Abstract
From 2014 to 2019, the Wits–UNC (University of Witwatersrand and University of North Carolina at Chapel Hill) AIDS Implementation Science D43 Training Program laid critical academic foundation by creating a graduate degree program in implementation science (IS) for master’s- and doctoral-level students in the Department of Epidemiology and Biostatistics at the Wits School of Public Health. Before this collaboration, funded by the Fogarty International Center (FIC) at National Institutes of Health, no IS degree existed in Southern Africa. The FIC “D43” is an international research training grant mechanism to strengthen global health research expertise through education. Historically, students from low-resource settings have been trained in health sciences at universities in the United States or the United Kingdom. This is not scalable or sustainable and therefore this D43 focused on building capacity in South Africa where HIV-related challenges are located. Consequently, South Africans and other African international students were able to apply to the newly offered program, allowing training at significantly lower costs. IS allows a systematic assessment of factors affecting the implementation of HIV interventions and in developing strategies for addressing them. It guides the successful scale-up of effective programs and informs policy to improve programs. The training aims to assist in lowering the HIV incidence rate, suppressing viral load for those infected, and meeting the UN 2030 Agenda for Sustainable Development. A second cycle of funding from 2019 to 2024 will enable the infrastructure built in the first program to train South African HIV researchers and practitioners in the field who are unable to enroll in a formal academic program.
Keywords
Background and Introduction
While progress has been made in reducing mortality from infectious diseases and childbirth around the world in the past two decades, there is still a long way to go in achieving optimal health outcomes for all. This is not due to lack of research about what needs to be done but because evidence-based interventions are not effectively implemented in many public health areas. For example, within the field of HIV, while rapid HIV testing and antiretroviral therapy have made a significant impact on the epidemic, achieving the UN General Assembly 2030 Sustainable Development Goals (UN General Assembly, 2015) requires HIV prevention and care services to substantially improve access and the quality of care. These are implementation issues and are major barriers to achieving outcomes. Researchers such as El-Sadr, Philip, and Justman (2014) have called for universities to embrace a research agenda in the emerging field of implementation science (IS) to build knowledge on how known interventions can be implemented at scale. IS involves “the study of methods for improving the uptake, implementation, and translation of research findings into routine and common practice” (El-Sadr et al., 2014, p. 1679) and “mobilis[es] theories, concepts and methods to better understand what, why, and how interventions work in the real world” (Ridde, 2016, p. 1).
In 2007, the Fogarty International Center (FIC), National Institutes of Health announced strategic goals to bridge the gap in implementation research and better understand the biological, social, and environmental factors that impact implementation, both to develop and test community-wide, multi-sector interventions that are not testable in clinical settings, and to identify how proven clinical interventions should be modified to achieve sustained health improvements in the “real world.” (Madon, Hofman, Kupfer, & Glass, 2007, p. 1728)
In 2014, FIC funded the University of North Carolina at Chapel Hill (UNC) in the United States and the University of Witwatersrand (Wits) in South Africa to codevelop an academic training program in IS to increase capacity among public health faculty and HIV/AIDS researchers in South Africa. While the program focused on HIV because of its funding structure, the curriculum was broad enough to train students and practitioners from other areas in public health. This funding enabled the establishment of the MSc and PhD programs in epidemiology and biostatistics with a concentration in IS at Wits School of Public Health, the first of its kind in Southern Africa. In fact, a survey by Ramaswamy, Mosnier, Reed, Powell, and Schenck (2019) showed no academic IS program outside of high-income countries.
Program Design
The purpose of the FIC grant was to build capacity in an African university to rigorously assess and address barriers to the implementation of HIV prevention and care. The following principles shaped the program design. First, for sustainability, both in terms of student enrollment and in assuring a focus on context appropriate research, it was imperative that the training program be situated in South Africa. Durlak and Dupre (2008) identified three categories affecting the ability of evidence-based interventions to achieve outcomes: intervention related, provider related, and community related. The latter two categories are strongly influenced by cultural, social, demographic, and economic characteristics of the local setting. Ramaswamy, Shidhaye, and Nanda (2018) reported on the difficulty of applying IS frameworks developed in Western settings to Indian contexts. Situating the program at Wits and creating partnership between Wits and UNC faculty in co-developing a curriculum and co-instructing courses would build local capacity to adapt existing approaches or to create new ones aligned with the needs of the local setting. This is a significant innovation compared to traditional FIC programs. Second, IS training needed to be integrated with the overall public health body of knowledge so that students could learn how implementation supported and reinforced public health intervention development. This necessitated the embedding IS content into the existing MSc/PhD degree program in the department of epidemiology and biostatistics as one of six concentrations offered, also the creation of an entirely new degree program would have taken more time than was available in the funding period. Third, in addition to students, there was the need to build capacity in Africa-based faculty who would be able to serve as research mentors in IS to students in the future. Finally, it was critical to provide quality, experiential opportunities through practicums to students to supplement the classroom training; IS by definition is learned through application in the field where implementation takes place (Peterson et al., 2018).
