Writing implementation research grant proposals: ten key ingredients

Team-based learning in Indonesian midwifery education: Implementation research

AIM

This study aims to implement team-based learning (TBL) and assess the impact on faculty members and students within midwifery education in Indonesia.

METHODS

Proctor's Framework for Implementation Research serves as the guiding approach in investigating the role of implementation strategies in implementing TBL within the context of midwifery education. The RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) framework was utilized to assess the outcome.

RESULTS

In this study, the implementation of TBL has demonstrated significant reach, with broad participation among both faculty and students in two schools. The efficacy of TBL is evident through enhanced student knowledge, engagement and active learning. Adoption of TBL was observed in both schools, with faculty and students expressing interest and active participation. High levels of implementation fidelity were maintained, even though with challenges related to preparation and implementation. These findings suggest that TBL can be successfully integrated into midwifery education, with positive implications. Regarding maintenance, faculty members have expressed their intention to continue using TBL in various topics for future lectures.

CONCLUSIONS

The implementation of TBL in Indonesian midwifery education has shown substantial reach and efficacy. Faculty and students are highly interested in adopting TBL for future use. Despite some implementation challenges, the study suggests that TBL can be effectively incorporated with minor adjustments, emphasizing its feasibility and potential impact. This research contributes to understanding TBL's applicability in various educational settings, especially in low-resource institutions.

Pre-treatment assessment of chemotherapy for cancer patients: a multi-site evidence implementation project of 74 hospitals in China

BACKGROUND

Chemotherapy, whilst treating tumours, can also lead to numerous adverse reactions such as nausea and vomiting, fatigue and kidney toxicity, threatening the physical and mental health of patients. Simultaneously, misuse of chemotherapeutic drugs can seriously endanger patients' lives. Therefore, to maintain the safety of chemotherapy for cancer patients and to reduce the incidence of adverse reactions to chemotherapy, many guidelines state that a comprehensive assessment of the cancer patient should be conducted and documented before chemotherapy. This recommended procedure, however, has yet to be extensively embraced in Chinese hospitals. As such, this study aimed to standardise the content of pre-chemotherapy assessment for cancer patients in hospitals and to improve nurses' adherence to pre-chemotherapy assessment of cancer patients by conducting a national multi-site evidence implementation in China, hence protecting the safety of cancer patients undergoing chemotherapy and reducing the incidence of adverse reactions to chemotherapy in patients.

METHODS

The national multi-site evidence implementation project was launched by a JBI Centre of Excellence in China and conducted using the JBI approach to evidence implementation. A pre- and post-audit approach was used to evaluate the effectiveness of the project. This project had seven phases: training, planning, baseline audit, evidence implementation, two rounds of follow-up audits (3 and 9 months after evidence implementation, respectively) and sustainability assessment. A live online broadcast allowed all participating hospitals to come together to provide a summary and feedback on the implementation of the project.

RESULTS

Seventy-four hospitals from 32 cities in China participated in the project, four withdrew during the project's implementation, and 70 hospitals completed the project. The pre-and post-audit showed a significant improvement in the compliance rate of nurses performing pre-chemotherapy assessments for cancer patients. Patient satisfaction and chemotherapy safety were also improved through the project's implementation, and the participating nurses' enthusiasm and belief in implementing evidence into practice was increased.

CONCLUSION

The study demonstrated the feasibility of academic centres working with hospitals to promote the dissemination of evidence in clinical practice to accelerate knowledge translation. Further research is needed on the effectiveness of cross-regional and cross-organisational collaborations to facilitate evidence dissemination.

A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol

Background

Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities.

Methods

The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness.

Discussion

This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.

Implementation Feasibility and Hidden Costs of Statewide Scaling of Evidence-Based Therapies for Children and Adolescents

OBJECTIVE

State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation.

METHODS

The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers.

RESULTS

All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from $500 to $3,500, with overall ongoing costs ranging from $100 to $6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from $5,000 to $24,000 per clinician, potentially limiting sustainability.

CONCLUSIONS

The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.

The use of implementation science theories, models, and frameworks in implementation research for medicinal products: A scoping review

BACKGROUND

The uptake, adoption and integration of new medicines and treatment regimens within healthcare delivery can take a decade or more. Increasingly, implementation science (IS) research is being used to bridge this gap between the availability of new therapeutic evidence and its actual application in clinical practice. Little is known, however, about the quality of IS research in this area, including the degree to which theories, models and frameworks (TMFs) are being used. The objective of this study was to conduct a scoping review of the use of TMFs in implementation research involving medicinal products.

METHODS

A search was conducted for English language abstracts and manuscripts describing the application of TMFs in IS studies for medicinal products. Eligible publications were those published between 1 January 1974 and 12 December 2022. All records were screened at the title and abstract stage; included full-text papers were abstracted using data extraction tables designed for the study. Study quality was appraised using the Implementation Research Development Tool.

