How IR works

Each aspect of the IR process is crucial to project success, and the degree to which individual steps are interconnected in practice increases the dissemination and uptake of the IR findings (see Figure 2). For this reason, the composition of the IR team should be multidisciplinary, bringing together people with relevant skills, backgrounds and experiences.

Stakeholders can play a crucial role in disseminating the IR findings through their own networks, supporting any recommended changes in the delivery of the intervention and promoting uptake within their networks.

An IR project has many overlapping steps that do not necessarily occur in a linear manner. The roadmap in Figure 3 illustrates the timings and steps in the IR process. Remember that each context is different and has its own complexities, so this roadmap should be adapted to your situation. The timing for an IR project will depend on the intervention problem and research methods chosen. This sample roadmap indicates some of the key overlapping activities that occur throughout an IR project.

Unlike other types of research – where the setting is controlled to create an ideal situation for success – IR is conducted in real life contexts and must necessarily address problems identified in the course of delivering an intervention in context. The research team does not manipulate the setting in any way and allows life to go on “as usual”. Factors such as political changes, health staff circumstances (e.g. staff changes or transfer), physical settings (e.g. natural disasters and geographic terrain), tradition (cultural, religious, institutional), stakeholder characteristics and public health related issues (e.g. disease outbreaks and epidemics) influence the real-life context in which an intervention takes place. These factors, which can be broadly classified as physical, socioeconomic and cultural environments, health systems, stakeholders and institutional cultures are key aspects of the research context in IR and require critical analysis to ensure that the research questions are framed in context. Together they contribute to and affect the planning, implementation, monitoring and outcomes of any intervention.

During an IR project, the key contextual factors should be analysed objectively (Figure 4). These factors vary considerably from one location to another and can be impacted by international, regional, national and local events.

Various aspects of the socioeconomic and cultural context can impact the delivery of an intervention such that an intervention that was effective in one locale could well be ineffective due to constraints inherent to the culture or circumstances. These factors also change over time as societies transition.

Geography can have a profound effect on the delivery of an intervention especially when related to access to health services and health interventions. Location of a target population (rural/urban), distance from the central facility or capital, physical barriers (such as mountains, rivers), extreme weather conditions, infrastructure (transport systems, electricity and water) and demographics (population size, distribution by location, gender and age) must be analysed where relevant to put the problem in context.

The general standard of living and level of inequality, as well as identification of vulnerable groups and socioeconomic status based on income levels, assets, educational status and occupation should analysed. The main types of dwellings (e.g. communal huts, apartments or gated communities), by location, food consumption, nutrition, access to clean water and sanitation etc. should also be analysed.

Analysis of cultural beliefs related to health, gender equality, literacy rates, ethnicity/tribal segregation related to the following should be conducted;

  1. policy environment and political factors, including the level of support for social services and health care services;
  2. government capacity to provide services
  3. ongoing or recently introduced health interventions should be conducted.

Engaging stakeholders in an IR project involves face-to-face consultations and discussions from the national to the community level – not just briefing the stakeholders and seeking their approval for the study, but actively involving them in the various discussions, decisions and negotiations.14

Conducting a stakeholder analysis is one of the most important activities undertaken by researchers in terms of understanding the context of the intervention, and should be done in a systematic and comprehensive way.16 17 18 The objective of the stakeholder analysis is to identify all relevant stakeholders, assess how they are likely to be affected by the research, and how they might respond to the research outcome. Stakeholder identification requires careful judgment, should not be exclusive (limiting the breadth of perspectives) or over-inclusive (diluting essential focus).

Depending on the IR issue of interest, stakeholders could include (but are by no means limited to):

  • Policy-makers and political leaders. Representatives who will ensure that health workers and end-users of the study are properly informed of any shift in policy.
  • Health care providers at facility and community level. Include health professionals in government and private medical facilities, traditional healers and drug sellers, managers of drug shops etc. who have been providing health care in a particular way for a long time. Since change does not come easily, it is critical to involve them in the design and implementation of any strategies that will enhance programme implementation.
  • Media specialists. Consulting this group of stakeholders is critical since with their capacity to communicate, they can help to share the results of an IR project widely.
  • Community members. It is at the community/village level that all health care interventions are implemented. In this light, community members can help ensure maximum support. Consultations at the community level should cut across all social, political and religious lines. Constant interaction is crucial for success and to ensure that the activity or proposed intervention is not discredited.

Engaging stakeholders often requires a similar approach and set of skills as creating a successful IR team, and the two activities can be usefully seen as forming a continuum (see “Module on Building an IR Team”).

The box highlights how stakeholder analysis was used in one instance to assess the perceptions, aspirations and expectations of a range of stakeholders in order to assess the policy environment prior to the introduction of a series of health service innovations.

An institutional analysis (a systematic study of the behaviour of organizations) is another important dimension to consider in planning for an IR project. This can be achieved through an analysis of strengths, weaknesses, opportunities and threats (or ‘SWOT’) associated with institutions that could potentially interact with the IR team in the course of the project, and with the intervention under study. A SWOT analysis will help establish the institutional factors with a potential impact on the success or failure of a given intervention.

Core research questions of IR projects are driven by implementation problems/issues and should be formulated in collaboration with stakeholders, including implementers, programmes or decision-makers in the health system, and should be designed to suit action-oriented research. As a result, IR is typically conducted within the health system, at least in part. One of the main purposes of analysing the health system is to predict how specific considerations might potentially affect the viability and impact of an intervention.

Figure 5 illustrates the many components of a health system beyond the health centres, clinics or hospitals that are found in the formal health sector.21 For example, community members may have a strong belief in the informal health sector and access it alongside the formal health system. From the community level, right up to the national level, there are various non-health ministries, departments and agencies whose work directly or indirectly impacts health care provision. The critical roles these stakeholders play must be fully considered in any IR study. For each component that is relevant to a specific IR project, it is helpful to undertake a systematic descriptive analysis to help identify the relevant decision-making agents and both the formal and informal institutions that govern its operation. All these complex, real-life interactions need to be considered when addressing IR. These complex interactions of individuals, groups, institutions, the family and society and the pluralistic health care systems that are available in many countries not only influence the health of people, they also affect the health services and health care provision in the formal and informal sectors.

Many health initiatives give rise to what can be described as ‘complex adaptive systems’ (CAS), a theory based on relationships, emergence, patterns and iterations.22 23 24 The underlying idea being that a myriad of complex systems continuously interact and trigger subsequent adaptations in their immediate environment. A CAS involves a large number of interacting agents, which have adaptive capabilities. They adapt in response to a changing environment, the context and to changes induced by a given intervention. The implication of this notion is that it is difficult to ‘control’ agent behaviour in real life situations. CAS are intrinsically unpredictable and unintended responses to interventions often occur. Therefore, understanding the CAS phenomena is important for better awareness, planning, implementation, monitoring and evaluation of approaches to scaling up health services.

CAS can result in unexpected behaviours in the context of health interventions through, for example, feedback loops, path dependence and emergent behaviours.

TDR Implementation research toolkit(Second edition)

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