Curriculum Development
In 2015, course descriptions and syllabi for the 11 new IS course offerings were submitted to the academic planning office at Wits. These courses were already specified in the grant proposal, through a process in which Wits and UNC faculty examined the core courses that were required by students in existing MSc programs at Wits, determined where these courses could be strengthened, and identified faculty expertise in topics deemed relevant to IS. Since there were no competencies in IS published at that time, this process primarily involved collaborative dialog. Subsequently, the content of the courses and the curriculum were fine-tuned as Wits participated in a World Health Organization (WHO)-led effort to develop IS competencies for low-income countries. While awaiting approval, four IS courses were offered to gauge interest. Fifty students participated, learning about new course offerings at Wits via course advertisements in the local newspaper and on the Wits SPH website: 10 in Implementation Science 1, 12 in Qualitative and Quantitative Research Mixed Methods, 8 in Data Management, and 20 in Monitoring & Evaluation and Surveillance. The curriculum was approved in January 2016, and 17, 13, and 8, students respectively enrolled in the first three cohorts. The breakdown by gender and degree is shown in Table 1.
Implementation Science Degree Enrollment From 2016 to 2018.
Across all cohorts, FIC funding provided full scholarships to eight South African students who were required to conduct HIV-focused practicum or dissertation research. The initial $1.4 million FIC investment precipitated support from the WHO Special Program for research and training in tropical diseases research (TDR) to fund 10 full-time students from 8 other countries in Africa: Burundi, Ethiopia, Ghana, Kenya, Nigeria, Malawi, Tanzania, and Zambia. Recruitment to the MSc program was through the Wits University website, but the availability of the TDR scholarships was promoted by a variety of African organizations, resulting in broad pan-African publicity for the program and a substantial number of student applications. For the PhD program, students were recruited by word of mouth solicitations to government and NGO (nongovernmental organization) research partners affiliated with Wits to enroll as part-time students. There were three reasons for this. First, while tuition in South African institutions is significantly less than in U.S. universities, a commitment to enroll full time in a PhD program for several years is still a financial burden for South African students. Second, admissions procedures to postgraduate programs at Wits are internationally competitive. For example, of the 170 applicants to the MSc concentration in 2018, 40 were short-listed and 8 accepted. South African applicants who had already established a research portfolio would be more likely to be accepted as PhD candidates. Finally, since the focus of the IS program in South Africa is on HIV-related implementation research, students with ties to organizations implementing HIV programs are likely to select dissertation topics in this area.
Content Development and Instruction
The instructional model was a collaborative approach between the universities. Eleven UNC faculty traveled to co-instruct with nine Wits faculty. They codeveloped the content for 11 new IS concentration courses. In order to meet the degree requirements for the MSc in Epidemiology and Biostatistics, students are required to take 12 courses. To complete the IS concentration, they take three required foundations courses, five IS core courses and can select four elective courses from across the discipline. All IS courses available to trainees are shown in Table 2.
MSc Implementation Science (IS) Degree Required Courses Co-Instructed by Wits and UNC Faculty.
Note. Wits = University of Witwatersrand; UNC = University of North Carolina at Chapel Hill; GIS = geographic information system.
Core courses required for all degree-seeking students.
Most of the participating faculty came from the UNC Gillings School of Global Public Health specializing in biostatistics, epidemiology, health behavior, nutrition, health policy, and maternal and child health. One of the lead SPH faculty had developed the IS concentration in the MPH program at UNC that began in 2013. One came from the UNC School of Medicine and another from the National Institutes of Health–funded UNC Clinical and Translational Science Awards Program specializing in data management. Collaborating Wits faculty held appointments in the Department of Epidemiology and Biostatistics and in the Center for Health Policy.