RESULTS

The initial scoping search identified 2697 publications, of which 9 were ultimately eligible for inclusion in the review. Most studies were published after 2020 and varied in their objectives, design and therapeutic area. Most studies had sample sizes of fewer than 50 participants, and all focused on the post-marketing phase of drug development. The TMF most frequently used was the Consolidated Framework for Implementation Research (CFIR). Although most studies applied all TMF domains, TMF use was limited to instrument development and/or qualitative analysis. Quality appraisals indicated the need for engaging patients and other stakeholders in the implementation research, reporting on the cost of implementation strategies, and evaluating the unintended consequences of implementation efforts.

CONCLUSIONS

We found that few IS studies involving medicinal products reported using TMFs. Those that did encompassed a wide variety of therapeutic indications and medicinal products; all were in the post-marketing phase and involved limited application of the TMFs. Researchers should consider conducting IS in earlier phases of drug development and integrating the TMFs throughout the research process. More consistent and in-depth use of TMFs may help advance research in this area.

Development of an implementation strategy for routine collection of generic patient reported outcome measures: a qualitative study in multidisciplinary community rehabilitation

PURPOSE

To explore staff perceptions of barriers and enablers towards implementing the EQ-5D-5L in community rehabilitation, and develop a theory-informed implementation approach for routine administration of generic patient-reported outcome measures (PROMs) using implementation science frameworks.

MATERIALS AND METHODS

A qualitative study was conducted at three sites. Multidisciplinary rehabilitation staff completed individual semi-structured interviews, which were transcribed and coded against the Theoretical Domains Framework (TDF). We identified and selected potentially effective behaviour change techniques using the Behavior Change Wheel. Hypothetical strategies were operationalised.

RESULTS

Twenty-one interviews were conducted, and four themes emerged: (1) The Impact of PROMs on patient centered-care; (2) Considerations for validity of PROMs; (3) Service-level impact of embedding PROMs; (4) Practical issues of embedding PROMs within the service. Barriers and enablers were mapped to seven of the TDF domains; relating most to clinicians' "belief about consequences", "reinforcement", and "environmental context and resources". Five hypothetical strategies were developed to overcome identified barriers and strengthen enablers. Key behaviour change techniques underpinning the strategies include: restructuring the physical environment, incentivisation, persuasion and education, enablement, and, social support.

CONCLUSIONS

Our implementation approach highlights the importance of automating processes, engaging site champions, routinely reporting, and using PROM data to inform service provision.

Ten years of implementation outcomes research: a scoping review

BACKGROUND

Proctor and colleagues' 2011 paper proposed a taxonomy of eight implementation outcomes and challenged the field to address a research agenda focused on conceptualization, measurement, and theory building. Ten years later, this paper maps the field's progress in implementation outcomes research. This scoping review describes how each implementation outcome has been studied, research designs and methods used, and the contexts and settings represented in the current literature. We also describe the role of implementation outcomes in relation to implementation strategies and other outcomes.

METHODS

Arksey and O'Malley's framework for conducting scoping reviews guided our methods. Using forward citation tracing, we identified all literature citing the 2011 paper. We conducted our search in the Web of Science (WOS) database and added citation alerts sent to the first author from the publisher for a 6-month period coinciding with the WOS citation search. This produced 1346 titles and abstracts. Initial abstract screening yielded 480 manuscripts, and full-text review yielded 400 manuscripts that met inclusion criteria (empirical assessment of at least one implementation outcome).

RESULTS

Slightly more than half (52.1%) of included manuscripts examined acceptability. Fidelity (39.3%), feasibility (38.6%), adoption (26.5%), and appropriateness (21.8%) were also commonly examined. Penetration (16.0%), sustainability (15.8%), and cost (7.8%) were less frequently examined. Thirty-two manuscripts examined implementation outcomes not included in the original taxonomy. Most studies took place in healthcare (45.8%) or behavioral health (22.5%) organizations. Two-thirds used observational designs. We found little evidence of progress in testing the relationships between implementation strategies and implementation outcomes, leaving us ill-prepared to know how to achieve implementation success. Moreover, few studies tested the impact of implementation outcomes on other important outcome types, such as service systems and improved individual or population health.

CONCLUSIONS

Our review presents a comprehensive snapshot of the research questions being addressed by existing implementation outcomes literature and reveals the need for rigorous, analytic research and tests of strategies for attaining implementation outcomes in the next 10 years of outcomes research.

Developing and Testing Implementation Strategies to support the Centers for Disease Control and Prevention's Initiative for Falls Risk Management in Outpatient Physical Therapy: A Protocol

Objectives

To develop and test implementation strategies to support implementing the Centers for Disease Control and Preventions' Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative for falls prevention and falls risk management in a novel setting, outpatient physical therapy.

Design

A feasibility implementation study engaging key partners involved in or affected by the implementation throughout the study.

Setting

Five outpatient physical therapy clinics embedded in a health system.

Participants

Key partners (physical therapists, physical therapist assistants, referring physicians, administrative clinic staff, older adults, and caregivers) involved in or affected by the implementation (N=48) will participate in surveys and interviews to identify barriers and facilitators prior to implementation and post implementation. Twelve key partners representing at least 1 of each group will participate in evidence-based quality improvement panels to identify which barriers and facilitators are most important and feasible to address and to assist in choosing and designing implementation strategies to support the uptake of STEADI in outpatient rehabilitation. STEADI will be implemented in 5 outpatient physical therapy clinics as a standard of care for the ∼1200 older adults attending those clinics annually.

