By Bradley Allf, Feature Writer for the UNC Institute for Global Health & Infectious Diseases
Getting tested for malaria in rural parts of the globe used to mean sending a sample of blood off to a faraway lab and waiting days or weeks for results. But not anymore. Advances in the development of malaria Rapid Diagnostic Tests (mRDTs) mean you can be tested in just 15 minutes using a drop of blood and a plastic test packet that’s about as simple to use as an at-home pregnancy test.
Yet in clinics in Ghana, health workers routinely ignore the mRDT results and treat all febrile patients with anti-malaria medication. Doing so wastes resources, exposes patients to needless antimicrobial treatment, and can increase the prevalence of drug-resistant malaria.
This is a clear example of the sort of problem that can be addressed by the emerging field of implementation science. Implementation science seeks to understand how research innovations can best be put into practice.
Michael Anaba is a graduate student from Ghana who is working to address this implementation problem in his home country. And he’s doing so with skills he learned from a newly developed implementation science master’s degree program at the University of Witwatersrand (Wits) in South Africa, started by a collaborating team from UNC and Wits.
From Bench to Bedside
Implementation science is a rather new field that addresses an old question: how do you translate research into practice?
“It’s a science that seeks to bridge the gap between what is known and how what is known is actually carried out in the field,” says Rohit Ramaswamy, PhD, associate professor in the UNC Gillings School for Global Public Health who leads an implementation science graduate program at UNC and teaches the core implementation science courses at Wits. “[It] seeks to understand what the determinants are for poor implementation and what strategies you can employ to improve the quality of implementation in the field.”
This can be as simple as addressing poor adherence in following hand washing best practices in a clinic, or as complicated as tackling the implementation of a multifaceted government health policy.
Ramaswamy is part of a team of researchers from the UNC Institute for Global Health & Infectious Diseases (IGHID) and the UNC Gillings School of Global Public Health that received a grant in 2014 to develop an implementation science degree program at Wits. The grant, funded by the Fogarty International Center (FIC), is a D43 research training program targeting U.S. and foreign trainees meant to strengthen global health research collaboration and improve the quality of HIV research in low and middle-income countries.
South Africa currently has the highest number of people living with HIV in the world and nearly 20 percent of South African adults aged 15-49 are HIV-positive. Unfortunately, the resources utilized to address the problem aren’t always used efficiently. The new degree program at Wits could go a long way toward addressing this and other health inefficiencies in South Africa and throughout the region.
Crafting the Program
After receiving the grant in 2014, the team worked with Wits faculty to piece together all the ingredients needed to make a new degree program. Course structures, program length, and even minutiae like what buildings would host the classes all had to be worked out. Eventually, the program was approved by Wits as a concentration within the School of Public Health’s Epidemiology and Biostatistics Department. In 2015, it accepted its first cohort of students.
This cohort of 17 MSc trainees enrolled in January of 2016. Four of these students are South Africans funded from the D43 grant. One part-time postdoctoral student is also currently supported on the award. The five-year D43 grant provides funding for faculty time (most UNC faculty involved in the project travel to South Africa annually to teach one week of face-to-face courses), as well as scholarships for South African students accepted to the program. The World Health Organization’s (WHO) Special Programme for Research and Training in Tropical Diseases (TDR) supports the additional trainees from other African countries. These include Burundi, Ethiopia, Ghana, Kenya, Nigeria, Malawi, Tanzania, and Zambia.
From this beginning, the program has blossomed into the most advanced implementation science program in Africa, with the first cohort due to graduate in December of this year.
Kathryn Salisbury, program manager for this project, says everything quickly fell into place. The collaborating faculty were able to rapidly create a successful degree program that has the ability to train eligible students from across the African continent in implementation science.
Enrollment in the program is open to both postdoctoral and master’s students and is highly competitive. Each course lasts just two weeks, and the first week of each course can be completed remotely. This allows for part-time enrollment—a necessity for many students—in addition to enabling non-enrolled health workers to take some courses as well. “The short courses allow a bit more flexibility for government employees and people that need this training but can’t spend 18 months doing a degree,” says Audrey Pettifor, PhD, professor at the UNC Gillings School for Global Public Health and principal investigator (P.I.) for the grant.
Pettifor has more than 20 years of experience working in South Africa, including at Wits. She appreciates that the grant allowed her team to create a training program that’s regionally focused.
“I think what’s really unique and special about this grant is that we’re really able to fund students from the region… most of the traditional Fogarty grants tend to fund U.S. students to go abroad,” says Pettifor. “This was really unique because it actually funds the local students.”