From 2015 to 2018, UNC faculty traveled to South Africa to spend 1 week in the classroom with a Wits co-instructor. All MSc courses at Wits are held in 2-week blocks throughout the year. The instructional model was designed so that the UNC faculty member was the primary lecturer during the first year, both UNC and Wits faculty colectured in the second year, and the Wits faculty member leads the course moving forward.
To minimize time in South Africa for UNC faculty who had semester-long teaching obligations at home, each 2-week course was designed with 1 week in the classroom and 1 week online using the Sakai online learning management system. However, the online modules also served a secondary purpose. Since the students were coming in with little prior experience in the field, they needed to have read the basic literature before they could discuss application. The first online week helped provide a common foundation for all students. Overall, the 2 weeks resulted in approximately 90 hours of engagement (50 instructional and 40 noninstructional hours) equivalent to a two-credit course in the United States. During the first online week students accessed readings posted in Sakai every day, reviewed a summary PowerPoint lecture, and took a daily quiz. They also posted one reflection or take-away and one clarifying question based on the readings. For example, a student posted, My key learning for today was from the paper by Burke et al, which gave an introduction to implementation. Although some of the concepts were familiar as we have covered them before, I really enjoyed the systematic layout of the paper and the way it explained some of the fundamental concepts of IS.
In Year 1, reflections and questions for the entire week were collected and answered in the second week, but in Years 2 and 3, in response to student requests, these posts were addressed in daily synchronous Q&A sessions with the UNC faculty member using Zoom, a web-based group-meeting application.
The in-class week used a variety of methods including lectures by instructors and guest lecturers; small group work in which students engaged in activities based on content that is traditionally considered homework and presented summaries to the instructors and their peers (McLaughlin et al., 2014) and case studies to reinforce the learning from the online week. The daily in-class topics paralleled the daily online agenda, with an emphasis on interpretation, increased depth and application to practice.
Practicum Support
IS cannot be learned without its application in practice. Implementation researchers have emphasized the need for a robust support system that reinforces training with experiential learning, tools, and technical assistance to maximize the effectiveness of implementation strategies (Wandersman et al., 2008). In addition to case studies, students completed a 6-month field practicum under the guidance of a local mentor. This involved identifying a qualified mentor, designing a robust IS-based research study and writing a protocol to submit for institutional review board approval ensuring application of the content in real-world settings. At first, mentors were unsure of how IS projects differed from traditional epidemiological research. Guidelines shown in Table 3 were developed to help student–mentor pairs select projects focusing on implementation issues. Table 3 also provides examples of practicum projects completed in 2017 by the first MSc cohort.
Topics for Implementation Research Projects and Examples of Practicum Projects.
To train practicum mentors on how to support students, Wits hosted a 2-day mentors’ workshop for faculty and practicum mentors from field sites in 10 countries. Mentors were purposively selected based on their reputation in distinguished academic and nonacademic institutions in their home countries. Many of the mentors had previous relationships with the students enrolled in the MSc program, because admitted students typically graduated from well-known institutions in their home countries. Examples were the University College Hospital, Nigeria; Ensign College of Public Health, Ghana; National Institute of Public Health, Burundi; National Institute of Medical Research, Tanzania; Centers for Disease Control and Prevention–Tropical Diseases Research Centre, Zambia; FHI360, Zambia; African Institute for Development Policy, Kenya; Aurum Institute, South Africa; and Right to Care, South Africa. Mentors were trained in the basic principles of IS, and in the details of how to be mentors to meet the requirements of the MSc program. This was followed by a matchmaking process where students from each country discussed their project ideas with multiple mentors, and an attempt was made to pair mentors and mentees with aligned interests. As an emerging field, IS is of interest to public health researchers worldwide, and the opportunity to learn about the field in addition to a desire to support students from their country provided the motivation for mentors to engage in this process.
In the first cohort, six mentors were identified as long-term partners based on their expressed interest and experience in working with students. One of the goals of the first cohort was to create examples of successful IS student projects that could serve as examples to guide future cohorts. In 2016, Wits and UNC faculty visited three mentor–student pairs in Ghana, Nigeria, and Zambia during the practicum period whose projects were considered advanced enough to meet this goal. Each 2- to 3-day visit involved a lecture on IS at the mentor’s institution and meetings with the student–mentor dyad fine-tuning the research protocol. Funding was unavailable to replicate this in subsequent years, but these visits served to build capacity and motivation in the host organizations, resulting in their willingness to mentor students across multiple cohorts.