Outcomes

Primary outcomes include clinic- and provider-level (physical therapists and physical therapist assistant) adoption and fidelity to STEADI screening, multifactorial assessment, and falls risk interventions for older adults (65 years or older) attending outpatient physical therapy. Key partners' perceived feasibility, acceptability, and appropriateness of STEADI in outpatient physical therapy will also be measured using validated implementation science questionnaires. Exploratory clinical outcomes of older adults' falls risk pre- and post rehabilitation will be investigated.

Implementation science for quality improvement in pediatric surgery

Despite the widespread integration of quality improvement principles into pediatric surgical practice, the actual adoption of evidence-based practices continues to be a challenge. The field of pediatric surgery, in particular, has been slow to adopt clinical pathways and protocols that lead to decreased practice variation and improved clinical outcomes. This manuscript provides an introduction to how implementation science principles into quality improvement efforts may optimize uptake of evidence-based practices, ensure success of these endeavors, and help assess the effectiveness of the interventions. Examples of implementation science application to pediatric surgical quality improvement endeavors are explored.

Facilitators and barriers of preventive behaviors against COVID-19 during Ramadan: A phenomenology of Indonesian adults

Introduction

Intercity mobility restriction, physical distancing, and mask-wearing are preventive behaviors to reduce the transmission of COVID-19. However, strong cultural and religious traditions become particular challenges in Indonesia. This study uses the Behavior Change Wheel to explore barriers and facilitators for intercity mobility restriction, physical distancing, and mask-wearing during Ramadan.

Methods

Semi-structured in-depth interviews with 50 Indonesian adults were conducted between 10 April and 4 June 2020. Having mapped codes into the Capacity, Opportunity, Motivation - Behavior (COM-B), and Theoretical Domain Framework (TDF) model, we conducted summative content analysis to analyze the most identified factors to preventive behaviors and proposed interventions to address those factors.

Results

Belief about the consequence of preventive behaviors was the most mentioned facilitator to all preventive behaviors among compliers. However, optimism as a TDF factor was commonly mentioned as a barrier to preventive behaviors among non-compliers, while environmental context and resources were the most commonly mentioned factors for intercity mobility restriction.

Conclusions

Public health intervention should be implemented considering the persuasion and involvement of religious and local leaders. Concerning job and economic context, policy related to the intercity mobility restriction should be reconsidered to prevent a counterproductive effect.

Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair

INTRODUCTION

Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science.

METHODS

A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation.

RESULTS

Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation.

CONCLUSIONS

This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.

Enhancing review criteria for dissemination and implementation science grants

BACKGROUND

The existing grant review criteria do not consider unique methods and priorities of Dissemination and Implementation Science (DIS). The ImplemeNtation and Improvement Science Proposals Evaluation CriTeria (INSPECT) scoring system includes 10 criteria based on Proctor et al.'s "ten key ingredients" and was developed to support the assessment of DIS research proposals. We describe how we adapted INSPECT and used it in combination with the NIH scoring system to evaluate pilot DIS study proposals through our DIS Center.

METHODS

We adapted INSPECT to broaden considerations for diverse DIS settings and concepts (e.g., explicitly including dissemination and implementation methods). Five PhD-level researchers with intermediate to advanced DIS knowledge were trained to conduct reviews of seven grant applications using both the INSPECT and NIH criteria. The INSPECT overall scores range from 0 to 30 (higher scores are better), and the NIH overall scores range from 1 to 9 (lower scores are better). Each grant was independently reviewed by two reviewers, then discussed in a group meeting to compare the experiences using both criteria to evaluate the proposal and to finalize scoring decisions. A follow-up survey was sent to grant reviewers to solicit further reflections on each scoring criterion.

RESULTS

Averaged across reviewers, the INSPECT overall scores ranged from 13 to 24, while the NIH overall scores ranged from 2 to 5. Reviewer reflections highlighted the unique value and utility for each scoring criterion. The NIH criteria had a broad scientific purview and were better suited to evaluate more effectiveness-focused and pre-implementation proposals not testing implementation strategies. The INSPECT criteria were easier to rate in terms of the quality of integrating DIS considerations into the proposal and to assess the potential for generalizability, real-world feasibility, and impact. Overall, reviewers noted that INSPECT was a helpful tool to guide DIS research proposal writing.

CONCLUSIONS

We confirmed complementarity in using both scoring criteria in our pilot study grant proposal review and highlighted the utility of INSPECT as a potential DIS resource for training and capacity building. Possible refinements to INSPECT include more explicit reviewer guidance on assessing pre-implementation proposals, providing reviewers with the opportunity to submit written commentary with each numerical rating, and greater clarity on rating criteria with overlapping descriptions.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

Development and psychometric evaluation of the Implementation Science Research Project Appraisal Criteria (ImpResPAC) tool: a study protocol

INTRODUCTION

The need for quantitative criteria to appraise the quality of implementation research has recently been highlighted to improve methodological rigour. The Implementation Science Research development (ImpRes) tool and supplementary guide provide methodological guidance and recommendations on how to design high-quality implementation research. This protocol reports on the development of the Implementation Science Research Project Appraisal Criteria (ImpResPAC) tool, a quantitative appraisal tool, developed based on the structure and content of the ImpRes tool and supplementary guide, to evaluate the conceptual and methodological quality of implementation research.

