Implementation Science Theories Research Articles

Developing a conceptual framework for implementation science to evaluate a nutrition intervention scaled-up in a real-world setting.

The aim of this paper is to identify and develop a comprehensive conceptual framework using implementation science that can be applied to assess a nutrition intervention in a real-world setting. We conducted a narrative review using electronic databases and a manual search to identify implementation science frameworks, models and theories published in peer-reviewed journals. We performed a qualitative thematic analysis of these publications to generate a framework that could be applied to nutrition implementation science. Based on this review, we developed a comprehensive framework which we have conceptualised as an implementation science process that describes the transition from the use of scientific evidence through to scaling-up with the aim of making an intervention sustainable. The framework consisted of three domains: Domain i - efficacy to effectiveness trials, Domain ii - scaling-up and Domain iii - sustainability. These three domains encompass five components: identifying an 'effective' intervention; scaling-up and implementation fidelity; course corrections during implementation; promoting sustainability of interventions and consideration of a comprehensive methodological paradigm to identify 'effective' interventions and to assess the process and outcome indicators of implementation. The framework was successfully applied to a nutrition implementation program in Bangladesh. Our conceptual framework built from an implantation science perspective offers a comprehensive approach supported by a foundational and holistic understanding of its key components. This framework provides guidance for implementation researchers, policy-makers and programme managers to identify and review an effective intervention, to scale it up and to sustain it over time.

Protocol for the Yapatjarrathati project: a mixed-method implementation trial of a tiered assessment process for identifying fetal alcohol spectrum disorders in a remote Australian community

BackgroundFetal alcohol spectrum disorder (FASD) is a highly prevalent neurodevelopmental disorder associated with prenatal alcohol exposure. Early identification can improve functioning for individuals and reduce costs to society. Gold standard methods of diagnosing FASD rely on specialists to deliver intensive, multidisciplinary assessments. While comprehensive, prevalence rates highlight that this assessment model cannot meet demand, nor is it feasible in remote areas where specialist services are lacking. This project aims to expand the capabilities of remote practitioners in north Queensland, Australia, where 23–94% of the community identify as First Nations people. Integrating cultural protocols with the implementation science theories of Knowledge-To-Action, Experience-Based Co-Design, and RE-AIM, remote practitioners with varying levels of experience will be trained in a co-designed, culturally appropriate, tiered neurodevelopmental assessment process that considers FASD as a potential outcome. This innovative assessment process can be shared between primary and tertiary health care settings, improving access to services for children and families. This project aims to demonstrate that neurodevelopmental assessments can be integrated seamlessly with established community practices and sustained through evidence-based workforce development strategies.MethodsThe Yapatjarrathati project (named by the local First Nations community and meaning ‘to get well’) is a mixed-method implementation trial of a tiered assessment process for identifying FASD within a remote Australian community. In collaboration with the community, we co-designed: (a) a culturally sensitive, tiered, neurodevelopmental assessment process for identifying FASD, and (b) training materials that up-skill remote practitioners with varying levels of expertise. Qualitative interviews for primary, secondary and end users will be undertaken to evaluate the implementation strategies. RE-AIM will be used to evaluate the reach, effectiveness, adoption, implementation and maintenance of the assessment and training process.DiscussionCo-designed with the local community, integrated with cultural protocols, and based on implementation science theories, the assessment and training process from this project will have the potential to be scaled-up across other remote locations and trialed in urban settings. The Yapatjarrathati project is an important step towards increasing the availability of neurodevelopmental services across Australia and empowering remote practitioners to contribute to the FASD assessment process.

Fidelity of Implementation in the Field of Learning Disabilities

Decades of research and billions of dollars have been spent to develop and evaluate evidence-based interventions and develop multitiered systems of support (MTSS) toward the goal of more effectively delivering interventions and improving student outcomes. Available evidence, however, suggests interventions are often adopted slowly and delivered with poor fidelity, resulting in uninspiring outcomes for students. The field of implementation science has emerged to address the science-to-practice gap in human service sectors (e.g., education) as a way of improving service recipient (e.g., student) outcomes. For the considerable investment in school-based intervention development and evaluation to have a significant public health impact for students, educators must integrate key findings from implementation science into their practice and research. Toward this end, the purpose of this article is four-fold. First, it overviews implementation science and implementation theories, models, and frameworks. Second, it discusses the relevance of implementation science and fidelity to both the systems-level implementation of MTSS and individual-level implementation of interventions to students with learning disability (LD). Third, it reviews the unique legal aspects related to service implementation for students with LD and the gap between state-level mandates and available science. Finally, it provides additional resources and recommendations for readers.