Accomplishments to Date
Overall, between 2015 and 2018, the program has built IS research capacity of 9 faculty members at Wits, 33 MSc and 5 PhD students from South Africa, and 8 other sub-Saharan African countries including 108 professionals from the South Africa Department of Health and NGOs who were able to take stand-alone courses for continuing education credit. This is attributable to flexible course offerings accommodating child care responsibilities and removing barriers to access to training in the United States such as GRE test scores and high costs. The typical cost to train African students in the United States is $45,000 per year (stipend, tuition, health insurance, travel), compared to $16,000 (stipend and tuition) in South Africa. We hope these benefits to students will allow Wits to grow as a center of IS excellence to further foster IS training in the region.
Student evaluations of the IS courses were very positive. Table 4 shows student ratings of the IS I and II courses relative to other Wits courses. The course evaluations, based on a standard questionnaire used for all Wits courses, are rated on a scale of 1 to 10. In 2018, individual interviews of the experience of the first graduating cohort were conducted using a formal theory of change linking implementation quality to student experience and outcomes. The results are being analyzed and will provide detailed insights of the students’ learning experience.
2016 Cohort Implementation Science I and II Course Evaluation Ratings.
Most important, students have made headway in applying what they have learned to improve HIV and other programs across Africa by contributing to the literature and engaging at professional conferences. To graduate from the program, PhD students are required to submit at least three manuscripts for publication to peer-reviewed journals. MSc students publish as well, and in 2017 and 2018, both the FIC and WHO grants supported students to attend international research conferences. The students from the 2016 and 2017 cohorts had 12 publications in peer-reviewed journals (Eboreime, Eyles, Nxumalo, Eboreime, & Ramaswamy, 2019; Eboreime, Nxumalo, et al., 2019; Manyeh, Ibisomi, Baiden, Chirwa, & Ramaswamy, 2019; Manyeh, Nathan, & Nelson, 2018; Matoga, Hosseinipour, et al., 2018; Matoga, Mmodzi, et al., 2018; McGavin et al., 2018; Naidoo, Railton, Jobson, et al., 2018; Naidoo, Railton, Khosa, et al., 2018; Naidoo, Zuma, et al., 2018; Naidoo, Matlakala, et al., 2019; Wambiya, Atela, Eboreime, & Ibisomi, 2018) and eight poster presentations.
Lessons Learned
The training program demonstrates an innovative approach to build capacity in global health by building collaborative partnerships between United States and local institutions. The Wits UNC D43 IS Program is significantly less expensive for students from sub-Saharan African countries than similar degree programs based at U.S. academic institutions. The key success factors are below starting with those that are likely to transfer across similar programs include the following:
Leadership support at the host institution: It is critical for the leadership in the host institution to be actively supportive and to be proactive in clearing barriers to implementation. The faculty and chair of the Department of Epidemiology and Biostatistics were all dedicated to the success of the partnership, as was the Dean of the SPH at that time. The Dean accelerated curriculum approval, a bureaucratic process that typically takes several years, while the department chair supported embedding the program as a concentration within an existing department to reduce start-up time. While these are specific examples, they reflect the general principle of engaged leadership support.
Faculty collaboration around codesign and co-instruction: Having a joint instructional model as a key design principle enabled faculty with subject matter expertise and faculty with contextual knowledge and experience with teaching students in a short course format to work together from the start, through multiple years. This facilitated the accelerated transfer of the courses to Wits. Codesign is another key ingredient for success.
Providing opportunities for application: The emphasis on application, using case studies and the field projects accelerated the translation of the theory of IS to address implementation issues in the field and resulted in a significant number of publications and conference presentations.
Prior relationship between UNC and Wits: UNC faculty members have adjunct appointments at Wits, and some Wits faculty completed their PhDs at UNC. Prior to this program, the scale of this relationship was small including a few faculty members on each side. This program allowed the collaboration to expand to over 20 faculty members, but the existing relationships served to foster the trust needed to broaden the involvement to other faculty and staff.
