health insurance in 1999. The problem here was the low enrolment in the health insurance scheme and by extension, limited access to health care in the rural population.

Example 2: In District Y

In District Y (population 145 000), sanitary conditions are poor (5% of households have toilets) and diseases connected with poor sanitation such as hepatitis, gastroenteritis and worm infestations are very common. The Department of Health has initiated a sanitary project that aims to increase the percentage of households with toilets by 15% every year. The project provides materials and the population is expected to provide labour. Two years after the programme began less than half the target was reached. (adapted from Varkevisser et. al. 1991)

Case study 1: Is your research problem justifiable?

Background: Any worthy research should be preceded by a knowledge gap. Accordingly, in implementation research, the knowledge should be used to overcome any identified bottlenecks to improve health service delivery. Therefore, any proposed research should address the discrepancy between the observed status and what is desired. Furthermore, a successful research project should be able to garner the support of the relevant stakeholders. Hence it must be acceptable, relevant, a priority, politically acceptable, timely, ethically sound, urgent and feasible. The table presents an analysis of the above variables for a study that set out to determine the barriers and motivators to voluntary medical male circumcision (VMMC) uptake among various age groups of men in Zimbabwe. The aim of the analysis is to establish if the research was justifiable.

Variable Explanation
Was there a discrepancy between the situation that existed and the ideal? Yes: The programme started in 2009, but as of September 2013, only 170 000 men were reached against a five-year target (2013–2015) of 1.9 million.
Was the research a priority? Yes: In 2009, Zimbabwe was one of the priority countries identified by WHO/UNAIDS to scale up VMMC. But after four years of implementation, a coverage of only 4.8% of the target population was achieved. Therefore, understanding the barriers and motivators to VMMC uptake can create a will an effective demand to address them as an urgent priority.
Was there a clear reason for the difference or discrepancy to the problem? No.
What factors could explain this difference? Negative attitudes towards circumcision; fear of pain; fear of complications; perceived threats to masculinity; costs.
Were the results urgently required by stakeholders e.g. policy-makers, implementers, health care providers Yes: There was a need to establish why the programme was not achieving its set targets.
Was the research politically acceptable? Yes: The project was run by the Minstry of Health (MoH) and Population Services International (PSI), and therefore had political support. The topic was of high interest to local and national authorities.
Was the research ethically sound? Yes: Results were shared with the stakeholders, research group and were beneficial to the community. Furthermore, informed consent was obtained from the research participants?
Were the recommendations applicable to the target community? Yes: The recommendations were used to craft context specific IEC (Information, Education and Communication) messages.
Specific goodwill ambassadors were identified within the community.
[Demonstrate that you have done your homework and are aware of resources available, as well as any additional resources needed to facilitate implementing the recommendations].
Was the research timely? Yes: Because despite the rapid scale up of service provision, uptake of VMMC had been slower than expected.
Was the research relevant? Yes: HIV is a public health problem affecting a significant proportion of the population, in terms of health as well as social and economic impacts.
Was the research new or innovative? Yes: The results identified other target populations such as women for the information, education and communication messages.
Other modes of dissemination were also identified.
Was the research feasible? Yes: Human resources to collect the information and implement the recommendations were available and WHO and PSI were willing to support the research.

Conclusion: The study to determine barriers and motivators to VMMC uptake among different age groups of men in Zimbabwe was justifiable because there was a discrepancy between the status and the desired state, the information was needed urgently, the research was politically acceptable to the stakeholders, and it was ethically sound and feasible to conduct in terms of human resources, time and funding.

Source: Hatzold K. et al. Barriers and motivators to voluntary medical male circumcision uptake among different age groups of men in Zimbabwe: results from a mixed methods study. PLoS One. 2014; 9(5):e85051.