3149 Embedding Implementation Science Within a Translational Health Sciences PhD: Educating Future Scientists to Bridge the Gap Between Research, Practice and Policy

OBJECTIVES/SPECIFIC AIMS: Determine the effectiveness of a curriculum designed to teach doctoral students to use implementation science theories, models and frameworks in optimizing scientific, social, political, cultural and organizational impact METHODS/STUDY POPULATION: Analysis of Integrated Final Projects across three cohorts of doctoral students (N=30) to identify sub-disciplinary knowledge integration and application. RESULTS/ANTICIPATED RESULTS: Integrated Final Projects indicate that the integration of IS, Program Theory and Research design within semester two yields application of integrated, sub-disciplinary knowledge to research design, identification of mechanisms of action and the address of barriers and facilitators to implementation of findings. Future analysis will be conducted to determine the degree to which dissertations reflect a similar level of sub-disciplinary integration and focus on implementation within the appropriate service setting. DISCUSSION/SIGNIFICANCE OF IMPACT: Training future translational researchers to understand and use implementation science theories, models and frameworks can potentially result in narrowing the science-to-service gap.

Developing management pathways for hypertensive disorders of pregnancy (HDP) in Indonesian primary care: a study protocol

BackgroundNational and international guidelines for the management of hypertensive disorders of pregnancy (HDP) are available in developing countries. However, more detailed clinical pathways for primary care settings are limited. This study focuses on Indonesia, where 72% of women who died from HDP and its complications had received less appropriate treatment according to international guidelines. There is an urgent need to develop primary care focused pathways that enable general practitioners (GPs), midwives and other relevant providers to manage HDP better.ObjectivesThis paper describes a study protocol for the development of HDP management pathways for Indonesian primary care settings.MethodsThis study design is informed by Implementation Science theories and consists of three phases. The exploratory phase will involve conducting semi-structured interviews with key Indonesian primary care stakeholders to explore their experiences and views on HDP management. The development phase will apply evidence from the literature review and results of the exploratory phase to develop HDP management pathways contextualised to Indonesian primary care settings. Consensus will be sought from approximately 50 experts, consist of general practitioners (GPs), midwives, obstetricians, nurses and policy makers using Delphi technique survey. The evaluation phase will involve a pilot study to evaluate the pathways’ acceptability and feasibility in a sample of Indonesian primary care practices using mixed methods.DiscussionThe implementation science frameworks inform and guide the phases in this study. Qualitative interviews in the exploratory phase are conducive to eliciting opinions from key stakeholders. Using Delphi technique at the development phase is suitable to seek participants’ consensus on HDP management in primary care. Observations, focus group discussions, interviews as well as analysis of patients’ medical records at the evaluation phase are expected to provide a comprehensive investigation of the implementation of the pathways in practice settings.

Longitudinal evaluation of a course to build core competencies in implementation practice

BackgroundFew training opportunities are available for implementation practitioners; we designed the Practicing Knowledge Translation (PKT) to address this gap. The goal of PKT is to train practitioners to use evidence and apply implementation science in healthcare settings. The aim of this study was to describe PKT and evaluate participant use of implementation science theories, models, and frameworks (TMFs), knowledge, self-efficacy, and satisfaction and feedback on the course.MethodsPKT was delivered to implementation practitioners between September 2015 and February 2016 through a 3-day workshop, 11 webinars. We assessed PKT using an uncontrolled before and after study design, using convergent parallel mixed methods. The primary outcome was use of TMFs in implementation projects. Secondary outcomes were knowledge and self-efficacy across six core competencies, factors related to each of the outcomes, and satisfaction with the course. Participants completed online surveys and semi-structured interviews at baseline, 3, 6, and 12 months.ResultsParticipants (n = 15) reported an increase in their use of implementation TMFs (mean = 2.11; estimate = 2.11; standard error (SE) = 0.4; p = 0.03). There was a significant increase in participants’ knowledge of developing an evidence-informed, theory-driven program (ETP) (estimate = 4.10; SE = 0.37; p = 0.002); evidence implementation (estimate = 2.68; SE = 0.42; p < 0.001); evaluation (estimate = 4.43; SE = 0.36; p < 0.001); sustainability, scale, and spread (estimate = 2.55; SE = 0.34; p < 0.001); and context assessment (estimate = 3.86; SE = 0.32; p < 0.001). There was a significant increase in participants’ self-efficacy in developing an ETP (estimate = 3.81; SE = 0.34; p < 0.001); implementation (estimate = 3.01; SE = 0.36; p < 0.001); evaluation (estimate = 3.83; SE = 0.39; p = 0.002); sustainability, scale, and spread (estimate = 3.06; SE = 0.46; p = 0.003); and context assessment (estimate = 4.05; SE = 0.38; p = 0.016).ConclusionProcess and outcome measures collected indicated that PKT participants increased use of, knowledge of, self-efficacy in KT. Our findings highlight the importance of longitudinal evaluations of training initiatives to inform how to build capacity for implementers.

