Introduction

• Overview of the health system and setting (context).
• Description of the nature of the problem.
• Analysis of the different factors that may influence the problem.
• Description of solutions tried (background) and the justification for further research.
• Information expected from the research and how this information will be used to solve the problem (outcomes).

To accomplish this, succinctly write about each of the items listed below. Just start writing and do not worry about how your ideas sound initially or about perfecting what you write. During the proposal development process, you will continually change, elaborate, delete and edit the introduction as you progress with researching and discussing the topic provided.

• Overview of the health care system in the country/region/district/community as these are relevant to the problem. Include illustrative statistics (if and when appropriate and/or available) to describe the context in which the problem occurs.
• Description of the nature of the problem.
• Analysis of the various factors that may influence the problem – why some factors need to be investigated.
• Brief description of any solutions to the problem that have been tried in the past (background), how well they worked and why further research is needed (justification for the study).
• Description of the type of information expected to result from the IR study and how this information will be used to solve the problem (outcomes).

There are four components to a good title:

• Use ‘action’ words rather than passive language.
• Reflect implementation and intervention themes.
• Include specific target populations (adolescents, children under five year of age, etc.).
• Refer to specific geographic location(s).

The title may not differ significantly from that of other research proposals, but the topic it addresses will reflect a need identified within the community. It is possible that you may also include “Implementation research” in your proposal title in order to highlight that you are applying for a research grant that is specific to IR.

Every IR proposal needs a robust rationale to present the case to policy-makers and/or funding agencies outlining the benefits of committing scarce resources to the proposed research project. The introduction section of the proposal must therefore strongly justify why the research problem you have identified is important and worthy of support. Justification should also be provided explaining how the selected research problem aligns with the national research agenda. To provide this justification, it is useful to begin by providing evidence through a systematic analysis of existing information.

Information to support your literature review can be found from a variety of resources and locations including:

• local documentation (e.g. related project progress reports, theses, dissertations, seminar proceedings);
• programme progress, annual or evaluation reports;
• medical and social science literature, including reviews that outline gaps in research and/or programmes;
• research results in journal articles and scientific publications;
• abstracts/presentations/papers from scientific meetings and conferences;
• new ideas/recommendations from previous research;
• funding agencies’ annual reports;
• questions asked by programme staff and/or students.

An IR project has its origin in the recognition of a problem that impedes the effective implementation of an intervention, strategy or policy, and that requires specific new understanding in order for the problem to be addressed.

If, for example, a malaria control programme has concerns over low levels of bed-net ownership in a given district – and yet its stores are filled with undistributed bed-nets – the programme may best be served by strengthening the distribution of the bed-nets rather than embarking on research to explore the problem.

The statement of the problem is an important part of the IR proposal because it:

• summarizes the purpose of the study;
• establishes the direction and captures the essence of the study;
• succinctly outlines the purpose and objectives of the study;
• reflects the research design;
• leads to the research question(s).

How to know if the problem is worthy of research?

To confirm that the problem identified constitutes an appropriate research project, you can ask the following questions:

• Is there a perceived difference or discrepancy between the situation that exists and the ideal or planned situation?
• Is there a clear reason for the difference or discrepancy in relation to the problem?
• Is there more than one possible answer or solution to the problem?
• Do current programme implementers/policy-makers identify the problem as a priority?

To ensure that you have identified a legitimate problem in need of research and worthy of funding, strategically situate your proposal so that it:

• enables researchers and stakeholders to critically evaluate existing knowledge, to pool this knowledge and to identify gaps that an IR project should fill;
• clarify the problem and the possible factors that may be contributing to it;
• facilitate decisions concerning the focus and scope of IR (relate significance to specific aims).

These three considerations should be emphasized in the introduction of your proposal and help formulate the rationale for conducting the research. Reflecting upon these considerations is also important in helping you first think broadly, and to subsequently narrow your focus to identify research objectives within that broader context.

