Using implementation strategies in community settings: an introduction to the Expert Recommendations for Implementing Change (ERIC) compilation and future directions

Implementation and Impact of Perinatal Food Is Medicine Programs: A Qualitative Research Study

BACKGROUND

Improving social determinants of health, such as access to nutritious food, is crucial for achieving health equity. Nutrition insecurity, especially during pregnancy and postpartum, can lead to poor maternal and birth outcomes. Food is Medicine (FIM) programs, which integrate food into the health care system to prevent or manage disease, have the potential to improve nutrition insecurity, but research about perinatal FIM programs is limited.

OBJECTIVE

The purpose of this study was to explore perceptions of public health impacts of perinatal FIM programs from the perspectives of both program implementers and program supporters and implementation strategies used to enhance program adoption, implementation, and maintenance.

DESIGN

Qualitative data were collected through semi-structured interviews. The interview guide was based on the Reach, Effectiveness, Adoption, Implementation, Maintenance framework.

PARTICIPANTS/SETTING

Program implementers (n = 16) and program supporters (n = 20) were recruited across the United States through purposive sampling in 2022 and 2023.

ANALYSIS

Data were analyzed using deductive thematic analysis and an iterative feedback loop with the project partner.

RESULTS

Interviews were completed with program implementers and program supporters and generated meaning units (n = 1,942), which were coded into themes aligned with each Reach, Effectiveness, Adoption, Implementation, Maintenance dimension. Perinatal FIM programs reached multiple priority populations who were mainly recruited through health care systems. Effectiveness measures typically included nutrition patterns and practices, as well as return on investment. Motivations for adopting programs primarily included partnerships and connections, financing, and policies and laws. Program components varied and were adapted to meet participants and setting needs. Policy, evidence, funding, and partnerships could lead to program maintenance. Implementation strategies applied by the program supporters included financial strategies and infrastructure changes.

CONCLUSIONS

There is a need to identify the core functions and adaptable forms of perinatal FIM programs, which could lead to identification of standard evaluation metrics. This could result in greater uptake by potential delivery agents, increased funding and policy support, and enhanced benefits for perinatal population experiencing health disparities.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022

BACKGROUND

Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes.

METHODS

We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes.

FINDINGS

Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions.

CONCLUSION

This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

Adaptations to a statewide walking program: Use of iterative feedback cycles between research and delivery systems improves fit for over 10 years

FitEx is an 8-week, group-based physical activity and fruit and vegetable consumption program co-created and implemented with the Cooperative Extension System. Effectiveness and delivery personnel perceptions of the program are promising; however, ongoing adaptations are required to continuously meet shifting needs of both researchers and delivery systems. We applied the APDER iterative cycles of implementation over 15 years to understand dynamic and ongoing adaptations as well as implications for FitEx sustainability. Each year, an IRPP between delivery (FitEx deliverers) and research (FitEx developers) systems shared feedback on program core elements and strategies for adaptation through regular team meetings, emails, and evaluations. While the core elements (delivering to groups, goal setting, feedback, and self-monitoring) of FitEx remained consistent, changes were made to address logistical factors, emergent research questions, and technological advancements. For example, program deliverers suggested decreasing training time and making program content available on demand rather than through traditional in-person training. Using APDER with a long-standing IRPP allowed the delivery system to provide feedback to program developers to co-create ongoing adaptations and data-driven decisions. Future work in response to shifting needs includes Fitbit integration and technological updates to the usability of the FitEx platform. Our aim is to report the 15+ years of applying the Assess, Plan, Do, Evaluate, Report (APDER) process with an integrated research-practice partnership (IRPP) for co-creation of ongoing adaptations of FitEx and to share methods for capturing relevant data for decision-making to integrate health promotion programs in community settings.