Multiple funding sources: The ability to strategically leverage the FIC D43 training grant to obtain funding from WHO’s TDR unit made it possible to train South African students and faculty, and a significant number of African students. Other institutions receiving only FIC funding were able to train faculty and researchers but not fund a large number of students. Similarly, institutions just receiving the WHO grant were unable to train faculty and preceptors. The dual funding gave Wits the unique opportunity to both build faculty capacity and fund a critical mass of students. While this happened opportunistically in this case, being intentional about seeking multiple funding sources for student scholarships will significantly enhance the sustainability of a program.
There have also been challenges, both academic and administrative, addressed over the past 4 years, and some pose a risk to sustainability. They are discussed here as guidance for future programs to consider.
Hybrid online and in person class: This format was new and instituted because of the need to optimize the time of UNC faculty. Wits students faced a steep-learning curve in using the Sakai system and engaging with complex readings asynchronously. Course to course variation meant a different course format every 2 weeks. Each faculty team approached online interaction differently.
Class sequencing and scheduling: Course order was influenced by the availability of UNC faculty to travel, and Wits faculty teaching schedules. This was primarily a result of the differing course structure between the two institutions; Wits courses are taught in 2-week blocks compared to UNC’s 16-week semester. This is no longer an issue as the teaching program has completely transitioned to Wits.
Teaching and administrative burden on the Wits faculty: There were limited resources to hire new faculty. Assessing student performance in South Africa requires external examiners to assess final exams and dissertations, and for a nascent field, it was a major challenge to find and train examiners. Also, there was logistical complexity associated with managing home country field practicums for students. This workload was imposed on faculty already heavily burdened. Early on, UNC faculty were able to provide some back up support but faculty burnout at Wits is a serious ongoing issue.
Reliance on external funding: FIC and WHO grants provided scholarship but as these have reduced over the years, it has become more difficult to attract students. The extension to the FIC grant beginning in 2019 (described below) enables few scholarships in the second phase of the program. A sustainable financing mechanism is needed. As IS is rapidly gaining prominence as a field, and donors are providing more funding for implementation research, integrating this program with other popular degree programs offered by the School of Public Health (e.g., the MPH program) and offering more standalone courses is a way to reduce reliance on external funding.
Growing the base of field preceptors: Developing IS knowledge in senior researchers and field mentors to support the student field projects is critical to program success; it is only through their support that students get to apply what they have learned and advance IS in Africa. Some students felt that since their mentors did not have training in IS, they did not fully understand the research questions and methods, and therefore, were unable to adequately support them in their fieldwork. Global interest in IS is rapidly growing, and 2019 saw the first global IS conference organized by and focused on implementation challenges in low- and middle-income countries. The extension to the FIC D43 Program in years 6 to 10 will capitalize on this interest by requiring mentors to attend IS short courses that are being developed for delivery at partner sites, or enroll in one or more of the academic courses offered at Wits. This will enable mentors and mentees to interact from a common base of knowledge.
Growing IS in Africa: Some Wits students have indicated the difficulty in finding employment in IS postgraduation, as potential employers have no exposure to the field. For students to advance in the field they need learning networks to disseminate the results of their research. Implementation research learning networks exist in Africa but are not often initiated by African implementation scientists. It is an imperative to develop African IS knowledge networks led by junior researchers.
The Way Forward
Years 1 to 5 of this D43 training grant were used to build capacity at Wits University in South Africa. Based on its initial success, the Wits–UNC partnership has received funding from the FIC for an additional 5 years from 2019 to 2024. This extension will enable the team to take IS training to public health professionals already working in the field of HIV research who are unable to enroll in a formal academic program as well as strengthening the academic program to address some of the challenges described above. Wits faculty now teach the courses independently. The new phase of this program will use expertise at Wits to offer targeted capacity building to selected organizations implementing HIV programs in South Africa. From these organizations, senior researchers will become part of a pool of research mentors and junior researchers that can enter the IS PhD program. As with the first phase of the program, the second phase is situated in South Africa, with select UNC faculty traveling to partner sites to support Wits faculty as needed. This continues to reinforce the premise of the first proposal that scalable and sustainable capacity building programs in global health can only be built if the program is truly “global,” and only if its locus rests where the trainees and the problems sit, not where the trainers and expertise lie.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: D43-TW009774 Fogarty HIV Research Training Program for low- and middle-income country institutions.