The term ‘statement of the problem’ may be misleading as it usually comprises of a self-contained paragraph, rather than a single statement. Here are some brief, additional suggestions to help ensure clarity:

• Use terms/ideas such as ‘purpose’, ‘intent’ and ‘objectives’ to highlight the main idea underlying the research.
• Identify the key concepts being explored.
• Describe the research design (e.g. case study, ethnographic study, descriptive, correlational, experimental).
• Highlight the unit of analysis in the study (e.g. independent and dependent variables, population, classroom, organization, programme, event) and data collection methodologies (e.g. surveys, interviews, observations).

Consider the following examples to guide you in the development of your statement.

To help you narrow your focus on, clarify and describe the core research problem from a broad perspective, it helps to consider the viewpoints of different stakeholders and to begin identifying the factors that may have contributed to the problem.

The research team should now be able to develop an overview of the problem and, through a systematic analysis of existing resources and literature, provide a rationale for why conducting the proposed research would provide answers, solutions or alternative strategies to the identified problem.

Follow the steps below to help narrow the focus and identify specific research objectives within the broader context of the research problem:

a. Clarify the viewpoints of all stakeholders.

• List all the problems.
• Illustrate existing discrepancies.

e.g. In relation to an increased defaulter rate among TB patients:

• Poor health services management, as identified by policy-makers.
• Social stigma associated with TB, as identified by affected communities.
• Negative attitudes of health workers, as perceived by service users.

b. Specify and describe the core problem.

• Quantify the problem.
• Describe the problem in detail.

e.g. In relation to an increased defaulter rate among TB patients:

• How widespread is the observation? Which regions/settings are persistently affected? Are there certain areas that may be potential low-compliant areas?
• Who is affected the most?
• How severe is the problem? What are the consequences? e.g. increasing morbidity, deaths, a waste of resources, development of multidrug resistance.

c. Identify the factors that may have contributed to the problem and clarify their relationship to the problem.

e.g. In relation to an increased defaulter rate among TB patients:

• Staff who are poorly trained because there are inadequate materials on TB.
• Health educators who have little understanding of patient prescriptions and do not provide systematic advice and counselling to patients. This results in patients not understanding treatment requirements and a high default rate.

Focusing on the core research problem may be best carried out by means of a problem analysis diagram depicted in Figure 4.

In IR studies, because the research problem is identified by and articulated by people who implement programmes, the tendency is to phrase the IR objectives in the typical way that programme objectives are stated, e.g. “to increase the Expanded Program on Immunization (EPI) coverage from 45% to 80%”, rather than as research objectives, i.e. “to explore factors contributing to the poor EPI Coverage.”

In addition, you need to consider whether the research is:

• relevant;
• new or innovative;
• urgent;
• politically acceptable;
• ethical.

When writing the research objectives, ensure that the team addresses the following questions:

• Is the research realistic? Describe the complexity of the proposed research. Are there adequate resources to carry out the research? Is it feasible to conduct and report the findings in 12 to 36 months?
• Is the research timely? You should provide a rationale for why your research is timely, and convince readers of the urgency for research in this area in order to generate information/solutions to problems affecting a specific community.
• How is the research relevant? Describe how large or widespread the problem is, who it affects and, and who considers it a problem. Also, refer to the potential for the disease/condition to spread/increase if not treated, the potential burden to the health system, and existing or potential economic impacts of the problem on the target population.

Is the research new or innovative?

Point out how the research will add value by doing something new or expand/improve upon something already in existence. You need to convince readers that you are not duplicating something that has already been done.

Is the research urgent?

Consider how the research results are urgently needed by policy-makers, implementers and health care providers in order to provide evidence to create a change, implement an intervention or put a stop to current practices.

Is the research politically acceptable?

IR projects should typically address topics of high interest to local and national authorities. It is advisable to involve policy-makers in the project design to ensure political acceptability and facilitate implementation of study results.

How will the results and/or recommendations be applicable to the target community?

Explain the likelihood of the adoption of the recommendations resulting from the research and how the findings will be used to improve health and health care. 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.

Is the research ethical?

Explain how the research will be beneficial to members of the community being studied. How will the research findings be shared with the target group? Can informed consent be obtained from the research participants? How will you take into account the condition of the participants?

a. Overall objectives

The overall objectives of an IR project should outline the purpose for conducting the research. It should also:

• state clearly what the study is expected to achieve in general terms;
• align with the broader social, economic and health concerns outlined in the overview of the introduction, and further focus the context of the research down to an essential purpose.

