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Costing the implementation of public health interventions in resource-limited settings: a conceptual framework

ABSTRACT: Background Failing to account for the resources required to successfully implement public health interventions can lead to an underestimation of costs and budget impact, optimistic cost-effectiveness estimates, and ultimately a disconnect between published evidence and public health decision-making. Methods We developed a conceptual framework for assessing implementation costs. We illustrate the use of this framework with case studies involving interventions for tuberculosis and HIV/AIDS in resource-limited settings. Results Costs of implementing public health interventions may be conceptualized as occurring across three phases: design, initiation, and maintenance. In the design phase, activities include developing intervention components and establishing necessary infrastructure (e.g., technology, standard operating procedures). Initiation phase activities include training, initiation of supply chains and quality assurance procedures, and installation of equipment. Implementation costs in the maintenance phase include ongoing technical support, monitoring and evaluation, and troubleshooting unexpected obstacles. Within each phase, implementation costs can be incurred at the site of delivery (“site-specific” costs) or more centrally (“above-service” or “central” costs). For interventions evaluated in the context of research studies, implementation costs should be classified as programmatic, research-related, or shared research/program costs. Purely research-related costs are often excluded from analysis of programmatic implementation. Conclusions In evaluating public health interventions in resource-limited settings, accounting for implementation costs enables more realistic estimates of budget impact and cost-effectiveness and provides important insights into program feasibility, scale-up, and sustainability. Assessment of implementation costs should be planned prospectively and performed in a standardized manner to ensure generalizability.

SUBMITTER: Sohn H

PROVIDER: S-EPMC7526415 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Project description:One of the major debates in implementation research turns around fidelity and adaptation. Fidelity is the degree to which an intervention is implemented as intended by its developers. It is meant to ensure that the intervention maintains its intended effects. Adaptation is the process of implementers or users bringing changes to the original design of an intervention. Depending on the nature of the modifications brought, adaptation could either be potentially positive or could carry the risk of threatening the theoretical basis of the intervention, resulting in a negative effect on expected outcomes. Adaptive interventions are those for which adaptation is allowed or even encouraged. Classical fidelity dimensions and conceptual frameworks do not address the issue of how to adapt an intervention while still maintaining its effectiveness.We support the idea that fidelity and adaptation co-exist and that adaptations can impact either positively or negatively on the intervention's effectiveness. For adaptive interventions, research should answer the question how an adequate fidelity-adaptation balance can be reached. One way to address this issue is by looking systematically at the aspects of an intervention that are being adapted. We conducted fidelity research on the implementation of an empowerment strategy for dengue prevention in Cuba. In view of the adaptive nature of the strategy, we anticipated that the classical fidelity dimensions would be of limited use for assessing adaptations. The typology we used in the assessment-implemented, not-implemented, modified, or added components of the strategy-also had limitations. It did not allow us to answer the question which of the modifications introduced in the strategy contributed to or distracted from outcomes. We confronted our empirical research with existing literature on fidelity, and as a result, considered that the framework for implementation fidelity proposed by Carroll et al. in 2007 could potentially meet our concerns. We propose modifications to the framework to assess both fidelity and adaptation. The modified Carroll et al.'s framework we propose may permit a comprehensive assessment of the implementation fidelity-adaptation balance required when implementing adaptive interventions, but more empirical research is needed to validate it.

Project description:BackgroundNumerous determinants have been linked to public mental health; however, they have not been brought together in a comprehensive conceptual framework. The goal of this work was to bring together academic research, practitioner expertise, and public perspectives to create a public mental health conceptual framework.MethodsThe development process proceeded in four stages. First, we identified a comprehensive list of potential determinants through a state-of-the-art academic literature review, grey literature review, and created mind maps created by peer researchers. Next, we conducted in-person workshops, consultations, and an online survey with academics, practitioners, policy makers, and members of the public to review the potential determinants, nominate additional determinants, and prioritise determinants by importance for understanding public mental health. This iterative process resulted in the final list of determinants contained in the framework. We then conducted rapid reviews to define each determinant and to identify key research, interventions, and resources. Finally, we worked with a design team to visualise the conceptual framework as an online tool and printable infographic.ResultsWe found substantial overlap between sources reflecting a shared understanding of the key drivers of public mental health. The unique determinants that emerged from each data source highlighted the importance of using multiple sources to create a comprehensive model. 72 potential determinants were prioritised through stakeholder consultations, resulting in a final list of 55 determinants and organised into four levels: individual, family, community, and structural.ConclusionsThis is the most complete conceptual framework for public mental health to date, bringing together academic research, policy and practitioner views, and lived experience perspectives. The co-production processes and tools we used provides a template for researchers looking to include multiple perspectives in their research. The conceptual framework draws together current knowledge on each determinant, but also highlights areas where further research is needed to better understand the relationship between each factor and mental health, which can inform the research agenda. This online tool and infographic can be used by practitioners to identify interventions for promoting mental health, and by the general public as a resource to increase awareness of the broad factors which shape public mental health.

Project description:BackgroundThe global response to HIV has started over 18 million persons on life-saving antiretroviral therapy (ART)-the vast majority in low- and middle-income countries (LMIC)-yet substantial gaps remain: up to 40% of persons living with HIV (PLHIV) know their status, while another 30% of those who enter care are inadequately retained after starting treatment. Identifying strategies to enhance use of treatment is urgently needed, but the conceptualization and specification of implementation interventions is not always complete. We sought to assess the completeness of intervention reporting in research to advance uptake of treatment for HIV globally.MethodsWe carried out a systematic review to identify interventions targeting the adult HIV care cascade in LMIC dating from 1990 to 2017. We identified components of each intervention as "intervention types" to decompose interventions into common components. We grouped "intervention types" into a smaller number of more general "implementation approaches" to aid summarization. We assessed the reporting of six intervention characteristics adapted from the implementation science literature: the actor, action, action dose, action temporality, action target, and behavioral target in each study.FindingsIn 157 unique studies, we identified 34 intervention "types," which were empirically grouped into six generally understandable "approaches." Overall, 42% of interventions defined the actor, 64% reported the action, 41% specified the intervention "dose," 43% reported action temporality, 61% defined the action target, and 69% reported a target behavior. Average completeness of reporting varied across approaches from a low of 50% to a high of 72%. Dimensions that involved conceptualization of the practices themselves (e.g., actor, dose, temporality) were in general less well specified than consequences (e.g., action target and behavioral target).ImplicationsThe conceptualization and Reporting of implementation interventions to advance treatment for HIV in LMIC is not always complete. Dissemination of standards for reporting intervention characteristics can potentially promote transparency, reproducibility, and scientific accumulation in the area of implementation science to address HIV in low- and middle-income countries.

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Costing the implementation of public health interventions in resource-limited settings: a conceptual framework

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