METHODS AND ANALYSIS

This study employs a three-stage sequential mixed-methods design. During stage 1, the research team will map core domains of the ImpRes tool, guidance and recommendations contained in the supplementary guide and within the literature, to ImpResPAC. In stage 2, an international multidisciplinary expert group, recruited through purposive sampling, will inform the refinement of ImpResPAC, including content, scoring system and user instructions. In stage 3, an extensive psychometric evaluation of ImpResPAC, that was created in stage 1 and refined in stage 2, will be conducted. The scaling assumptions (inter-item and item-total correlations), reliability (internal consistency, inter-rater) and validity (construct and convergent validity) will be investigated by applying ImpResPAC to 50 protocols published in Implementation Science. We envisage developing ImpResPAC in this way will provide implementation research stakeholders, primarily grant reviewers and educators, a comprehensive, transparent and fair appraisal of the conceptual and methodological quality of implementation research, increasing the likelihood of funding research that will generate knowledge and contribute to the advancement of the field.

ETHICS AND DISSEMINATION

This study will involve human participants. This study has been registered and minimal risk ethical clearance granted by The Research Ethics Office, King's College London (reference number MRA-20/21-20807). Participants will receive written information on the study via email and will provide e-consent if they wish to participate. We will use traditional academic modalities of dissemination (eg, conferences and publications).

Where is "policy" in dissemination and implementation science? Recommendations to advance theories, models, and frameworks: EPIS as a case example

BACKGROUND

Implementation science aims to accelerate the public health impact of evidence-based interventions. However, implementation science has had too little focus on the role of health policy - and its inseparable politics, polity structures, and policymakers - in the implementation and sustainment of evidence-based healthcare. Policies can serve as determinants, implementation strategies, the evidence-based "thing" to be implemented, or another variable in the causal pathway to healthcare access, quality, and patient outcomes. Research describing the roles of policy in dissemination and implementation (D&I) efforts is needed to resolve persistent knowledge gaps about policymakers' evidence use, how evidence-based policies are implemented and sustained, and methods to de-implement policies that are ineffective or cause harm. Few D&I theories, models, or frameworks (TMF) explicitly guide researchers in conceptualizing where, how, and when policy should be empirically investigated. We conducted and reflected on the results of a scoping review to identify gaps of existing Exploration, Preparation, Implementation, and Sustainment (EPIS) framework-guided policy D&I studies. We argue that rather than creating new TMF, researchers should optimize existing TMF to examine policy's role in D&I. We describe six recommendations to help researchers optimize existing D&I TMF. Recommendations are applied to EPIS, as one example for advancing TMF for policy D&I.

RECOMMENDATIONS

(1) Specify dimensions of a policy's function (policy goals, type, contexts, capital exchanged). (2) Specify dimensions of a policy's form (origin, structure, dynamism, outcomes). (3) Identify and define the nonlinear phases of policy D&I across outer and inner contexts. (4) Describe the temporal roles that stakeholders play in policy D&I over time. (5) Consider policy-relevant outer and inner context adaptations. (6) Identify and describe bridging factors necessary for policy D&I success.

CONCLUSION

Researchers should use TMF to meaningfully conceptualize policy's role in D&I efforts to accelerate the public health impact of evidence-based policies or practices and de-implement ineffective and harmful policies. Applying these six recommendations to existing D&I TMF advances existing theoretical knowledge, especially EPIS application, rather than introducing new models. Using these recommendations will sensitize researchers to help them investigate the multifaceted roles policy can play within a causal pathway leading to D&I success.

Main actors in the new population policy with a growing trend in Iran: a stakeholder analysis

The total fertility rate in Iran has declined to below replacement level recently, and a new approach has been taken to tackle this issue. Thus, this study aimed to identify the involved stakeholders and their characteristics in the new population policy change in Iran. We employed a qualitative approach using the purposive sampling of key informants and the identification of relevant documents. The main stakeholders were divided into seven key groups: religious, political, governmental, professional, international sectors, media, and nongovernmental organizations. In addition, there was no centralized, clear, and comprehensive mechanism to guide the activities of stakeholders to coordinate and bring the total fertility rate to the replacement level in Iran. Despite the importance of the new population policy in Iran, in recent years, we still experience dispersion and inconsistency among various actors in this area. It is imperative to go through a consensus and coalition at macro-level authorities alongside evidenced-based population policymaking.

Methods to improve the translation of evidence-based interventions: A primer on dissemination and implementation science for occupational safety and health researchers and practitioners

Objective

A limited focus on dissemination and implementation (D&I) science has hindered the uptake of evidence-based interventions (EBIs) that reduce workplace morbidity and mortality. D&I science methods can be used in the occupational safety and health (OSH) field to advance the adoption, implementation, and sustainment of EBIs for complex workplaces. These approaches should be responsive to contextual factors, including the needs of partners and beneficiaries (such as employers, employees, and intermediaries).