Budget impact analysis for implementation decision making, planning, and financing

Shelley et al. (in Accelerating integration of tobacco use treatment in the context of lung cancer screening: relevance and application of implementation science to achieving policy and practice. Transl Behav Med 2022;12:1076-1083) laid out how implementation science frameworks and methods can advance the delivery of tobacco use treatment services during lung cancer screening services, which until recently was mandated by the Centers for Medicare and Medicaid Services. Their discussion provides an important overview of the full process of implementation and highlights the vast number of decisions that must be made when planning for implementation of an evidence-based practice such as tobacco use treatment: what specific tobacco use treatment services to deliver, when to deliver those services within the lung cancer screening process, and what implementation strategies to use. The costs of implementation play a major role in decision making and are a key implementation determinant discussed in major implementation frameworks. When making decisions about what and how to implement, budget impact analyses (BIAs) can play an important role in informing decision making by helping practitioners understand the overall affordability of a given implementation effort. BIAs can also inform the development of financing strategies to support the ongoing sustainment of tobacco use treatment service provision. More attention is needed by the research community to produce high-quality, user-friendly, and flexible BIAs to inform implementation decision making in health system and community settings. The application of BIA can help ensure that the considerable time and effort spent to develop and evaluate evidence-based programs has the best chance to inform implementation practice.

Using ERIC to Assess Implementation Science in Drowning Prevention Interventions in High-Income Countries: A Systematic Review

This systematic review identifies and describes the use of the Expert Recommendation for Implementing Change (ERIC) concepts and strategies using public health approaches to drowning prevention interventions as a case study. International calls for action have identified the need to better understand the implementation of drowning prevention interventions so that intervention design and implementation is improved. In high-income countries (HICs), interventions are sophisticated but still little is known or written about their implementation. The review was registered on PROSPERO (number CRD42022347789) and followed the PRISMA guidelines. Eight databases were searched. Articles were assessed using the Public Health Ontario Meta-tool for quality appraisal of public health evidence. Forty-nine articles were included. Where ERIC strategies were reported, the focus was on evaluative and iterative strategies, developing partnerships and engaging the target group. The review identified few articles that discussed intervention development and implementation sufficiently for strategies to be replicated. Findings will inform further research into the use and measurement of implementation strategies by practitioners and researchers undertaking work in drowning prevention in HICs and supports a call to action for better documentation of implementation in public health interventions.

Matching barriers and facilitators to implementation strategies: recommendations for community settings

BACKGROUND

Implementation science aims to improve the integration of evidence-based interventions in real-world settings. While its methods and models could potentially apply to any field with evidence-based interventions, most research thus far has originated in clinical settings. Community settings often have fewer resources, missions beyond health, and a lack of support and expertise to implement evidence-based interventions when compared to many clinical settings. Thus, selecting and tailoring implementation strategies in community settings is particularly challenging, as existing compilations are primarily operationalized through clinical setting terminology. In this debate, we (1) share the process of using an existing match tool to select implementation strategies to increase uptake of nutrition and physical activity policy, systems, and environment interventions in community settings and (2) discuss the challenges of this process to argue that selecting implementation strategies in community settings has limited transferability from clinical settings and may require a unique implementation strategy compilation and pragmatic matching tool.

MATCHING BARRIERS TO IMPLEMENTATION STRATEGIES

The impetus for this debate paper came from our work selecting implementation strategies to improve the implementation and eventual scaling of nutrition and physical activity policy, systems, and environment interventions in a community settings. We conducted focus groups with practitioners and used the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change match tool to select potential implementation strategies to overcome prominent barriers. There was limited congruence between tool outputs and optimal strategies, which may in part be due to differences in context between clinical and community settings. Based on this, we outline needs and recommendations for developing a novel and pragmatic matching tool for researchers and practitioners in community settings.

CONCLUSIONS

More work is needed to refine the implementation barrier-strategy matching process to ensure it is relevant, rapid, and rigorous. As leading implementation strategy scholars note, as more researchers document contextual factors and strategies selected to address them, the knowledge base will increase, and refined mapping processes can emerge.