Different funding agencies use varying terminology to describe and characterize objectives, goals, aims etc. Sometimes these terms are used interchangeably.

b. Specific objectives

Specific objectives are a breakdown of general objective(s) into measurable action statements that outline what will be done, where and for what purpose. Here are some brief suggestions for framing specific objectives:

• Use action verbs when defining specific objectives (e.g. determine, compare, verify, calculate, describe, establish, evaluate).
• Avoid the use of vague, non-action verbs (e.g. appreciate, understand or study). Use verbs such as: train, supervise and distribute when describing project activities.
• Resist the temptation to put too many or over-ambitious specific objectives in your IR proposal that cannot be achieved.
• Ensure that the different aspects of the problem and its contributory factors are covered logically and in a coherent manner by the specific objectives.

After formulating your specific objectives ask yourself the following questions: Are the specific objectives clear, defined in operational terms that can be measured, realistic? Do they demonstrate what the research will do, where and for what purpose?, and, how will the research results will be used to solve the research problem?

Should be of interest to the researchers, policy-makers; decision-makers, funding agencies, health care providers and the community the research will affect. In addition, research questions:

• are answerable;
• are shaped by the problem and in turn shape the design of the research;
• are clear and specific;
• provide important information required to evaluate ongoing interventions and/or progress;
• analyse possible causes for missed/failed targets (in order to find solutions).

An IR question aims to achieve one or more of the following:

a. Describe the health situation and intervention (include both situations and interventions in place, as well as potential/new interventions). For example:

• Magnitude of the problem.
• Distribution of the health needs of the population.
• Risk factors for specific problems.
• People’s awareness of the problem.
• Utilization patterns of relevant services.
• Cost-effectiveness of available and potential/new interventions.

b. Provide information required to evaluate ongoing interventions or progress and needed for making adjustments in the intervention. For example:

• Coverage of priority health needs.
• Coverage among target groups.
• Acceptability of services.
• Quality of services.
• Cost-effectiveness of the intervention(s).
• Impact of the programme on health outcomes.

c. Analyses possible causes for missed targets in order to find solutions. i.e.:

• Availability.
• Acceptability.
• Affordability.
• Service delivery challenges/barriers.

This information is required to formulate adequate policies, adapt or plan an intervention, and assess progress and the need for adjustments.

As your team conducts its own implementation research, remember that the research question determines the methods, and the purpose determines the design. IR questions address the design, implementation and outcomes of programmes. IR also explores the following questions: Are there any unintended consequences? Why is it happening as it is? IR questions are driven by implementation problems and should be designed for action-oriented research in collaboration with stakeholders.

In light of this, IR questions:

• Primarily address the needs of policy-makers, programme managers and health care providers, not just those of the researcher(s).
• Describe the health situation and interventions (include interventions in place and the potential ones).
• Provide information required to evaluate ongoing interventions or progress needed for making adjustments in the interventions.
• Analyse possible causes for missed targets (i.e. in order to find solutions).

Table 2 provides examples of how various research and IR domains – such as epidemiological, clinical efficacy and programme effectiveness – respectively address a question of zinc deficiency and diarrhoea.

Formulating IR questions

Once the problem has been identified, the next step is to formulate a question addressing that problem. Your approach depends on the particular context and availability of information.

Therefore, engage programme stakeholders early to formulate IR questions. The way questions are formulated drives research methods. These are helpful sources for formulating IR questions:

• Programme progress, annual or evaluation reports from monitoring and evaluation activities.
• Medical, health and social science literature, meta-analyses, and literature reviews.
• Scientific meetings and conferences.
• New ideas from previous research or formative qualitative studies (e.g., interviews).
• Funding agencies’ annual reports.
• Questions asked by programme staff and students.
• Local documents – project progress reports, theses, dissertations, seminar proceedings.
• Annual review or dissemination meetings.
• Geographic information systems (GIS) data that identify geographic location and distribution of problems.

A programme may generate multiple implementation problems and questions, simultaneously. This can be overwhelming, so it is important to prioritize IR questions, to ensure efficiency and the responsible practice of IR. The criteria shown in Table 3 help with prioritizing IR questions.

