Implementation research for advancing health equity: design and competency-based assessment of a short-term implementation research training program focused on health equity in global health

This paper evaluates a one-week competency-based training program at the University of Alabama at Birmingham, demonstrating that the intensive workshop significantly improved participants' self-assessed knowledge and confidence in applying implementation research to address global health inequities, despite showing no statistically significant change in objective knowledge scores.

The Gist

Imagine the world of global health as a massive, complex construction site. On one side, you have brilliant architects who design amazing new buildings (scientific discoveries and medical treatments). On the other side, you have the workers on the ground trying to actually build them in difficult, muddy, or rocky terrain (real-world communities, often in places with few resources).

The problem? The blueprints often don't match the terrain, and the workers don't always know how to use the tools. This gap is where Implementation Research (IR) comes in. It's the "foreman" that figures out how to get those blueprints built successfully, especially for the people who need them most but are often left out (health equity).

This paper is about a one-week "foreman training camp" called the Sparkman Center for Global Health Summer Institute. It took place in Birmingham, Alabama, in July 2024. The goal was to teach 28 professionals from 12 different countries how to be better "foremen" specifically for building health solutions that are fair to everyone.

Here is a breakdown of what happened, using simple analogies:

1. The Problem: The "Toolbox" Was Missing

Before this camp, many health workers had great ideas but lacked the specific tools to make them work in real life.

• The Gap: There are many schools that teach you how to design a building (research), but very few teach you how to build it in a storm or on a cliffside (implementation in global health), especially when you have to make sure the poor and vulnerable get the same quality roof as everyone else (equity).
• The Barrier: Long, expensive university degrees are out of reach for many busy professionals. They needed a "quick-start" guide that was practical, not just theoretical.

2. The Solution: The "Summer Institute" Boot Camp

The organizers created an intensive, one-week workshop. Think of it as a survival course for health builders.

• The Location: They held it in Birmingham, a city with a deep history of fighting for civil rights. This wasn't an accident; it was like teaching a class on "fairness" in a place where the history of unfairness is written on the walls. They even visited a Civil Rights Institute to ground the lessons in real history.
• The Curriculum: Instead of just listening to lectures, the participants did three main things:
  • Learned the Rules: They studied the "foreman's handbook" (theories and frameworks) on how to get things done.
  • Practiced the Craft: They worked on their own real-life projects (like fixing a broken water system in Zambia or helping HIV patients in Kenya) and applied the new rules to them.
  • The "Equity Lens": They were forced to wear special glasses that only let them see the people who were being left behind. They had to redesign their projects to ensure those people got included.

3. The Test: Did They Learn?

To see if the training worked, the organizers gave the participants two types of tests, like checking a student's homework and their actual ability to build a shelf.

• Test A: The "Confidence Check" (Self-Evaluation)

  • Before the camp: Participants were like hikers who thought they knew the trail but hadn't looked at the map. They felt okay about some things (like talking to neighbors) but very unsure about the technical stuff (like rigorous study designs).
  • After the camp: Their confidence skyrocketed. They went from feeling like they knew about 58% of the material to feeling like they knew 88% of it. They felt much more capable of tackling the hard parts of their jobs.

• Test B: The "Hard Quiz" (Objective Assessment)

  • This was a 40-question true/false test to see what they actually knew, not just what they felt they knew.
  • The Result: Their scores went up slightly (from about 65% to 68%). While this number didn't jump as high as their confidence, it showed they learned the core facts. Interestingly, the test became slightly "easier" for everyone after the training, meaning the training helped even the lower-scoring participants catch up to the higher-scoring ones.

4. The Projects: Building the Houses

During the week, the participants took their own real-world projects and upgraded them.

• The Focus: Most projects were in Africa and Asia, tackling big issues like HIV, maternal health, cancer, and diabetes.
• The Equity Twist: Every project had to answer the question: "Who are we leaving out?"
  • One group looked at how to get medicine to women in rural villages who couldn't travel to a city clinic.
  • Another group figured out how to help young people who were afraid to get tested for HIV because of stigma.
  • They used specific "blueprints" (frameworks) to map out exactly how to reach these vulnerable groups.

5. The Verdict: A Successful Pilot

The participants loved the camp. They said it was practical, well-organized, and gave them real tools they could use immediately.

• What worked: The mix of learning, doing, and talking to peers was the secret sauce.
• What they want more of: They asked for more time to practice, more "office hours" with the teachers after the camp ended, and follow-up sessions to keep the momentum going.

