Implementation Research Research Articles

IntroductionIntegrated emergency care systems are essential for achieving universal health coverage and managing time-sensitive conditions. In India, emergency care remains fragmented, with limited resources and coordination across healthcare tiers. The INDIA-EMS study aims to develop and evaluate a patient-centric, high-quality integrated emergency care model in diverse Indian districts.MethodologyThe proposed implementation research is designed as a mixed methods study to be conducted over a 3-year period in selected districts of the states of Punjab, Gujarat, Madhya Pradesh, Odisha and Puducherry. The public/private medical college hospital/ tertiary care hospital in the district will serve as a hub and primary health care services as spokes. The health facilities will be graded according to the availability of resources for their readiness and preparedness to provide care for handling a particular emergency condition. The steps to build and implement the model are: 1. a gap analysis related to emergency care at both pre-hospital and health facility level; 2. a community-based survey in a sample of 30,000 in 5 districts for EMD burden estimates and health-seeking behaviour at baseline and endline; 3. use a consolidated framework for implementation research to develop, optimise and implement hub and spoke model through three cycles of iterative processes; and; 4.evaluation for feasibility, acceptability, cost, effectiveness and coverage.DiscussionA high-quality patient-centric integrated emergency care model may be able to ensure efficient delivery of care to patients experiencing time-sensitive emergencies and advance towards the coveted target under Sustainable Development Goals (SDGs).Ethics and disseminationEthics approval was obtained in all the project sites. The results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and state-level dissemination.Trial registrationThe trial is registered with CTRI (Clinical Trial Registry of India; CTRI/2024/01/061304).

BackgroundDigital Coordination Centres (DCCs) represent an innovative approach in hospital settings, designed to enhance patient flow, operational efficiency, and real-time decision-making. While their potential is widely recognised, there is limited understanding of the factors influencing their implementation. This study evaluated the implementation of a DCC in a large Australian hospital, with a focus on identifying enablers, barriers, and strategies for improvement.MethodsA process evaluation was conducted during Phase 1 of the DCC’s implementation. Forty-two semi-structured interviews were undertaken with staff and stakeholders involved in, or affected by, the DCC. Thematic analysis was guided by the Consolidated Framework for Implementation Research (CFIR), to identify key influences on implementation and to identify strategies for ongoing improvement and future scalability. ResultsKey enablers included strong leadership, system adaptability, and improved communication across services. Barriers involved data accuracy, system integration, and initial staff resistance -particularly around role clarity and perceived surveillance, which participants suggested could be addressed through enhanced training, role refinement, and strengthened feedback mechanisms. The CFIR provided a useful lens for structuring analysis but required adaptation to address overlapping constructs and digital-specific barriers.ConclusionsThis study offers practical insights into the implementation of a hospital-based DCC and demonstrates the value and challenges of using CFIR to evaluate complex digital health innovations. Findings highlight the importance of adaptable design, sustained leadership, continuous evaluation, and stakeholder-driven refinement. These insights can guide the successful implementation and scaling of digital coordination solutions in similarly complex healthcare environments.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12913-025-13343-y.

Use of implementation theories, models, and frameworks (TMFs) in HIV research is growing substantially, yet their impact may be limited by superficial application and poor alignment with community needs. This review highlights recent examples of TMF use in pre-exposure prophylaxis (PrEP) implementation studies and discusses how to increase their accessibility and utility for more equitable implementation. Studies from 2022-2025 ( n = 26) demonstrate more sophisticated TMF use, often layering frameworks and integrating participatory approaches and co-creation. Key themes include treating TMFs as boundary objects to facilitate partner dialogue, grounding theory in lived experience, and developing specific program theories. TMFs can support equitable PrEP implementation when applied flexibly and in partnership with communities. Researchers and practitioners can use TMFs as adaptable tools for dialogue and as the basis for further co-creation. Structured, participatory methods that help co-adapt frameworks and develop context-specific theories of change are crucial for translating assessment into effective, actionable strategies and improving HIV prevention outcomes.