Pettifor also values the collaborative nature of the program, saying the logistics of getting the program off the ground and through a number of “huge logistical hurdles” would not have been possible without the support and expertise of the faculty at Wits.
Real World Application
For the master’s students, the 18-month program culminates in a six-month research project called a practicum. Through these projects, many of which focus on HIV, each student is able to directly apply what they learned at Wits to develop an independent implementation science research project.
Michael Anaba investigated the implementation of malaria rapid diagnostic tests in Ghana, as discussed above, for his practicum. Though he and the other students in his cohort are still writing up their master’s papers for publication, Anaba’s project has already proved useful to health workers, policy makers, and program implementers in Ghana by outlining the current quality of mRDT implementation at Ghanaian health centers.
Anaba, who is due to graduate this December, says his prior experience working in healthcare motivated him to pursue the implementation science degree. “As a registered nurse back in Ghana, I witnessed how new medicines, vaccines and diagnostic tools that have the capacity to lead to significant improvements in health outcomes have failed remarkably in the clinical setting,” he says. With the tools he has developed at Wits, he now feels equipped to begin addressing some of those failings after graduation.
Mitch Matoga is another master’s student in the implementation science program. His participation in the new degree program is supported by a second UNC IGHID D43 training grant, the Malawi HIV Implementation Research Scientist Training Program (M-HIRST), which is also funded by the FIC. Matoga learned about the new degree offering at Wits through his past involvement in UNC-Project Malawi, when Mina Hosseinipour, MD, MPH, scientific director of UNC Proejct-Malawi and P.I. of the M-HIRST grant, told him about the new degree.
Matoga, who is from Malawi, says he decided to attend the program because he sees a specific need for scientists who can translate research into routine practice and policy.
“Research is mostly conducted in a controlled setting, ‘the ideal world,’ and the results can be groundbreaking,” says Matoga. “However, the gap is in translating these findings into feasible, acceptable, cost-effective and setting-specific interventions. This is where implementation scientists come in.”
For his practicum, Matoga investigated how to improve partner notification strategies for healthcare workers with HIV-positive and STI (sexually transmitted infection)-positive patients.
Matoga describes this experience and the other opportunities made available to him by the program at Wits as “phenomenal.” Anaba agrees, saying the courses have afforded him “unparalleled exposure and access to world-renowned experts working in various fields of implementation research.”
Looking to the Future
Moving forward, there are a number of goals for the new degree at Wits. First, the team wants to continue developing the self-sustaining capacity of the program. During its first year, UNC professors taught the implementation courses with Wits faculty partners. But in the second year, those Wits partners began co-teaching the courses with the UNC faculty. Going forward, the local faculty will begin taking on all the teaching. “[It] has been sort of a transfer of skills from us to the Wits faculty,” says Ramaswamy.
In addition, the team wants to grow the program, which at this point only accepts 12-15 students per year. They also hope to further develop the implementation science skills of the field supervisors who oversee some aspects of the students’ work.
And then there’s the critical goal of increasing the involvement of the South African health ministries. “The next step is to take this education component, this framework, and teach it to the people that are in the government health sector to make changes in the programs that they oversee,” says Program Manager Kathryn Salisbury. “Rather than wait for the graduates to get these jobs and then implement and make changes, we want to figure out how to make these changes on the ground right now with the people that are doing the work.”
Engaging with the government health ministries will allow for an even deeper local impact on healthcare in South Africa and the surrounding regions.
Closing the Gap
With the first cohort poised to graduate this year, Ramaswamy reflects on how all the work the team has done has come together to create a sustainable future for implementation science in Africa.
“What we want is these students who are graduating to become mentors for the next set of students,” he says. “It’s a fantastic opportunity to not just say ‘we’ve graduated a bunch of students’ but to say that these students are going to go back to their countries and… remain as resources for the next set of students who come.” Those relationships will be the starting point for what Ramaswamy sees as a large, sustainable network of implementation scientists across Africa.
Pettifor echoes his sentiments. “For me, having worked in South Africa for so many years, it’s just really exciting to see a program that’s funding local students and providing resources to build capacity on the ground,” she says.
One study found that it takes an average of 17 years for new evidence-based findings to get adopted into clinical practice. The team from UNC and Wits believes that their work in starting the implementation science degree is a step toward closing that gap. Doing so will result in better health outcomes, a quicker transition from discovery to implementation and will build the foundations of a larger implementation capacity in Africa.
And while the newly minted implementation scientists graduating this year may not be chasing the latest drug or surgical technique, they are doing something perhaps even more important for public health: ensuring that those breakthroughs are being effectively utilized to help people.