The Bottom Line

This paper shows that you can take a group of busy health professionals and, in just one week, give them a powerful new set of tools to build fairer health systems. It proved that a short, intense, hands-on training can boost both their confidence and their actual knowledge, helping them design projects that don't just look good on paper, but actually work for the people who need them most.

The authors say this is just the beginning. They plan to keep refining the training, making it available online, and helping these "foremen" lead similar camps in their own countries to spread the word even further.

Technical Summary

Problem Statement
Implementation Research (IR) is a critical tool for addressing health inequities and complex global health challenges, yet existing training programs often lack a specific focus on equity issues within global health contexts. Furthermore, many IR trainings are inaccessible due to cost and logistical barriers, or they fail to provide competency-based instruction with real-world application. A significant gap exists in standardized, validated methodologies for evaluating the impact of competency-based IR training programs, particularly those designed for low- and middle-income country (LMIC) settings. Additionally, few programs explicitly target the advanced competencies required to tackle health inequities.

Methodology
This study presents a competency-based assessment of the 2024 Sparkman Center for Global Health (SCGH) Summer Institute (SI), a one-week intensive workshop held at the University of Alabama at Birmingham. The training aimed to equip participants to articulate IR principles, distinguish global health IR from other settings, apply IR approaches, and operationalize IR to address health inequity. The curriculum utilized a mix of lectures, case examples, problem-solving clinics, and a cultural visit to the Birmingham Civil Rights Institute to contextualize equity discussions.

The evaluation employed a pre- and post-intervention design using two primary instruments adapted from previously validated tools for LMIC settings:

1. Self-evaluation of Implementation Research Competencies: A 16-item scale assessing self-rated knowledge and self-efficacy across six themes (stakeholder engagement, scientific inquiry, implementation strategies, resources, communication/advocacy, and context/ethics).
2. Objective Assessment: A 40-item true-false questionnaire testing knowledge of IR principles, concepts, and methodologies.

Data were collected from 28 participants from 12 countries. Quantitative analysis involved comparing pre- and post-SI scores using t-tests and ranksum tests, while Item Response Theory (Rasch model) was applied to the objective assessment to estimate item difficulty and discrimination. Thematic analysis was conducted on open-ended survey responses to assess participant experience and satisfaction.

Key Results

• Participant Demographics: The cohort included professionals from 12 countries, with 46.4% women. Over 40% had five or more years of global health experience, and approximately half had prior introductory IR coursework.
• Project Development: Participants developed research proposals focused on maternal/child health, infectious diseases (particularly HIV), non-communicable diseases, and mental health, primarily in LMICs (Africa and Southeast Asia). Most utilized frameworks such as CFIR, EPIS, and RE-AIM, explicitly integrating equity considerations for vulnerable populations.
• Self-Assessed Competencies: Significant improvements were observed in self-assessed knowledge and self-efficacy. The mean self-assessed knowledge score increased from 57.67% (95% CI: 43.78–71.55) to 87.68% (95% CI: 76.96–98.41), with a p-value of 0.003. The largest gains were noted in stakeholder engagement, scientific inquiry, and applying IR strategies to real-world problems.
• Objective Knowledge: Objective assessment scores showed a modest, non-significant increase from 65.35% to 68.18% (p=0.324). Item Response Theory analysis indicated that item difficulty remained stable, but the discrimination parameter decreased (from 0.79 to 0.63), suggesting the tool became less effective at distinguishing between high and low-ability participants after the training.
• Satisfaction: Participants reported high satisfaction (over 94%) with the training's structure, content, and delivery, specifically highlighting the practical focus on stakeholder engagement and real-world case studies.
• Correlation: There was no significant correlation between self-assessed and objectively assessed knowledge at baseline (r=0.05), indicating a disconnect between perceived and actual competence prior to the training.

Significance and Claims
The paper claims to be one of the first studies to rigorously evaluate IR training in global health and equity using competency-based assessments adapted for LMIC settings. Its primary contribution lies in demonstrating that a short-term, intensive, hands-on workshop can significantly improve participants' self-efficacy and perceived knowledge in applying IR to address health inequities. The study validates the use of specific assessment tools in this context and highlights the importance of integrating equity frameworks explicitly into IR training.

The authors note that the findings will be used to refine future iterations of the SCGH Summer Institute, with plans to expand reach through online/hybrid delivery, offer tiered training levels, and develop long-term engagement strategies. The paper concludes that while short-term training is effective for building foundational competencies and confidence, continued refinement of assessment tools and evaluation of long-term impact (e.g., competency retention, funding, and publications) are necessary to maximize the impact of IR training on global health equity.