Though integrating psychiatric care into primary care is thought to be a pivotal step, a huge gap remains in translating this training into clinical practice at primary health centers (PHCs) in India. To address this, we aim to explore the perspectives of the primary care doctors (PCDs) from an implementation research angle. An anonymous online survey with a semi-structured questionnaire gathered PCDs' perspectives on integrating primary care psychiatry training into India's healthcare system, focusing on Acceptability, Adoption, Appropriateness, and Feasibility subsets based on the conceptual framework for implementation outcomes. The survey reached 7,200 PCDs via a pan-India mental health capacity-building program, with 124 PCDs from 5 states participating. A 134 PCDs completed the Fidelity questionnaire. PCDs were grouped by mental health training status for comparative analysis. A mixed-method analysis was conducted on the data. Overall, PCDs reported high ratings across the subsets of Acceptability (91.1%-91.9%), Feasibility (75.8%-91.9%), Adoption (87.9%-93.5%), and Appropriateness (89.5%-92.7%). Clinical practice outcomes in terms of Fidelity (33.6%-52.2%) remained limited. Mental health training was significantly linked to increased comfort in managing mental health issues at PHCs (Acceptability subset, χ² = 4.79, p = .02), a greater readiness to start screening for mental health disorders (Adoption subset, χ² = 4.73 p = .03) and increased prescription practice at PHC for mental health disorders (Fidelity subset, χ² = 4.01, p = .04). Qualitative data analysis identified barriers such as stigma, time constraints, limited access to medications, staff shortages, and inadequate follow-up systems that hindered effective integration of mental health care at PHCs. Though psychiatry training of PCDs improves resource availability, addressing systemic challenges is essential for ensuring effective mental health service delivery at the primary care level.

Association of Nurses in AIDS Care Position on Breastfeeding and Chestfeeding: Ensuring Equity, Autonomy, Access, and Respect in HIV-Related Infant Feeding Decisions.

There is increasing attention in clinician care to the importance of using person-first language. Clinicians' words can reinforce clinicians' pre-existing stigmas and biases. People who use drugs (PWUD) continue to face stigma from clinicians. Person-first language is a way to reduce stigma and perpetuation of bias. Through specific structured in-person interviews, we examined the usage of stigmatizing language in the care of PWUD by surveying key clinicians- such as physicians, nurses, and social workers-and patients who self-identified as PWUD at Tufts Medical Center (Boston, MA) between July 2022-September 2022. Interview guides were created using the Consolidated Framework for Implementation Research (CFIR) 2.0 as a framework. We evaluated perceptions of person-first language and barriers to using person-first language amongst participants. Interviews were coded with Dedoose Software and inductive thematic analysis (ITA) methods were used until all themes were captured; CFIR 2.0 determinants used during interview guide creation were used as preliminary themes and modified as needed. We interviewed thirty-four people, including eleven PWUD at time of interview. Most clinicians agreed that language is important and matters when talking to patients and during documentation. Almost all patients agreed that language was important to them and impacted their relationship with their provider. However, there were responders that felt that person-first language was unnecessary, ineffective, and overly verbose in the medical setting. Major barriers to using person-first language were unawareness, lack of formal training, and perceived generational differences in appropriate language. Addressing language usage is a critical opportunity to promote inclusion and reduce bias amongst PWUD. As medical charts become increasingly accessible by patients, the use of language by the clinician becomes increasingly important. To create and maintain equitable systems of care, it is important to meet clinicians where they are at and to work with them to address these issues. This can include targeted educational sessions and resources informing clinicians on preferred language use and curriculum for providers-in-training.