The review of literature synthesizes the relevant and most up-to-date information on the proposed research topic and frames the research question(s) being investigated. A literature review should demonstrate that you have read the existing work in the field with insight, thereby providing the reader with a picture of the current state of knowledge and of major questions in the subject area that are also being investigated.

A thorough literature review enables you to avoid duplicating existing research by discovering what research has already been conducted on a given topic. Reviewing the existing literature will help you refine your statement of the problem, analyse various approaches already used in related studies, and assist in forming a convincing rationale for your research. By reading your overview, readers should be convinced that you are familiar with the topic and that you have carried out extensive background research in the field.

A literature review:

• Involves comprehensive literature searches to identify relevant and up-to-date resources, reading and synthesizing the existing information and literature into a succinct overview.
• Demonstrates the relevance of proposed research by establishing what is already known about the research problem and how it has been approached in the past.
• Provides a rationale for why it is crucial to conduct the research.
• Highlights what is not known about the topic.
• Helps you refine the statement of the problem.
• Frames the ‘state of knowledge’ on the topic and sets up the research question(s) being investigated.
• Establishes credibility.

You should strategically situate your research problem in the existing knowledge and literature, in order to establish a rationale for why it is important that your identified problem should be researched. Writing this kind of rationale is the first step in developing the synthesis of existing knowledge for an IR proposal.

Conducting a literature review involves reviewing the existing knowledge and carrying out library searches to find relevant resources (i.e. research articles, research studies, reports, government documents, and white papers), reading, and then organizing and synthesizing the information into a succinct overview of the topic. You may find that you need to read about the topic for several days or weeks before beginning to compile or collate available information. At some point, however, you do need to begin to draft the review content. Often you will find that once you begin to write, the process can feel overwhelming and you need to go back and do some more reading. You need to look for major concepts, read with a purpose, be a critical reader and try to write while still reading and reviewing. Writing, reading and re-writing is typically an iterative process. As such, developing a comprehensive synthesis of the existing information can be a protracted task.

Ultimately, a literature review should aim to:

• Present an argument based on existing information and publications.
• Synthesize information from many sources.
• Critique research studies for methodological shortcomings (when and if appropriate).
• Support your research question through analysis and synthesis.

The review of literature is not merely an expression of the research team’s opinion of an issue or topic, but instead presents an objective argument based on existing information, including published literature. An effective synthesis doesn’t depend on, or elaborate upon, one or two studies, but synthesizes the existing information from various sources. It should be well written with one paragraph logically flowing into the next. A literature review does not simply describe or summarize the content of cited articles/publications, but critiques research studies for methodological shortcomings, as appropriate.

It may have been acceptable previously for proposals not to provide a strong synthesis of the existing knowledge due to the research team’s location and lack of access to libraries and resources. That is no longer the case now that anyone who has access to the Internet can explore most of the existing literature. Several search engines, such as Pubmed (http://www.ncbi.nlm.nih.gov/pubmed), Hinari (http://www.who.int/hinari/en/) and Google Scholar (http://scholar.google.com) will be helpful in this regard. You can also work with a librarian, or assign a specific member of the project team to help you find and access the information you need.

Referencing

The ideas included in the review of literature should have a logical flow and should be properly cited using the reference style (e.g. Chicago, Harvard etc.) required by the agency to which the proposal is being submitted. There are various software programmes available to help manage, store and use references effectively (e.g. EndNote, Mendeley). If possible, install the 30-day trial EndNote software or the free Mendeley software onto your computer.

It is essential that you use and cite references properly and consistently, and in accordance with the applicable style guide. Not adhering to the conventions of proper referencing suggests sloppy organization and may hamper the chances of a proposal being successful. Moreover, if you do not reference properly, you run the risk of plagiarizing content and/or ideas, which can have severe career and academic ramifications. There are programmes that can help you check against plagiarism during your write up. An example is Desktop Plagiarism Checker (https://desktop_plagiarism_checker.en.softonic.com/).

All the references cited within your proposal (and only the ones cited in your proposal) must be listed in the references section of your proposal document.