Methods

By synthesizing seminal literature and texts and leveraging our collective knowledge as D&I science and/or OSH researchers, we developed a D&I science primer for OSH. First, we provide an overview of common D&I terminology and concepts. Second, we describe several key and evolving issues in D&I science: balancing adaptation with intervention fidelity and specifying implementation outcomes and strategies. Next, we review D&I theories, models, and frameworks and offer examples for applying these to OSH research. We also discuss widely used D&I research designs, methods, and measures. Finally, we discuss future directions for D&I science application to OSH and provide resources for further exploration.

Results

We compiled a D&I science primer for OSH appropriate for practitioners and evaluators, especially those newer to the field.

Conclusion

This article fills a gap in the OSH research by providing an overview of D&I science to enhance understanding of key concepts, issues, models, designs, methods and measures for the translation into practice of effective OSH interventions to advance the safety, health and well-being of workers.

Using practice facilitation to improve alcohol-related care in primary care: a mixed-methods pilot study protocol

Background

Alcohol use is a significant risk factor for disability and death in U.S. adults, and approximately one out of every six Veterans seen in primary care (PC) report unhealthy alcohol use. Unhealthy alcohol use is associated with increased risk for poor medical outcomes, substantial societal costs, and death, including suicide. Based on substantial evidence from randomized controlled trials and the U.S. Preventive Services Task Force, VA/DoD clinical guidelines stipulate that all Veterans screening positive for unhealthy alcohol use should receive evidence-based alcohol care in PC, including brief counseling interventions (BI) and additional treatment (e.g., pharmacotherapy) for those with alcohol use disorders (AUD). The VA pioneered implementing alcohol screening and BI in PC, yet substantial implementation gaps remain. To improve alcohol-related care, this study will conduct a pilot study to assess whether a multi-faceted evidence-based implementation strategy—practice facilitation—has the potential to improve PC-based alcohol-related care at a single VA clinic.

Methods

We will first recruit and conduct qualitative interviews with Veterans with unhealthy alcohol use (n = 20–25) and PC stakeholders (N = 10–15) to understand barriers and facilitators to high-quality alcohol care and use results to refine and hone the multifaceted practice facilitation intervention. Qualitative interviews, analysis, and refinement of the intervention will be guided by the Consolidated Framework for Implementation Research (CFIR). Focus groups with a small sample of PC providers and staff (n = 5–7) will be used to further refine the practice facilitation intervention and assess its acceptability and feasibility. The refined practice facilitation intervention will then be offered in the PC clinic to assess implementation (e.g., reach) and effectiveness (reduced drinking) outcomes based on the RE-AIM framework.

Discussion

This research directly addresses one of the largest public health crises of our time, as alcohol kills more people than opioids and is associated with increased risk of suicide. If successful, this pilot may generate an intervention with far-reaching effects on adverse outcomes experienced by Veterans with unhealthy alcohol use, including increased access to care and suicide prevention.

Trial registration Clinicaltrials.gov identifier: NCT04565899; Date of registration: 9/25/2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00300-x.

Use of Theoretical Frameworks in the Development and Testing of Palliative Care Interventions

CONTEXT

Palliative care (PC) research has grown over the last 20 years. Yet, the causal components and pathways of PC interventions remain unclear.

OBJECTIVES

To document the prevalence and application of theoretical frameworks in developing and testing PC interventions.

METHODS

We conducted a secondary analysis of previously published systematic reviews of PC randomized clinical trials. Trials were evaluated for explicit mention of a theoretical framework, process or delivery model, or clinical practice guideline that supported the development of the intervention. We used a structured data extraction form to document study population, outcomes, and whether and how authors used a theoretical framework, process/delivery model, or clinical practice guideline. We applied an adapted coding scheme to evaluate use of theoretical frameworks.

RESULTS

We reviewed 85 PC trials conducted between 1984 and 2021. Thirty-eight percent (n = 32) of trials explicitly mentioned a theoretical framework, process or delivery model, or clinical practice guideline as a foundation for the intervention design. Only nine trials included a theoretical framework, while the remaining 23 cited a process/delivery model or clinical practice guideline.

CONCLUSION

Most PC trials do not cite a theoretical foundation for their intervention design. Future work should focus on developing and validating new theoretical frameworks and modifying existing theories and models to better explain the mechanisms of the variety of PC interventions.

Market viability: a neglected concept in implementation science

This debate paper asserts that implementation science needs to incorporate a key concept from entrepreneurship—market demand—and demonstrates how assessing an innovation’s potential market viability might advance the pace and success of innovation adoption and sustainment. We describe key concepts, language distinctions, and questions that entrepreneurs pose to implementation scientists—many of which implementation scientists appear ill-equipped to answer. The paper concludes with recommendations about how concepts from entrepreneurship, notably market viability assessment, can enhance the translation of research discoveries into real-world adoption, sustained use, and population health benefits. The paper further proposes activities that can advance implementation science’s capacity to draw from the field of entrepreneurship, along with the data foundations required to assess and cultivate market demand.