BackgroundLower-level private for-profit health service providers form part of the pluralistic health systems delivering immunization services in urban areas of sub–Saharan Africa. However, their operational context is less documented since the conventional national Expanded Programme on Immunization (EPI) programmes tend to support delivery through public structures. Yet, private providers contribute greatly to immunization service coverage in urban settings. This paper explores the operational level context and stakeholders’ perspectives regarding immunization data among lower-level private for-profit service providers in the city of Kampala, Uganda. The objective of this baseline assessment was to document the current implementation context of immunization data among urban lower-level private for-profit immunization service providers to inform implementation research to improve immunization data in Kampala, Uganda.MethodsThe study adopted an exploratory qualitative design where key informant interviews and in-depth interviews were conducted. Analysis was guided by the health systems building-block framework, which informed the design of the codebook with coding done in Atlas.ti, a qualitative data management software.ResultsOverall, private for-profit immunization service providers reflected a context consisting of both barriers and opportunities underlying immunization data management practices. The barriers identified included: high staff turnover; data overload and manipulation tendencies; a transient population that access immunization services from different service providers without data linkage systems; computation of catchment populations, which affects utilization coverage data; financial barriers to the collection of community-level data; and inadequate facilitation leading to lean human resources at EPI departments managing immunization data from private providers. Nonetheless, opportunities to improve immunization data included the ability to widen data coverage through their services, enhanced public–private-partnership through data sharing arrangements, linkage of urban data among providers, improved recording of urban surveillance data, additional human resource to record data, widened scope for capturing adverse events data, improved community data linkages, and transitioning from paper-based to electronic data capture.ConclusionsOpportunities to improve urban immunization data management through private for-profit providers exist amidst numerous barriers. This calls for innovative strategies by the programme managers to design interventions with specific emphasis on addressing barriers inherent among urban lower-level private for-profit service providers if immunization data management among these entities is to be improved.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12961-025-01351-7.

Building Implementation Science Capacity in Academic Pharmacy: Report of the 2020-2021 AACP Research and Graduate Affairs Committee.

Background and objectives: The Ayushman Bharat Health Account (ABHA) represents a significant advancement in India's healthcare infrastructure, particularly aimed at enhancing access to medical services for underprivileged populations in both rural and urban settings. The study aimed to evaluate the awareness and understanding of the ABHA among underprivileged populations in both rural and urban settings, to analyze the attitude of the community toward digital health records and the ABHA system, and to analyze the relationship between the status of ABHA and various sociodemographic characteristics of the study population.Materials and methods: A mixed-method study was conducted in Bhopal as part of the baseline survey for the multi-centric study under the Indian Council of Medical Research (ICMR) Task Force Project titled "Task force study for evaluation of community level acceptability, scalability and linkage within the health system of ICMR pre-validated Labike technologies for screening & diagnosis in rural and urban population - An Implementation research". A door-to-door household survey was conducted among a selected underprivileged population living in both rural and urban areas. Categorical variables were expressed as frequencies and percentages, and chi-square was calculated to study the association between sociodemographic characteristics, such as gender, age, residence, education, and employment, and ABHA status, and thematic analysis was conducted for qualitative data.Results: The study's results illustrate the distribution of participants by various sociodemographic characteristics among 5709 participants. A total of 2460 (43%) of the participants were females, and the majority of the participants (2187, 38.3%) belonged to the 15-30 years of age. In this study, only 96 (3.4%) and 66 (2.3%) of residents of rural and urban areas of central India had ABHA, and this difference was statistically significant. Unlinked Aadhaar numbers (40.6% rural vs. 51.2% urban), a shortage of mobile phones, and poor awareness levels, which revealed notable differences between rural and urban populations, were the main obstacles to the generation of ABHA. This study assessed the relationship between a number of sociodemographic factors and the generation of an ABHA. The factors that significantly influence the likelihood of ABHA generation are gender (χ² = 11.6, p < 0.05), place of residence (χ² = 5.8, p = 0.01), educational status (χ² = 4.4, p = 0.03), and employment status (χ² = 14.4, p < 0.0001), as evidenced by the statistically significant association found between these factors and ABHA generation.Conclusions: The study found many obstacles despite the promising framework that ABHA developed while evaluating awareness and understanding of the ABHA among underprivileged populations in both rural and urban settings. The study analyzed community attitudes toward the ABHA system through in-depth interviews, which found four major themes: (1) unavailability of mobile phones; (2) Aadhaar not linked to mobile numbers; (3) not willing to get ABHA number; (4) unaware of ABHA and no interest in getting it. This study also assessed the relationship between the status of ABHA and various sociodemographic characteristics of the study population, in which gender, residence, education, and employment were found to be statistically significant.

