Lessons from Polio Eradication: A Synthesis of Implementation Strategies for Global Health Services Delivery from a Scoping Review
Johns Hopkins Bloomberg School of Public Health (Neel, Olateju, Peters, Schleiff); University of Alabama at Birmingham (Alonge)
"[M]ost implementation strategies deployed under GPEI in LMICs were multifaceted, focusing on stakeholder engagement and capacity building, and addressing management and problem solving in real time."
It can be challenging for public health practitioners to identify implementation strategies that will be the most effective for achieving desired health outcomes in their own context. This study describes the implementation strategies used by the Global Polio Eradication Initiative (GPEI) across low and middle-income country (LMIC) settings, including the challenges selected strategies were aimed to address and how they were operationalised.
The researchers nested this scoping review into a literature review conducted as part of a parent study, Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE). They systematically searched PubMed for articles between January 1 1988 and April 25 2018 using polio search terms. Strategies from included studies were organised according to the Expert Recommendations for Implementing Change (ERIC) framework, specified using Proctor's framework, and linked to various outcomes (implementation, services delivery, impact).
Although 152 unique articles met inclusion criteria (from 1,885 articles included in the parent study), only 43 out of the 152 articles described a suitable quantitative study design for evaluating outcomes. The researchers extracted 66 outcomes from the 43 unique studies, which represented diverse country settings.
Tables 2-5 in the paper describe the implementation strategies utilised in the GPEI from 1988 to 2018 following four themes identified from the broader STRIPE scoping review: management and problem solving (7 strategies referenced 106 times out of 496 total strategy references); monitoring and evaluation (4 strategies referenced 75 times out of 496 total references); engagement and capacity building (12 strategies referenced 206 times out of 496 total references); and communications and advocacy (3 strategies referenced 109 times out of 496 total references). A majority of included articles (n = 127, 83.6%) reported mostly multifaceted (i.e., combined multiple strategies or components).
The most common implementation strategies were developing mechanisms for feedback, monitoring, and evaluation (n = 69); increasing awareness among the population (n = 58); involving stakeholders, workers, and consumers in the implementation efforts (n = 46); conducting workshops (n = 33); using mass media (n = 31); and building robust record systems to capture outcomes (n = 31). Strategies focused on setting up and adapting infrastructure for services delivery, developing community partnership, and community-led engagement activities featured prominently and were relevant across different LMIC settings reviewed.
Tables 6-8 in the paper describe the implementation, service delivery, and impact outcomes that were described in the 43 unique studies included in the outcome analyses. Out of the 66 outcomes, coverage of polio vaccination (n = 13) and morbidity (n = 12) were the most frequently identified outcomes overall; feasibility and sustainability were rarely evaluated. Among the service delivery outcomes, effectiveness was the most frequently reported outcome. Effectiveness outcomes focused on a range of issues, from the effectiveness of social mobilisation campaigns to the efficacy of various polio vaccinations, and to the overall effectiveness of GPEI programming in geographic areas. Acceptability outcomes tracked the impact of community engagement strategies.
Two other implementation outcomes - acceptability and fidelity - also emerged from the data as significant for driving global health services delivery. Over time, acceptability became an increasing concern for the GPEI, as implementers struggled to penetrate pockets of low coverage and faced resistance from communities who were fatigued or mistrustful of the campaign. The GPEI was compelled to address these issues through numerous engagement and communication strategies (e.g., identifying and preparing champions and early adopters, leveraging existing networks and collaborations), often tailored to meet highly localised needs. "The polio eradication experience suggests that achieving coverage of health interventions is dually dependent on implementation processes that enable both precision and modification, and attention to demand-side factors that affect uptake and satisfaction."
Per the researchers, the findings from this review are consistent with GPEI priorities and its operational emphases over time, reflecting priorities to engage communities and individuals, reach hard-to-reach and hard-to-vaccinate populations, and improve programme operations. Consistent with other studies, this review highlighted the importance of strategies to build partnership and coalitions, co-deliver other interventions and provide other health services beyond polio vaccination, develop mechanisms for feedback and accountability, engage local communities and gain their trust, and conduct monitoring and evaluation, including setting up robust data systems.
The researchers conclude that this review provides a catalogue of implementation strategies and outcomes relevant for advancing global health services delivery in LMICs drawing from the GPEI. They call for additional implementation research to unravel the mechanisms of implementation strategies and their effectiveness. They stress that published evaluations should not shy away from presenting failures to improve public health outcomes. Instead, these studies should try to explain why targets were unmet to facilitate understanding and inform future implementation.
Frontiers in Health Services 4:1287554. https://doi.org/10.3389/frhs.2024.1287554. Image credit: Mulugeta Ayene, UNICEF (CC BY-NC-ND 2.0)
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