The application of implementation science theories for population health: A critical interpretive synthesis.

Background and PurposeOver the last decade, the field of implementation science (IS) has yielded an array of theoretical approaches to clarify and understand how factors influence the application and scaling-up of evidence-based practice in health care. These developments have led to questions about whether IS theories and frameworks might be of value to population health researchers and decision makers. The purpose of this research was to conduct a critical interpretive synthesis to explore, if, and how, key IS theories and frameworks might inform population health interventions aimed at reducing the burden of illness across populations.MethodsAn initial list of theories and frameworks was developed based on previous published research and narrowed to focus on theories considered as formative for the field of IS. A standardized data extraction form was used to gather key features of the theories and critically appraise their relevance to population health interventions.ResultsTen theories were included in the review and six deemed most applicable to population health based on their consideration of broader contextual and system-level factors. The remaining four were determined to have less relevant components for population health due to their limited consideration of macro-level factors, often focusing on micro (individual) and meso (organizational) level factors.ConclusionsTheories and frameworks are important to guide the implementation and sustainability of population health interventions. The articulation of meso level factors common in IS theories may be of value to interventions targeted at the population level. However, some of the reviewed theories were limited in their consideration of broader contextual factors at the macro level (community, policy or societal). This critical interpretive synthesis also found that some theories lacked provision of practical guidance to address interventions targeting structural factors such as key social determinants of health (e.g., housing, income).

Criteria for selecting implementation science theories and frameworks: results from an international survey

Criteria for selecting implementation science theories and frameworks: results from an international survey

Criteria for selecting implementation science theories and frameworks: results from an international survey

BackgroundTheories provide a synthesizing architecture for implementation science. The underuse, superficial use, and misuse of theories pose a substantial scientific challenge for implementation science and may relate to challenges in selecting from the many theories in the field. Implementation scientists may benefit from guidance for selecting a theory for a specific study or project. Understanding how implementation scientists select theories will help inform efforts to develop such guidance. Our objective was to identify which theories implementation scientists use, how they use theories, and the criteria used to select theories.MethodsWe identified initial lists of uses and criteria for selecting implementation theories based on seminal articles and an iterative consensus process. We incorporated these lists into a self-administered survey for completion by self-identified implementation scientists. We recruited potential respondents at the 8th Annual Conference on the Science of Dissemination and Implementation in Health and via several international email lists. We used frequencies and percentages to report results.ResultsTwo hundred twenty-three implementation scientists from 12 countries responded to the survey. They reported using more than 100 different theories spanning several disciplines. Respondents reported using theories primarily to identify implementation determinants, inform data collection, enhance conceptual clarity, and guide implementation planning. Of the 19 criteria presented in the survey, the criteria used by the most respondents to select theory included analytic level (58%), logical consistency/plausibility (56%), empirical support (53%), and description of a change process (54%). The criteria used by the fewest respondents included fecundity (10%), uniqueness (12%), and falsifiability (15%).ConclusionsImplementation scientists use a large number of criteria to select theories, but there is little consensus on which are most important. Our results suggest that the selection of implementation theories is often haphazard or driven by convenience or prior exposure. Variation in approaches to selecting theory warn against prescriptive guidance for theory selection. Instead, implementation scientists may benefit from considering the criteria that we propose in this paper and using them to justify their theory selection. Future research should seek to refine the criteria for theory selection to promote more consistent and appropriate use of theory in implementation science.

Improving opioid safety practices in primary care: protocol for the development and evaluation of a multifaceted, theory-informed pilot intervention for healthcare providers

IntroductionIn North America, drug overdose deaths are reaching unprecedented levels, largely driven by increasing prescription opioid-related deaths. Despite the development of several opioid guidelines, prescribing behaviours still contribute to poor...

Translational research: The ingredients are only the start of the recipe for better dietetic practice

Translational research: The ingredients are only the start of the recipe for better dietetic practice

Application of Implementation Science Methodology to Immediate Postpartum Long-Acting Reversible Contraception Policy Roll-Out Across States.