Teen dating violence affects between 8.2% and 30% of adolescents, leading to significant mental and physical health consequences including depression, anxiety, substance use disorders, and increased risk of sexually transmitted infections. This narrative review synthesizes current evidence on prevention interventions for teen dating violence, examining their effectiveness and exploring applications for clinical practice. Based on findings from a comprehensive systematic review of 28 studies, this review identifies several types of effective prevention approaches. School-based universal programs such as Green Dot, Me & You, and Dating Matters have demonstrated effectiveness in reducing violence perpetration and changing attitudes toward violence. Targeted interventions for high-risk populations, particularly adolescents with previous violence exposure, often show stronger effects than universal approaches. Brief interventions using motivational interviewing and personality theory-based approaches show promise for healthcare settings, while digital prevention programs offer scalability and accessibility advantages. The evidence reveals that interventions are generally more effective at changing attitudes and norms than directly modifying violent behaviors, suggesting that cognitive shifts may precede behavioral change. Programs show differential effectiveness across gender, previous violence exposure, and socioeconomic characteristics, highlighting the importance of tailored approaches. Healthcare provider training demonstrates significant improvements in knowledge and screening practices, though implementation barriers remain. Economic evaluation suggests that prevention investments can yield substantial returns, with one program showing a benefit-cost ratio of 62.9. Sustained effects remain challenging to achieve, with some programs requiring multiple years of implementation. The predominantly U.S.-based research raises questions about generalizability across different cultural contexts. Future research priorities include long-term outcome studies, implementation research, culturally adapted interventions for diverse populations, and economic evaluations. Effective teen dating violence prevention requires comprehensive, multi-level approaches that address individual, family, school, and community factors, with sustained commitment and resources for implementation.

Stepped wedge cluster randomized trials (SW-CRTs) are a type of uni-directional crossover designs and are increasingly common in prevention and implementation research. Although sample size formulas have been developed to support the planning of SW-CRTs, almost no prior methods incorporated the baseline measurement of the outcome-a common feature in many randomized trials and, increasingly, in cross-sectional SW-CRTs. In this article, we systematically investigate the possibility of addressing a baseline outcome measurement in designing cross-sectional SW-CRTs. We provide three linear mixed modeling approaches to adjust for the baseline outcome and derive the corresponding variance formula of the treatment effect estimator under each. The derived formulas reveal the efficiency implications of including a baseline outcome measurement, and provide a natural vehicle for the efficiency comparisons across adjustment approaches to generate practical recommendations. We validate the power and sample size methods under each baseline adjustment approach using simulations and provide an illustrative sample size calculation with a baseline outcome using the context of a real SW-CRT.

Evaluating the introduction of COVID-19 oral antivirals through a test and treat program: outcomes from a cohort study in four African countries.

Wounds and skin conditions are common in residential aged care settings and can result in significant physical, psychosocial and economic impacts on residents and care systems. Ensuring high-quality evidence-based wound and skin care in residential aged care facilities is essential to promote resident well-being. However, the integration of such practices is a complex knowledge translation endeavour, influenced by contextual challenges. A comprehensive, systematic and theory-based framework can be used to guide the complex process. The aim of this study was to develop and validate a framework for wound care knowledge translation in residential aged care facilities. A multi-method, three-phase design was used. Phase 1 involved two systematic reviews to identify elements from theoretical and empirical perspectives, resulting in a draft framework. Phase 2 consisted of an online participatory design workshop with 10 key stakeholders to contextualise the elements identified in Phase 1. In Phase 3, a two-round modified e-Delphi process was conducted with 11 international experts to refine and validate the framework. The developed framework, which recognises knowledge translation as a process, comprises four vertical phases: pre-implementation, implementation, evaluation and sustainment. Additionally, it includes four horizontal components: Process steps, Adoption process, Values as a moral compass and Engagement for individual behaviour change and team development. Consensus was reached on the 'PAVE' framework's comprehensiveness, relevance, usability and value for guiding knowledge translation in residential aged care facilities. The PAVE framework offers a tool for implementation scientists, gerontology nurses and researchers to plan and guide knowledge translation for establishing evidence-based wound and skin care practices in residential aged care facilities, improving the quality and safety of care to older people. The framework holds potential for broader application across various interventions and healthcare settings. Future studies should explore the PAVE framework's effectiveness in diverse healthcare settings.

