Developing a framework of core competencies in IR for LMICs

The framework was developed over three phases using a mixed-methods approach consisting of a survey of IR researchers, trainers and trainees in selected academic institutions from mainly LMICs, and a consultative Delphi process with selected IR experts from both LMICs and HICs.

Phase 3: developing a conceptual model for IR competencies in LMICs

Using a modified Delphi method (multiple rounds of review and aggregated anonymous responses to reach group consensus), a 2-day review meeting was conducted with 23 IR professionals from LMICs and HICs on 6–7 February 2019 to evaluate the draft V.2.0 of the framework. The review meeting focused on the description of the competencies, sequencing of domains and competencies, and assigned proficiency levels. The 23 IR experts included 11 of the 16 IR programme coordinators from the 7 LMIC institutions, and other IR experts from institutions in HICs and from TDR, Alliance for Health Policy and Systems Research and the WHO Department of Reproductive Health and Research.

Participants at the meeting were introduced to the meeting’s purpose, preceding efforts in developing competencies and methodology used for developing the draft framework. They were then asked to silently reflect on the first two domains and write specific notes regarding the domain names, domain definitions and competencies under that domain. Notes were collected and a facilitated discussion followed, moderated by the principal investigator for the study team until consensus was reached. This process was repeated until all domains were reviewed in the same fashion. Suggested changes to the draft framework of core competencies were noted and organised under five categories: (1) addition/deletion of domains and/or competencies; (2) merging/combining domains and/or competencies; (3) re-wording/re-describing domains/or competencies; (4) re-assigning competencies to a different domain; and (5) changes to sequencing of competencies and domains for training and other recommendations. The final draft of the framework (V.3.0) was then prepared to reflect these changes.

Based on the consensus and recommendations from the 2-day review meeting, the competency on ‘Applying ethical principles in conducting IR’ was elevated to a domain, 7 competencies were deleted and 25 competencies/sub-competencies were added, and nine competencies were re-described. The suggested changes made during this phase are summarised (online supplementary table 4), and were implemented to produce the final version (V.3.0) of the framework (online supplementary table 5). The final version of the framework comprised of 11 domains, 59 competencies and 52 sub-competencies, and these were organised in a conceptual model based on the recommendations from the review meeting (figure 1).

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Figure 1

Circles of knowledge and skills relevant for implementation research education and training programme.

The conceptual model depicts the IR core competencies for LMICs as concentric circles of knowledge and skills (figure 1), that is, training in IR following the outlined competencies is not a linear process but circular and iterative, and starting points in IR training may vary widely by the project, institution and challenge being addressed. Stakeholders (innermost circle) are a core component to all aspects of IR. Trainees in IR will need to know how to identify appropriate stakeholders, engage with them meaningfully, form robust collaborations and implement change via these collaborations throughout the IR process. The IR process (middle circle) can be conceptualised as inclusive of four interconnected thematic areas: scientific inquiry, systems, resources, and communication and advocacy. For example, scientific inquiry, where many IR enterprises may start, includes domains focused on development of research questions, understanding and applying appropriate theories, frameworks and study designs to address those questions, possessing a comprehensive knowledge of methodology and the capacity to conduct IR in a rigorous manner (outer circle). Similarly, researchers must possess an understanding of the resources available and required to conduct IR in their settings, and be able to leverage those resources for the other thematic areas included in the IR process, just as skills to conduct scientific inquiry may be relevant for leveraging resources and facilitating the other thematic areas. This interconnectedness among thematic areas (represented by four rectangular blocks in figure 1) highlights the lack of a clear dichotomy between practice and research in IR,13 and the need for trainees to be proficient in knowledge and skills to do both. The systems thematic area encompasses the health systems, implementing organisations, and communities affected by implementation, and an understanding of their associated bottlenecks and barriers and how to identify facilitators for ameliorating these barriers and integrate solutions back into the systems where neccessary. Other results of the IR process that are developed in collaboration with stakeholders through scientific inquiry should be integrated into systems and this further requires skills in communication and advocacy.

Ethical engagement and context are two of the cross-cutting concepts that trainees must understand and apply throughout their work in IR. Implementation researchers need to know how to assess context, including stakeholders (innermost circle), the IR process (middle circle) and the domains under each thematic areas representing the IR process (outer circle), and determine aspects that may be modifiable, implementing change to context as needed and as appropriate. The application of ethical principles for conducting biomedical and clinical research may be different compared with IR.19 It is important for IR trainees to recognise the ethical considerations that are peculiar to IR, and work with key stakeholders to address these considerations throughout the IR process. These include assessing the risks and benefits to the study population, from whom and how best to obtain informed consent, provision of ancillary care during IR, upfront assessment of sustainability and scalability of the intervention if proven successful in a given context.19

How does this framework of core competencies in IR for LMICs compare with others developed for HIC settings?