Perceptions of successful domestic and international research grant applications among experienced and novice researchers

Purpose

The main purpose of the study was to identify the key elements that characterize successful grant proposals and the relative importance of issues that constitute difficulties and concerns in preparing the proposals. The study aimed, in particular, to explore grantsmanship perceptions based on the experiences of researchers in Thailand who had, or had not yet, successfully been awarded domestic and/or international research funding.

Design/methodology/approach

Anonymous online questionnaires were distributed to researchers in biomedical and public health fields in Thai academic institutes. The online survey asked the anonymous participants to complete a questionnaire comprising both multiple-choice and open-ended questions.

Findings

About 19% of 300 respondents had received both domestic and international research grants, and 60% of domestic research grants. The top 5 issues in grant applications were: (1) choosing a topic that matched the grant opportunity, (2) feasibility of research design and methods, (3) suitable research design and methodology, (4) model and theoretical justification, and (5) ethical considerations. Significant differences in perceptions among researchers were found for the feasibility of research design and methods and proposing a reasonable and justifiable budget.

Originality/value

The information derived from this analysis reflected the perceptions of the researchers and may or may not correlate with those of grant agency reviewers. The results of this study may be insightful and instructive for other researchers and form the basis for training and mentoring researchers in informed and effective grantsmanship, particularly novice researchers with limited or no experience in grant proposal writing. This study particularly reflected grantsmanship perceptions among researchers in Thailand. It may also serve to exemplify lessons learned for researchers in other low-income and middle-income countries (LMIC) exposed to similar settings and situations applying for research grants.

How has implementation been incorporated in health technology assessments in the United Kingdom? A systematic rapid review

OBJECTIVES

Health interventions in a clinical setting may be complex. This is particularly true of clinical interventions which require systems reorganization or behavioural change, and/or when implementation involves additional challenges not captured within a clinical trial setting. Medical Research Council guidance on complex interventions highlights the need to consider economic evaluation alongside implementation. However, the extent to which this guidance has been adhered to, and how, is unclear. The failure to incorporate implementation within the evaluation of an intervention may hinder the translation of research findings into routine practice. This will have consequences for patient care. This study examined the methods used to address implementation within health research conducted through funding from the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme.

METHODS

We conducted a rapid review using a systematic approach. We included all NIHR HTA monographs which contained the word "implementation" within the title or abstract published between 2014 and 2020. We assessed the studies according to existing recommendations for specifying and reporting implementation approaches in research. Additional themes which were not included in the recommendation, but were of particular relevance to our research question, were also identified and summarized in a narrative synthesis.

RESULTS

The extent to which implementation was formally incorporated, and defined, varied among studies. Methods for examining implementation ranged from single stakeholder engagement events to the more comprehensive process evaluation. There was no obvious pattern as to whether approaches to implementation had evolved over recent years. Approximately 50% (22/42) of studies included an economic evaluation. Of these, two studies included the use of qualitative data obtained within the study to quantitatively inform aspects relating to implementation and economic evaluation in their study.

DISCUSSION

A variety of approaches were identified for incorporating implementation within an HTA. However, they did not go far enough in terms of incorporating implementation into the actual design and evaluation. To ensure the implementation of clinically effective and cost-effective interventions, we propose that further guidance on how to incorporate implementation within complex interventions is required. Incorporating implementation into economic evaluation provides a step in this direction.

The use of theory in process evaluations conducted alongside randomized trials of implementation interventions: A systematic review

Interventions to implement changes into health care practice (i.e., implementation interventions) are critical to improving care but their effects are poorly understood. Two strategies to better understand intervention effects are conducting process evaluations and using theoretical approaches (i.e., theories, models, frameworks). The extent to which theoretical approaches have been used in process evaluations conducted alongside trials of implementation interventions is unclear. In this study context, we reviewed (a) the proportion of process evaluations citing theoretical approaches, (b) which theoretical approaches were cited, and (c) whether and how theories were used. Systematic review (PROSPERO: CRD42016042789). MEDLINE, PsycINFO, Embase, CINAHL, and Cochrane CENTRAL were searched up to July 31, 2017. For all studies, data extraction included names and types of theoretical approaches cited. For studies citing a theory, data extraction included study characteristics and extent of theory use (i.e., "informed by," "applied," "tested," "built/created" theory). We identified 123 process evaluations. Key findings: (a) 77 (63%) process evaluations cited a theoretical approach; (b) the most cited theory was normalization process theory; (c) 32 (26%) process evaluations used theory: 7 (22%) were informed by, 18 (56%) applied, 7 (22%) tested, and none built/created theory. Although nearly two thirds of process evaluations cited a theoretical approach, only a quarter were informed by, applied, or tested a theory-despite the potential complementarity of these strategies. When theory was used, it was primarily applied. Using theory more substantively in process evaluations may accelerate our understanding of how implementation interventions operate.