Healthy eating and active living policy, systems, and environmental changes in rural Louisiana: a contextual inquiry to inform implementation strategies

BACKGROUND

Healthy eating and active living policy, systems, and environmental (PSE) changes are implemented across the United States through Cooperative Extension. However, translating multisector PSE changes to practice in community settings is challenging and there is a lack of knowledge about barriers and facilitators to PSE changes among state Extension systems using standardized frameworks. Therefore, a research-to-practice partnership effort aimed to identify Louisiana Cooperative Extension Service Family and Consumer Science (LFCS) practitioners' barriers and facilitators to implementing PSE changes in rural Louisiana communities.

METHODS

A qualitative approach using the 2022 Consolidated Framework for Implementation Research (2022 CFIR) was used. Focus group discussions were conducted at five LFCS regional trainings between February and May 2022. All LFCS practitioners with any level of experience implementing healthy eating and active living PSE changes were eligible to participate, with emphasis on understanding efforts within more rural communities. Focus group discussions were audio-recorded and transcribed verbatim. Researchers analyzed qualitative data using the constant comparison method and 2022 CFIR domains and constructs including Inner Setting (LFCS organization), Outer Setting (rural Louisiana communities), Innovation (PSE changes), and Individuals (PSE change implementation actors/partners).

RESULTS

Across the five regions, LFCS practitioners (n = 40) described more barriers (n = 210) than facilitators (n = 100); findings were often coded with multiple 2022 CFIR domains. Reported Inner Setting barriers were lack of formal or informal information sharing and lack of access to knowledge and information. Outer Setting barriers included sustaining and initiating community partnerships and local environmental or political conditions. Individual barriers included a lack of time and expertise, and Innovation barriers included the complex nature of rural PSE changes. Facilitators were mentioned at multiple levels and included community partner buy-in and practitioners' motivation to implement PSE changes.

CONCLUSIONS

Implementation strategies are needed to build on organizational strengths and to overcome multi-level barriers to PSE change implementation among LFCS practitioners. The results from the in-depth contextual inquiry used could serve as a guide for future pragmatic assessment efforts among other state Extension systems or as a model for identifying barriers and facilitators and associated implementation strategies among other public health systems in the U.S. and abroad.

Implementation and dissemination of home- and community-based interventions for informal caregivers of people living with dementia: a systematic scoping review

BACKGROUND

Informal caregivers of people with dementia (PwD) living at home are often the primary source of care, and, in their role, they often experience loss of quality of life. Implementation science knowledge is needed to optimize the real-world outcomes of evidence-based interventions (EBIs) for informal caregivers. This scoping review aims to systematically synthesize the literature that reports implementation strategies employed to deliver home- and community-based EBIs for informal caregivers of PwD, implementation outcomes, and the barriers and facilitators to implementation of these EBIs.

METHODS

Embase, MEDLINE, Web of Science, and Cochrane Library were searched from inception to March 2021; included studies focused on "implementation science," "home- and community-based interventions," and "informal caregivers of people with dementia." Titles and abstracts were screened using ASReview (an innovative AI-based tool for evidence reviews), and data extraction was guided by the ERIC taxonomy, the Implementation Outcome Framework, and the Consolidated Framework for Implementation Science Research; each framework was used to examine a unique element of implementation.

RESULTS

Sixty-seven studies were included in the review. Multicomponent (26.9%) and eHealth (22.3%) interventions were most commonly reported, and 31.3% of included studies were guided by an implementation science framework. Training and education-related strategies and provision of interactive assistance were the implementation strategy clusters of the ERIC taxonomy where most implementation strategies were reported across the reviewed studies. Acceptability (82.1%), penetration (77.6%), and appropriateness (73.1%) were the most frequently reported implementation outcomes. Design quality and packaging (intervention component suitability) and cosmopolitanism (partnerships) constructs, and patient's needs and resources and available resources (infrastructure) constructs as per the CFIR framework, reflected the most frequently reported barriers and facilitators to implementation.

