Arianna Means shares why preventing childhood illnesses is imperative for global health

^{Arianna Means is an implementation scientist bridging the knowledge to practice gap (Photo by Elizar Mercado).} 

A large number of children around the world die every year from illnesses that are preventable. For Arianna Means, assistant professor of global health, those deaths are unacceptable. 

“We have so many evidence-based interventions to reduce child mortality that are inexpensive, and that are unequivocally effective,” Means said. “It's really about getting those interventions to the right people in the right places. That is our challenge.”  

Means is an implementation scientist at the University of Washington School of Public Health, and her work is focused on getting those interventions to the right people in the right places. Implementation science is a newer field of study that can have lifesaving impact. It bridges the gap between biomedical research that finds solutions to health problems and the lived realities of communities and healthcare workers who need those solutions the most. This gap is known as the know-do gap, or the estimated 17 years it takes to get an intervention from a research paper and into the hands of people for whom it is most useful. 

The Department of Global Health’s Implementation Science program is at the forefront of this work. Means’ focus as an implementation scientist is primarily in child health and community-based programming. She codirects implementation science in the Department of Global Health’s GlobalWACh program, where she studies how to improve maternal and child health and health care around the world.  

“The power of implementation science is fueled by community participation,” Means said. “People — frontline health care workers, local policymakers, patients, caregivers — often know the way to fix things. As implementation scientists, our job is to listen to those ideas and help formulate them into interventions that are feasible, acceptable and appropriate to all groups.” 

Research has found strong evidence that deworming programs, childhood vaccinations, and proper care for children after they leave the hospital lead to improved growth and survival, which are three of the main areas in which Means works, but the benefits of this research aren't reaching everyone who needs access to it. This is where implementation science comes into play. 

A few years ago, a research consortium that Means was engaged in was attempting to understand why children who had recently been in hospitals and were expected to recover were instead dying after they returned home. Means and her collaborators in Kenya conducted a survey that revealed that families were having trouble accessing medicine and follow-up care once they were home. Nearly 90% of families left the hospital with unanswered questions or didn’t know where to go to get the drugs they were prescribed.  

With this information, the implementation science team was able to work toward overcoming these barriers. The team took feedback from the families and used it to to design an intervention in Bangladesh and Kenya that will support families when their child is discharged from the hospital following an acute illness. Discharge managers will provide counseling and unconditional cash transfers to families during hospital discharge to help them stabilize their child during an extremely vulnerable point of recovery.  

Means emphasizes that collaboration with diverse partners is foundational to the design of effective implementation strategies. Before the hospital discharge interventions starts, the research consortium — including the KEMRI Wellcome Trust Research Programme (sponsor), the UW, University of Oxford, icddr,b (formerly known as the International Centre for Diarrhoeal Disease Research, Bangladesh) and others — will work with community members, health care providers, and policymakers, to understand opportunities and barriers this multi-component intervention might face, and how to tailor the intervention to enhance its cost effectiveness and feasibility in the context of each country. The newly designed intervention will be piloted and evaluated in both countries, before large scale testing. 

Engaging with the community is critical to understanding the barriers to implementing interventions. Take the case of Shigella, a diarrheal pathogen that affects children and has a very high mortality rate. Several candidate Shigella vaccines are currently being developed to prevent severe Shigella infection and associated outcomes, such as child stunting and death. A potential Shigella vaccine could also contribute to reducing antimicrobial resistance as fewer children are treated with antibiotics. 

But developing a vaccine that can prevent Shigella is not sufficient for achieving public health impact. Researchers have to work with policymakers to learn what the constraints are to getting vaccines to children. These constraints might include challenges such as changing the vaccination cards that families receive that lets them know of their routine vaccination schedule. It involves figuring out how to ship the vaccine and where to store it. It also involves understanding how the community feels about the vaccine and if there are any concerns they might have about its effects. 

“Every policymaker wants to use the best available evidence that will make their constituents and countries healthier as a whole,” Means said. “But they have to do so within the constraints related to costs, relative priorities and burdens of other diseases.”  

These topics are being studied by Means and her team in the Enterics for Global Health consortium, where they are proactively engaging policymakers in countries with high Shigella burden around the world to understand their preferences for a future Shigella vaccine, and opportunities to optimize rollout of a future vaccine. Using mixed methods and behavioral economics, Means and team are focused on reducing the knowledge-to-practice gap before the evidence-based intervention, a new vaccine, is even widely available. 

Means’ journey into implementation sciences started soon after she graduated college and moved to Zambia for three years as a Peace Corps volunteer. At the time, the prevalence of HIV in Zambia was around 15% and the country had just begun rolling out antiretrovirals at a large scale in rural areas. As a volunteer, Means was assigned to support a rural health center on implementing public health interventions for HIV, including antiretroviral rollout, as well as malaria and food insecurity.  

Without intending to, Means was getting firsthand experience in implementation science. By working with local HIV support groups to improve antiretroviral services and organizing a bed net distribution campaign led by traditional healers to prevent mosquito bites and malaria, Means observed how essential it is to work in partnership with community members to learn how to best implement this work. This included engaging local community members to champion these projects, gaining policymaker buy-in, and evaluating lessons learned and sharing those learnings with key groups. 

After this experience, Means attended the University of Washington for a Master of Public Health (MPH) in epidemiology. While working toward her MPH, the School of Public Health’s Department of Global Health was preparing to launch its first doctoral program in Implementation Science, led by Professor Kenny Sherr. After her experience in Zambia, Means was eager to join the program, and was eventually the second ever graduate of the School’s PhD in Global Health Metrics and Implementation Science. 

Since then, Means has worked with scientists and communities in the United States and globally on improving access to health care interventions. The desire for incorporating implementation science is evident in the demand for training and sharing of knowledge. In addition to teaching implementation science courses to students at the UW, Means has taught and worked with nearly 1,000 students around the world per year who participate in an online learning course or attend The Implementation Science in Global Health Summer Institute at the UW. She has brought her implementation science expertise as an external collaborator to the National Academy of Medicine, provided trainings for scientists at the National Institutes of Health and helped convene annual workshops for evaluators working at health departments throughout the country. 

“All families, no matter where they are in the world, should have access to the services that they need for their children to grow, be healthy, and thrive,” Means said. “The power, and the importance, of implementation science is ensuring that the many evidence-based interventions needed to support these children, be it deworming medications, vaccines, or nutritional care, reaches them in ways that are empowering and enduring.”