Purpose Providing long-acting reversible contraception (LARC) in the immediate postpartum period is an evidence-based strategy for expanding women’s access to highly effective contraception and for reducing unintended and rapid repeat pregnancy. The purpose of this article is to demonstrate the application of implementation science methodology to study the complexities of rolling-out policies that promote immediate postpartum LARC use across states. Description The Immediate Postpartum LARC Learning Community, sponsored by the Association of State and Territorial Health Officials (ASTHO), is made up of multi-disciplinary, multi-agency teams from 13 early-adopting states with Medicaid reimbursement policies promoting immediate postpartum LARC. Partners include federal agencies and maternal and child health organizations. The Learning Community discussed barriers, opportunities, strategies, and promising practices at an in-person meeting. Implementation science theory and methods, including the Consolidated Framework for Implementation Research (CFIR), and a recent compilation of implementation strategies, provide useful tools for studying the complexities of implementing immediate postpartum LARC policies in birthing facilities across early adopting states. Assessment To demonstrate the utility of this framework for guiding the expansion of immediate postpartum LARC policies, illustrative examples of barriers and strategies discussed during the in-person ASTHO Learning Community meeting are organized by the five CFIR domains—intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and process. Conclusion States considering adopting policies can learn from ASTHO’s Immediate Postpartum LARC Learning Community. Applying implementation science principles may lead to more effective statewide scale-up of immediate postpartum LARC and other evidence-based strategies to improve women and children’s health.

Building capacity in implementation science research training at the University of Nairobi.

BackgroundHealth care systems in sub-Saharan Africa, and globally, grapple with the problem of closing the gap between evidence-based health interventions and actual practice in health service settings. It is essential for health care systems, especially in low-resource settings, to increase capacity to implement evidence-based practices, by training professionals in implementation science. With support from the Medical Education Partnership Initiative, the University of Nairobi has developed a training program to build local capacity for implementation science.MethodsThis paper describes how the University of Nairobi leveraged resources from the Medical Education Partnership to develop an institutional program that provides training and mentoring in implementation science, builds relationships between researchers and implementers, and identifies local research priorities for implementation science.ResultsThe curriculum content includes core material in implementation science theory, methods, and experiences. The program adopts a team mentoring and supervision approach, in which fellows are matched with mentors at the University of Nairobi and partnering institutions: University of Washington, Seattle, and University of Maryland, Baltimore. A survey of program participants showed a high degree satisfaction with most aspects of the program, including the content, duration, and attachment sites. A key strength of the fellowship program is the partnership approach, which leverages innovative use of information technology to offer diverse perspectives, and a team model for mentorship and supervision.ConclusionsAs health care systems and training institutions seek new approaches to increase capacity in implementation science, the University of Nairobi Implementation Science Fellowship program can be a model for health educators and administrators who wish to develop their program and curricula.

Implementation Science: Buzzword or Game Changer?

The purpose of this supplement article is to provide a resource of pertinent information concerning implementation science for immediate research application in communication sciences and disorders. Key terminology related to implementation science is reviewed. Practical suggestions for the application of implementation science theories and methodologies are provided, including an overview of hybrid research designs that simultaneously investigate clinical effectiveness and implementation as well as an introduction to approaches for engaging stakeholders in the research process. A detailed example from education is shared to show how implementation science was utilized to move an intervention program for autism into routine practice in the public school system. In particular, the example highlights the value of strong partnership among researchers, policy makers, and frontline practitioners in implementing and sustaining new evidence-based practices. Implementation science is not just a buzzword. This is a new field of study that can make a substantive contribution in communication sciences and disorders by informing research agendas, reducing health and education disparities, improving accountability and quality control, increasing clinician satisfaction and competence, and improving client outcomes.

Hiding in plain sight: communication theory in implementation science.

BackgroundPoor communication among healthcare professionals is a pressing problem, contributing to widespread barriers to patient safety. The word “communication” means to share or make common. In the literature, two communication paradigms dominate: (1) communication as a transactional process responsible for information exchange, and (2) communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. In this paper, we debate the merits of encompassing both paradigms.DiscussionWe conducted a two-staged literature review searching for the concept of communication in implementation science to understand how communication is conceptualized. Twenty-seven theories, models, or frameworks were identified; only Rogers’ Diffusion of Innovations theory provides a definition of communication and includes both communication paradigms. Most models (notable exceptions include Diffusion of Innovations, The Ottawa Model of Research Use, and Normalization Process Theory) describe communication as a transactional process. But thinking of communication solely as information transfer or exchange misrepresents reality. We recommend that implementation science theories (1) propose and test the concept of shared understanding when describing communication, (2) acknowledge that communication is multi-layered, identify at least a few layers, and posit how identified layers might affect the development of shared understanding, (3) acknowledge that communication occurs in a social context, providing a frame of reference for both individuals and groups, (4) acknowledge the unpredictability of communication (and healthcare processes in general), and (5) engage with and draw on work done by communication theorists.SummaryImplementation science literature has conceptualized communication as a transactional process (when communication has been mentioned at all), thereby ignoring a key contributor to implementation intervention success. When conceptualized as a transformational process, the focus of communication moves to shared understanding and is grounded in human interactions and the way we go about constructing knowledge. Instead of hiding in plain sight, we suggest explicitly acknowledging the role that communication plays in our implementation efforts. By using both paradigms, we can investigate when communication facilitates implementation, when it does not, and how to improve it so that our implementation and clinical interventions are embraced by clinicians and patients alike.

