I presented at the 2021 AORTIC Cancer research in Africa. There was a pre-conference the past two days and I was asked to lead this morning with a discussion on why implementation science research for cancer in Africa. What many people do not know was that the invitation which came July 12, came exactly one month before my sister in law passed August 12. I took it as her parting gift. She knows I love to talk. She also knows that I do research, implementation science research in Africa. But I have never done Cancer work. Never even felt it was my place to do so until her cervical cancer came knocking at our door steps. The preparation for the presentation has been one giant healing process for me. I literally wrote poetry, yea or maybe verses on ways to disseminate cervical cancer research using her experience as an entry point. I was so tempted to do so at the presentation that I opted out last minute. Not because I don’t think they were great and I will publish them here one day, but more because ours is still a very conservative field and the idea of decolonizing how we present research or even saying anything anti racism scares people, though I am working on verses for research. But I digress. For now, here is the standard presentation I gave and yes, I gave it in her memory as stories still, to help guide those who want to fight like hell so we don’t have to tell anymore stories like Angie’s.
I know we have heard a lot about implementation science the past couple of days, with a lot of talks about what it is and how to do, but let me paint another picture if I may of why this matter for the region.
So I am an implementation researcher, interested in how you sustain evidence-based interventions in resource-limited settings.
I am also a storyteller.
I grew up in Lagos, Nigeria, with a show called Tales by moonlight which is similar to what griots do in many other African settings, and so stories are all I know, and it was refreshing to hear Dr, Eche tell his implementation story these past few days. I think we heard yesterday for example, that policymakers respond to data, I agree.
As someone who used to work in the UN, I would also add that policymakers respond to stories, especially stories about data, stories about what works or doesn’t work, even stories about the constituents they serve. So let me tell you a story If I may of why implementation science matters for cancer research in Africa
And I want to begin from with the story of Angie. Angie, a 53-year-old woman, as is typical in most African countries, presented in the clinic with stage 4 cervical cancer.
There were no warning signs, or least when she saw some, she didn’t take it seriously. She never had pap smear in her life until she presented. She didn’t even have any access to universal health care insurance.
Only reason she presented actually, was because she couldn’t eat anymore, and felt something was obstructing her ability to eat, and was seeing blood in her stool. Angie’s story is typical in many African settings, and in particular for understanding why context matters for implementation science cancer research in the sub-Saharan Africa.
And to illustrate that a bit, I allow me to use some analogies. In our settings, analogies are like proverbs, they are like miniature tales, building blocks if you like in simple form of ways that the field can proceed.
This recent paper by Haines in implementation science describes context as a fabric. A blue fabric in this case, and just as embroiderers must first understand the fabric they are working with, researchers and practitioners of implementation science must obtain an understanding of the context in which they work in before selecting or adapting an intervention or any implementation strategy.
The red needle in this case represents the implementation strategies and thread is the intervention you may have in mind, and all of that have to be in harmony with the context in which you find yourself in.
I really like this paper, but let me address context in another way. Enter Yucca which many of us in Africa, may know as Cassava.
But if you traveled to South America, it is called yucca and it is used to make empanada, yucca fritters or yucca chips. Now this same tuber, if you come to my home country of Nigeria, can be found in local dishes such as Abacha, or what the Igbos’s call African salad, or eba and soup, eba being a typical Yoruba dish, or quite simply garri and groundnut, something we all eat in Nigeria as a favorite meal.
I use Yucca and Cassava here to illustrate again context matters. It the same tuber, but if you went to South America, its used differently, if you come to Nigeria, even within one country, it is also used differently. Context, like all the stories we will tell with implementation science it matters.
Another reason why context matters is that, the past couple of days was spent on ideas of what works with implementations, the how to do it literature of implementation science, and to all of that I want to add one thing that was missing and is this idea of starting with Why. And So for implementation science in the region, always start with why.
And if we stayed with cervical cancer, Remember to start with why for something so preventable and treatable, Remember to start with why for something where one in four women will die, unless they have access to life saving evidence-based therapies that exisit. Remember to start with why with resolutions that exist, the historic 90-70-90 resolution last year for example which calls the 194 member states of the World Health Organization (WHO) to achieve specific targets by 2030. Resolutions like this are actually fertile grounds and justification for implementation science in the region.And when you start with Why, you will find out that implementation science is an open and inclusive field that basically means workings not only within the context you find yourself in, but also broadening your collaborators, to include working with multiple experts and non-experts that you can work with to expand the field.