Determinants of Implementing Evidence-Based Trauma-Focused Interventions for Children and Youth: A Systematic Review

A systematic review was conducted to identify determinants (barriers and facilitators) of implementing evidence-based psychosocial interventions for children and youth who experience emotional or behavioral difficulties due to trauma exposure. Determinants were coded, abstracted, and synthesized using the Exploration, Preparation, Implementation, and Sustainment framework. Twenty-three articles were included, all of which examined implementation of Trauma-Focused Cognitive Behavioral Therapy or Cognitive-Behavioral Intervention for Trauma in Schools. This review identified multilevel and multiphase determinants that can be addressed by implementation strategies to improve implementation and clinical outcomes, and suggests how future studies might address gaps in the evidence base.

Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review

INTRODUCTION

HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC.

METHODS

We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner.

RESULTS AND DISCUSSION

Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability.

CONCLUSIONS

Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.

Implementation Science Methodologies for Complementary and Integrative Health Research

Published results of efficacy and effectiveness studies on complementary health approaches should lead to widespread uptake of evidence-based practices, but too often, the scientific pathway ends prematurely, before the best ways to improve adoption, implementation, and sustainability can be determined. The National Center for Complementary and Integrative Health (NCCIH) supports the full continuum of the biomedical research pipeline, whereby a complementary health intervention moves from basic and mechanistic research through efficacy trials and through dissemination and implementation. Implementation science has traditionally been thought of as something that only happens after efficacy and effectiveness have been demonstrated, but it can be prudent to evaluate implementation measures earlier in the process. Implementation science assesses more than just barriers and facilitators; it evaluates specific implementation strategies and characterizes the extent that the intervention is modified within the context of the implementation strategy and health care delivery setting. The best choices for implementation science in complementary health interventions depend on the research questions. Implementation science that tests strategies to address implementation at multiple ecologic levels is a high priority to NCCIH.

Skills for Developing and Maintaining Community-Partnerships for Dissemination and Implementation Research in Children's Behavioral Health: Implications for Research Infrastructure and Training of Early Career Investigators

By engaging with community partners, dissemination and implementation scholars can enhance research relevance and translation. We illustrate the skills needed for developing and maintaining community partnerships by presenting two case studies of partnerships between early-career investigators and child welfare systems to implement mental health interventions. The cases represent two models of partnership (investigator-led and agency-led), highlighting the value and difficulty of conducting community-engaged implementation research. The experiences described feature strategies for building and managing relationships, navigating rules and regulations, adaptation, and securing resources. We offer suggestions for improving training and research infrastructures to support community-engaged implementation scholars.

From Research Training to Scientific Advancement-Contributions from the Implementation Research Institute: An Introduction to the Special Issue

The special series is designed to provide examples of funded implementation research conducted by alumni of the first four cohorts of the Implementation Research Institute (IRI). The introduction links the six substantive papers to the conceptual and methodological challenges laid out in a 2009 publication in this journal which led to the IRI training program in the emerging science of implementation with a special focus on behavior health settings. The 7th paper in the series illustrates an innovative evaluative approach to design and measurement of IRI fellow publications and grants informed by the training program such as bibliometrics. The introduction also notes some elements identified in the 2009 foundational paper not represented in these papers such as costs as well as important developments and foci in the decade since 2009 such as de-implementation, sustainability, dynamic adaptation processes, and hybrid designs that need to be an integral part of training programs in implementation research.

Roles dissemination and implementation scientists can play in supporting research teams

The field of dissemination and implementation (D&I) science is rapidly growing, with many scientists seeking to apply D&I science to enhance and expand the impact of their work. As the D&I field grows and collaborations of implementation scientists with other fields flourish, a description for the roles for D&I scientists as they collaborate with researchers from other fields could be beneficial. This paper exemplifies how the D&I scientist/researcher collaborative process might work and important elements to consider in doing so, as well as provide an outline on how collaborations might progress for different project needs. This is discussed through example scenarios to consider an implementation scientists' engagement in a research project and describe potential roles for implementation scientists in supporting research teams. We then discuss characteristics to consider when incorporating a D&I expert into a team and considerations in navigating the scenarios.

Pelvic floor muscle training for women with pelvic organ prolapse: the PROPEL realist evaluation

Background

Pelvic organ prolapse is estimated to affect 41–50% of women aged > 40 years. A multicentre randomised controlled trial of individualised pelvic floor muscle training found that pelvic floor muscle training was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. Provision of pelvic floor muscle training for prolapse has continued to vary across the UK, with limited availability of specialist physiotherapists to deliver it.

Objectives

This project aimed to study the implementation and outcomes of different models of delivery to increase the service provision of pelvic floor muscle training, and to follow up treatment outcomes for the original trial participants.

Design

A realist evaluation of pelvic floor muscle training implementation conducted within three full case study sites and two partial case study sites; an observational prospective cohort study comparing patient-reported outcomes pre and post intervention in all five sites; and a long-term follow-up study linking previous trial participants to routine NHS hospital data.

Setting

The setting for the realist evaluation was pelvic floor muscle training service delivery models in three NHS sites. The setting for the patient-reported outcome measures study was pelvic floor muscle training services in five NHS sites.