Guiding Healthcare Technology Implementation

Healthcare technology is used to improve delivery of safe patient care by providing tools for early diagnosis, ongoing monitoring, and treatment of patients. This technology includes bedside physiologic monitors, pulse oximetry devices, electrocardiogram machines, bedside telemetry, infusion pumps, ventilators, and electronic health records. Healthcare costs are a challenge for society, and hospitals are pushed to lower costs by discharging patients sooner. Healthcare technology is being used to facilitate these early discharges. There is little understanding of how healthcare facilities purchase, implement, and adopt technology. There are two areas of theories and models currently used when investigating technology: technology adoption and implementation science. Technology adoption focuses mainly on how the end users adopt technology, whereas implementation science describes methods, interventions, and variables that promote the use of evidence-based practice. These two approaches are not well informed by each other. In addition, amplifying the knowledge gap is the limited conceptualization of healthcare technology implementation frameworks. To bridge this gap, an all-encompassing model is needed. To understand the key technology implementation factors utilized by leading healthcare facilities, the prevailing technology adoption and implementation science theories and models were reviewed. From this review, an integrated technology implementation model will be set forth.

What are the implications of implementation science for medical education?

BackgroundDerived from multiple disciplines and established in industries outside of medicine, Implementation Science (IS) seeks to move evidence-based approaches into widespread use to enable improved outcomes to be realized as quickly as possible by as many as possible.MethodsThis review highlights selected IS theories and models, chosen based on the experience of the authors, that could be used to plan and deliver medical education activities to help learners better implement and sustain new knowledge and skills in their work settings.ResultsIS models, theories and approaches can help medical educators promote and determine their success in achieving desired learner outcomes. We discuss the importance of incorporating IS into the training of individuals, teams, and organizations, and employing IS across the medical education continuum. Challenges and specific strategies for the application of IS in educational settings are also discussed.ConclusionsUtilizing IS in medical education can help us better achieve changes in competence, performance, and patient outcomes. IS should be incorporated into curricula across disciplines and across the continuum of medical education to facilitate implementation of learning. Educators should start by selecting, applying, and evaluating the teaching and patient care impact one or two IS strategies in their work.

Implementation Science in the Real World: A Case Study of HIV Rapid Testing

Implementation science theories offer technical principles for carrying out activities designed to create or improve systems; however, such theories tend not to provide pragmatic or streamlined guidance when it comes to executing the actual implementation. We assembled a streamlined and comprehensive six-step theory-based implementation science model (ADAPTS - Assessment, Deliverables, Activate, Pretraining, Training, Sustainability) derived from the methods we have used to successfully execute multiple self-sustaining implementation efforts within the Veteran's Affairs Healthcare System. This paper provides a case study of our ADAPTS implementation science model, using a complex multisite HIV rapid testing implementation project as an exemplar.

Access to care for vulnerable veterans with hepatitis C: a hybrid conceptual framework and a case study to guide translation

The Veterans Health Administration (VHA) is the largest single provider of medical care to people with hepatitis C (HCV) in the USA. Given the advent of promising new HCV therapies, the VHA is now faced with a large number of chronically HCV-infected veterans with concomitant psychiatric or substance use comorbid conditions who will need to either be retreated or newly treated for HCV or will require management for chronic liver disease. There is a critical need in the VHA for behavioral medicine and hepatology specialists, along with infectious disease and primary care providers with an interest in hepatitis C, to provide coordinated care for these complex patients. The VHA Health Services Research and Development Service has advocated for the application of strong implementation science theories and methods to translate new models of healthcare delivery in clinical practice. To inform the delivery and evaluation of integrated behavioral medicine and specialty care for vulnerable patient populations, we sought to develop an enriched framework which incorporates implementation science theory and strong conceptual models for access to care. In this paper, we present a hybrid conceptual framework that accomplishes this goal. To illustrate how this hybrid model could inform the translation of a novel method of healthcare delivery, we provide a case study of a VHA initiative to improve access to integrated behavioral medicine and specialty care among veterans with HCV.