CONCLUSION

Included studies focused largely on intervention outcomes rather than implementation outcomes and lacked detailed insights on inner and outer setting determinants of implementation success or failure. Recent publications suggest implementation science in dementia research is developing but remains in nascent stages, requiring future studies to apply implementation science knowledge to obtain more contextually relevant findings and to structurally examine the mechanisms through which implementation partners can strategically leverage existing resources and regional networks to streamline local implementation. Mapping local evidence ecosystems will facilitate structured implementation planning and support implementation-focused theory building.

TRIAL REGISTRATION

Not applicable.

Overcoming challenges in conducting systematic reviews in implementation science: a methods commentary

Consolidation of the literature using systematic reviews is a critical way to advance a discipline and support evidence-based decision-making in healthcare. However, unique challenges exist that impact the conduct of systematic reviews in implementation science. In this commentary, we reflect on our combined experience to describe five key challenges unique to systematic reviews of primary implementation research. These challenges include (1) descriptors used in implementation science publications, (2) distinction between evidence-based interventions and implementation strategies, (3) assessment of external validity, (4) synthesis of implementation studies with substantial clinical and methodological diversity, and (5) variability in defining implementation 'success'. We outline possible solutions and highlight resources that can be used by authors of primary implementation research, as well as systematic review and editorial teams, to overcome the identified challenges and optimise the utility of future systematic reviews in implementation science.

Implementation in action: developing implementation strategies for an evidence-based prevention program

In this commentary, I introduce existing literature on implementation mapping and the development of implementation strategies. I argue that educational materials describing essential features of a prevention program are needed regardless of the program site and therefore may be a good starting point in the implementation process. I use the development of educational materials and resources for the Stroll Safe outdoor falls prevention program as an example to illustrate the process used.

Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework to Advance the Science and Practice of Healthy Food Retail

Although healthy food retail strategies are widely used, there appears to be a limited understanding of the processes and determinants for successful adoption, implementation, and sustainment. To fill this gap, we recommend the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to be used to advance the science and practice of healthy food retail. In this perspective, we: (1) introduce EPIS and describe why it was chosen as a recommended implementation science framework for healthy food retail, (2) highlight healthy food retail evidence supporting EPIS, and (3) discuss research and practice needs moving forward.

Built environment approaches: Extension personnel's preferences, barriers, and facilitators

Introduction

Interventions that modify the built environment can increase population physical activity levels and prevent chronic disease. The national Cooperative Extension System is poised to implement built environment approaches (i.e., pedestrian/bicycle infrastructure and enhanced access to physical activity spaces), but implementation strategies (i.e., methods or techniques to move research to practice) are needed to improve uptake. Effective implementation strategies address relevant barriers and capitalize on facilitators. The purpose of this study was to understand 1) barriers and facilitators to implementing built environment approaches in two state Extension systems, 2) preferences for built environment approaches, and 3) preferences for implementation strategies.

Methods

A cross-sectional online survey was used to understand Extension personnel's preferences for and barriers and facilitators to built environment approaches through a mixed-methods study design. This work was informed by anthropological inquiry as the overall research philosophy, and by the Health Impact Pyramid, Leeman et al.'s classification of implementation strategies, and the Consolidated Framework for Implementation Research as the theoretical frameworks. The survey was distributed to eligible Extension personnel (n = 42) in two states. Quantitative data analysis consisted of numbers/proportions and Friedman tests. Qualitative analysis was completed through a rapid deductive approach to quickly produce actionable results.

Results

Fourteen respondents (33%) completed the survey. Most had not implemented physical activity interventions in their communities or had implemented only individual-level interventions, though were interested in implementing built environment approaches. Benches, playground improvements, and crosswalks were the most desired approaches, while facilitation, assessing community strengths and needs, and technical assistance were desired implementation strategies. The most common barriers were relative priority and available resources; facilitators were external policy and incentives and implementation climate.

Discussion

Extension personnel are receptive to built environment approaches and engaged with community coalitions. Yet, invested parties prefer individual-level interventions, and agents perceive a lack of resources for implementation. Implementation strategies that build capacity in both the Extension system and community coalitions may address these barriers through increasing relative priority and sharing existing resources. This work is a first step toward compiling implementation strategies to address relevant barriers to built environment approaches in community settings.