The core competencies framework presented in this study covers most of the competencies that have been identified from HIC settings,4–8 but it differs in its emphasis on contexts, health systems, ethics, equity issues, communication and advocacy skills (while the other frameworks emphasise IR theories, methods and designs). This difference may reflect how IR is viewed differently in LMIC settings compared with HICs. IR is defined mostly by broad principles that encompass intervention-specific and broader health system issues in LMICs,3 11 and by set of theories, models and approaches, applied to intervention-specific issues in HICs.6 This distinction in how IR is applied further highlights the weaknesses of health systems in LMICs, and the greater need to address health systems and contextual issues in IR in LMICs. There may be opportunity for future studies in IR to learn how theories, models and approaches developed for HIC settings are adapted and applied in LMICs, and how lessons from these adaptations are applied for addressing implementation questions in HICs.

Unlike one of the HIC studies,6 this study showed significant differences in the proficiency mean score for some competencies comparing respondents’ self-reported proficiency level. Respondents with higher self-reported proficiency assigned higher proficiency to competencies around strategies and methods for scaling up or down, addressing inequities, facilitating stakeholders engagement and addressing ethical issues in the conduct of IR. There were also associations between respondents’ self-reported proficiency level and their perception of the proficiency level needed to achieve a competency. Respondents tended to assign most competencies to the same proficiency level they self-reported as having achieved in IR. These findings suggest that perception about proficiency needed to achieve a specific competency may vary by individual expertise level for stakeholders in LMIC settings. ‘Proficiency’ may have been interpreted differently by different respondents, and a majority appear to have interpreted proficiency as ‘difficulty level’ in demonstrating a certain competency and not necessarily the ‘ability’ to perform the competency.7 Hence, it may not be adequate to define proficiency levels for IR competencies based on perception of survey respondents in an LMIC setting as was done in a previous HIC study,6 and an alternative approach should be explored. For example, proficiency levels may be defined based on educational theories or models, for example, the Osler’s model for assessing clinical skills and competencies in medical education could be adapted to IR competencies.20 Such adaptation would assume that there are different levels of proficiency (ie, ability) within each competency and sub-competency, and that these levels can be independently assessed, for example, through knowledge-testing, demonstrated ability to successfully perform the competency under a testing situation or supervised condition, and/or a demonstrated ability to successfully perform the competency without supervision.

Study limitation and next steps

The overall response rates of 75% (n=16) and 56% (n=89) in the first and second rounds of survey may appear low; however, these are well above the typical range for both online and paper-based surveys (about 32%–33%).21 Moreover, the study population had representation from all of the institutions that were previously identified, and prior studies have suggested that a response rate of 40% may be adequate for sorting competencies by proficiency levels.6 There was an over-representation of respondents from institutions in Latin America (34%) because of the existence of a network of IR institutions in Latin America that included the Universidad de Antioquia Colombia, which was one of the seven LMICs institutions that was purposively selected for this project.

A major limitation of this study is the lack of involvement of practitioners from LMICs in the development of the framework. To make the framework to be more relevant for practitioners and policymakers in LMICs, an immediate next step would be to review the list of competencies with networks of practice and key practitioners in LMICs, with the view of understanding how the framework can be tailored for training and supporting practitioners. Other important next steps may involve the development of a conceptual model showing the pathways through which the existing IR training programme in LMICs may produce impact at the population level, and clarifying the roles that the competencies play along these pathways. Such a conceptual model will be useful for two purposes: for strengthening the evaluation of existing IR training programme, and to serve as the basis of future validation studies for the outlined core competencies.

The sequence of domains and competencies presented in the framework suggests a linear sequence for teaching and training researchers with little or no prior exposure to IR. However, this sequence can be customised to the experience of a trainee or group of trainees based on the implementation objective or phases of implementation. For example, the first four domains of the framework may be targeted to trainees involved in planning an IR project, while the next five domains could be targeted to trainees involved in the implementation of IR, and the last two domains could be targeted to those involved in the post-IR phase. On the whole, it is unlikely that all the competencies would be embodied in a single implementation researcher, and these competencies have been laid out such that different members within an IR team can combine expertise to demonstrate these competencies.

This framework of IR competencies extend the work that has been done previously by others,4–6 and will be useful for objectively assessing training needs and the effectiveness of IR training programme in LMICs, and tailoring training programme to address specific needs among implementation researchers in LMICs.