Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC. Design and methods We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007–2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned. Results Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners. Conclusions IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Intervention In this review, we are not studying the efficacy or effectiveness of specific EBI or exposures. Rather, we are studying how the above 'participants' have used IS to advance FP in LMIC. The studies we examine will emphasize the following two facets of using IS:  Implementation strategies: the design, introduction, integration, and facilitation of activities aimed at enhancing the adoption, implementation, and sustainability of an FP-related EBI.  Implementation research: inquiries that draw upon applicable theory, adapt, and customize methods, and is embedded in, or is overlaid upon, the conduct of implementation strategies to generate knowledge on their processes, effects and/or effectiveness.
Comparison This systematic review does not require comparison or control groups.

Contexts
Studies may be excluded from the third stage of the systematic review (see below) if during the full-text review analysts determine that the application of IS described in it does not sufficiently reflect the following "defining characteristics of implementation science employed in global health" 1. Contextualization of implementation strategy and research design and methods according to levels of analysis, their environments. 2. Relevance of the implementation strategy and research to addressing health problems, decision-making needs, setting priorities and/or building commitment and levels where implementation strategy is conducted.
3. Research questions are framed or based on needs identified by consumers of the evidence, and research design, methods and data sources are appropriate for the underlying implementation and decision contexts. 4. Multi-stakeholder and multidisciplinary co-creation of implementation strategies, co-production of research and collaborative use of results. 5. Embeddedness of the research in 'real world' conditions, i.e., the reality of the implementing organizations and communities and in the context of health systems. 6. Research is designed to provide evidence or solutions to implementers through short feedback loops that can be used for real-time improvements. 7. Research focuses on processes and outcomes and seeks to explain the generative process whereby results were produced under certain circumstances.

Outcomes
Mainly, this systematic review will:  Synthesize trends, including strengths and gaps, with respect to the operationalization of IS to advance FP in LMIC. o How have IS concepts and constructs been incorporated and applied toward the design and execution of implementation strategies to promote EBI uptake? o How have IS theory and methods been employed in the application of research on processes, effects and effectiveness of strategies aimed at promoting EBI uptake? o How have the principles of IS (see 'contexts' section below) been emphasized during the combined applications of implementation strategies and research?
Render insight and lessons learned, and direct recommendations for the future applications of IS to facilitate better adoption, implementation, and sustainment of FP-related EBI in LMIC to readers from policy, research, donor and technical assistance realms.

Additional outcomes
The studies, themselves, will have reported outcomes and examining these will add value and help reinforce the main outcomes of this review. Accordingly, reviewers will examine eligible studies for characteristics of the outcomes that each reports: 1. Improve populations' health. 2. Enhance policy design and implementation. 3. Strengthen health systems and scale up, 4. Improve management and service delivery. 5. Support and empower communities to learn and act.
This will illustrate trends-in the value by each study, in terms of the individual knowledge contribution and impact on populations and health systems broadly. Supplemental