Delivering HIV testing and pre-exposure prophylaxis (PrEP) in community pharmacies can expand access to HIV services for populations with limited access to care. However, few pharmacies in the United States have successfully implemented these services. We investigated implementation barriers and facilitators of pharmacy-based HIV testing and PrEP initiation in Philadelphia, an Ending the HIV Epidemic priority jurisdiction with high rates of HIV and bacterial STIs, located in a state with relatively restrictive laws governing pharmacy scope of practice. Using a sequential, exploratory mixed-methods study design, we conducted 15 in-depth interviews with pharmacists and key implementing partners, followed by an online survey of pharmacists, pharmacy students, and technicians (n = 59). Interviews and surveys were analyzed using the Consolidated Framework for Implementation Research. Data were collected from October 31, 2023, to October 17, 2024. Interviewees representing three pharmacy sites had initiated HIV testing, but no sites had yet successfully implemented pharmacy-based PrEP. The primary barriers to delivering HIV testing were based on inner setting barriers (existing work burden, overly complex protocols). Legal restrictions and reimbursement concerns were the primary barriers to implementing pharmacy-based PrEP. Participants described potential solutions and mitigating strategies to these barriers, such as collaborative practice agreements and developing standing orders with medical providers, integration with telePrEP models, streamlined blueprints and protocols, and practice-based champions. Survey respondents indicated high levels of acceptability but lower levels of perceived implementation feasibility. To optimize implementation sustainability and success, implementation strategies need to adequately address legal barriers and reimbursement concerns and be integrated into the pharmacy workflow.

Lethal means management innovations in community pharmacies: A preimplementation study in 6 states.

Indonesia comprises 16,771 islands, including 111 small islands and atolls. The Indonesian government has established community health centres, known as puskesmas in Indonesian, to provide health services to the entire populations of the country, including those in remote areas. In 2014, the Indonesian government introduced a national health insurance system with the goal of providing equitable access to health care for all citizens. However, not all health issues can be managed by these community health centres, necessitating a referral system to more advanced healthcare facilities. This study aims to evaluate the implementation of the referral system by community health centres in small island areas, with a view to addressing a research gap on this topic. This implementation research explores the challenges associated with the referral system using the intervention mapping approach. This approach involves six stages: (1) needs assessment, (2) change matrix development, (3) devising strategies to optimise referrals based on practical theories, (4) program preparation, (5) adoption and implementation planning, and (6) evaluation planning. The target population will comprise patients, healthcare workers at community health centres and various other stakeholders. The study is to be conducted on three small islands in Sangihe Islands Regency, North Sulawesi Province: Nusa Tabukan, Marore and Kahakitang. The evaluation of the referral program addresses the gap in the implementation of referrals from community health centres on small islands, providing valuable information for the government and policymakers regarding healthcare delivery in hard-to-reach and remote areas. The study's results are expected to offer valuable insights into systematic research processes and provide recommendations for interventions designed to improve the referral system from community health centres to regional hospitals.

Barriers and facilitators to the implementation of a midwifery-led care model: a qualitative systematic review.

Examining structural characteristics for implementing opioid use disorder services in community-based pharmacies.

Implementing Clinical Decarbonization Actions: Lessons Learned from the University of California Health System.

Implementation of Teen Dating Violence Laws and Policies in High Schools: Staff and Student Perceptions.