And as you do, as you pick out which outcomes, or frameworks or strategies you will use, be prepared to optimize them for your context. Many of them will not fit ERIC, storytelling isn’t in ERIC as an implementation strategy and that’s ok.
I say go for what works for you, let all that was shared these past few days be a guide, so long as you remember your why and that your context matters. This is the time to begin to galvanize efforts to decolonize even all we know with implementation science and just because it has been done in the West doesn’t meant it has to be in your setting.
In addition, and if we stay with decolonizing the field, also maintain what you know works in your setting, in your context.
You live there, so you know it better than any expert that may come to your setting. So harness that knowledge, it is just as vital as whatever knowledge you will bring from IS to your context.
And finally, be prepared to evolve. Change is evitable, CoVID 19 being a great example Of the need for example to embrace disruptions. Embrace whatever struggles you come across as you evolve. That and be open to other ideas, like the idea of health or implementation science occurring beyond a Western Paradigm.
Professor Collins Airhihenbuwa, my mentor, over 30 years ago, developed a framework called the PEN-3 cultural model, which helps to situate some of the work many of us do in the region, and it asks that we begin always by interrogating what is positive about our context, what is existential or unique about where we find ourselves, and then ultimately what are the hurdles, or challenges to be mindful of along the way, and for me the past few days of listening in, has allowed me to see first-hand, that the leadership within Aortic, in fact all they have done with setting up this conference, is the right start for tackling cancer research in the region.
I wholeheartedly believe that AORTIC is going to be a great resource and leader for anyone in the region try to navigate the rugged complexity landscapes of doing implementation science research in the Africa. And the stories we will tell, for example with the Aortic implementation science special interest group will be the escort that propels the field forward in the region. It’s your story that will convey all our gains, all our failures, and all we hold dear, or should condemn or de-implement for example with implementation science in the region.
So finally as you think through context, one thing I want to emphasize is that we all get into the habit of doing is rapid cycles of what will work or not work in our setting. Some of the speakers, Donna Shelley for example, talked about rapid cycle evaluations. The response to the COVID pandemic has been one massive rapid cycle evaluation, that I believe everyone trying to do work in the region should seize upon because the tools for cancer, whether with prevention or treatment exists and have been in existence for decades yet they continue to remain out of reach to the people who need it the most.
This idea of making a plan, then doing, then studying, then acting, or making another plan will do the field well and help save lives now. If you choose to move in this direction, let me stay in the issue of just planning and tie it squarely to the issue of sustainability. I believe that it is unethical for people to implement interventions in regions with limited resources without even a simple plan on how you last.
Most of the research you will come across implemented in the region, are never sustained. This paper for example by Johnson et al on NIH R01 grants in general with an implementation science focus found that none had plans to last.
We found the same thing in a systematic review I led, about 5 years ago about the sustainability of research in the region. We also noted that if you are going to come do any implementation science work in the region, the least you can do is plan to last.
It should not be done in the end, not even in the begin, but throughout the lifecycle of whatever interventions you have in mind. Having a plan, can be as simple as gathering the right stakeholders to work with, learning from them, be willing to change or adapt along the way, while nurturing what truly matters in within the context in which you find yourself.
And so in recap, I loudly and enthusiastically appeal to the group to come do implementation science work in the region particularly with cancer, and as you do, with whatever frameworks or strategies you use, plan, plan, plan to last.
Thank you to the organizers of this conference for allowing me to speak, Drs. Odedina, Alaro, Bello, I thank you for the invitation. Your invitation came at a time when my family was dealing with the stage 4 cervical cancer burden of Angie my Sister in-law. We lost her to cervical cancer this past August 12th. But I give this presentation in her memory for the many other Angies we all have to fight like hell for, so they live, in a region where context matters. Implementation science needs more storytellers and I hope that AORTIC works to cultivate the next generation of storytellers truly making a difference in word and deed for cancer research in the region.