Methods

Realist evaluation qualitative data were collected at four time points in three case study sites to understand the implementation models, uptake, adherence and impact. Interviews involved service managers/leads, consultants, staff delivering pelvic floor muscle training and women receiving pelvic floor muscle training.

Main outcomes measures

Patient-reported outcomes were collected at baseline and at 6 and 12 months across five sites, including the Pelvic Organ Prolapse Symptom Score, health-related quality of life (measured using the EuroQol-5 Dimensions, five-level version, questionnaire), prolapse severity (measured using the Pelvic Organ Prolapse Quantification System), urinary incontinence (measured using International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form) and need for further treatment.

Results

A total of 102 women were recruited to the patient-reported outcome measures cohort study (target, n = 120), and 65 women had matched baseline and 6-month Pelvic Organ Prolapse Symptom Scores. The mean Pelvic Organ Prolapse Symptom Score was 10.18 (standard deviation 5.63) at baseline and 6.98 (standard deviation 5.23) at 6 months, representing a statistically significant and clinically meaningful difference. There was no statistically significant difference between the outcomes obtained from delivery by specialist physiotherapists and the outcomes obtained from delivery by other health-care professionals (mean change in Pelvic Organ Prolapse Symptom Score: –3.95 vs. –2.81, respectively). Services delivered using higher-band physiotherapists only were more costly than services delivered using other staff mixes. The effect of the original pelvic floor muscle training intervention, over a post-intervention period of > 10 years, was a reduction in the odds of any treatment during follow-up (odds ratio 0.61, 95% confidence interval 0.37 to 0.99). The realist evaluation revealed stark differences in implementation. The site with a specialist physiotherapy service resisted change because of perceived threats to the specialist role and concerns about care quality. Pelvic floor muscle training delivery by other health-care staff was easier when there was a lack of any existing specialist service; staff had prior training and interest in pelvic health; staff had support, autonomy, time and resources to deliver pelvic floor muscle training as part of their core role; and surrounding services supported a flow of pelvic floor muscle training referrals.

Limitations

The number of available matched pre and post outcomes for women and the lack of Pelvic Organ Prolapse Quantification System examinations were limitations of this study.

Conclusions

It is possible to train different staff to effectively deliver pelvic floor muscle training to women. Women’s self-reported outcomes significantly improved across all service models. Training should be adequately tailored to differential skill mix needs.

Future work

Future work should include further implementation of pelvic floor muscle training and should include pre- and post-outcome data collection using the Pelvic Organ Prolapse Symptom Score.

Study registration

This study is registered as Research Registry 4919.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 47. See the NIHR Journals Library website for further project information.

Guidance for conducting feasibility and pilot studies for implementation trials

BACKGROUND

Implementation trials aim to test the effects of implementation strategies on the adoption, integration or uptake of an evidence-based intervention within organisations or settings. Feasibility and pilot studies can assist with building and testing effective implementation strategies by helping to address uncertainties around design and methods, assessing potential implementation strategy effects and identifying potential causal mechanisms. This paper aims to provide broad guidance for the conduct of feasibility and pilot studies for implementation trials.

METHODS

We convened a group with a mutual interest in the use of feasibility and pilot trials in implementation science including implementation and behavioural science experts and public health researchers. We conducted a literature review to identify existing recommendations for feasibility and pilot studies, as well as publications describing formative processes for implementation trials. In the absence of previous explicit guidance for the conduct of feasibility or pilot implementation trials specifically, we used the effectiveness-implementation hybrid trial design typology proposed by Curran and colleagues as a framework for conceptualising the application of feasibility and pilot testing of implementation interventions. We discuss and offer guidance regarding the aims, methods, design, measures, progression criteria and reporting for implementation feasibility and pilot studies.

CONCLUSIONS

This paper provides a resource for those undertaking preliminary work to enrich and inform larger scale implementation trials.

Ten recommendations for using implementation frameworks in research and practice

Background

Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.

Discussion

Ideally, an implementation framework, or multiple frameworks should be used prior to and throughout an implementation effort. This includes both in implementation science research studies and in real-world implementation projects. To guide this application, outlined are ten recommendations for using implementation frameworks across the implementation process. The recommendations have been written in the rough chronological order of an implementation effort; however, we understand these may vary depending on the project or context: (1) select a suitable framework(s), (2) establish and maintain community stakeholder engagement and partnerships, (3) define issue and develop research or evaluation questions and hypotheses, (4) develop an implementation mechanistic process model or logic model, (5) select research and evaluation methods (6) determine implementation factors/determinants, (7) select and tailor, or develop, implementation strategy(s), (8) specify implementation outcomes and evaluate implementation, (9) use a framework(s) at micro level to conduct and tailor implementation, and (10) write the proposal and report. Ideally, a framework(s) would be applied to each of the recommendations. For this article, we begin by discussing each recommendation within the context of frameworks broadly, followed by specific examples using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Summary

The use of conceptual and theoretical frameworks provides a foundation from which generalizable implementation knowledge can be advanced. On the contrary, superficial use of frameworks hinders being able to use, learn from, and work sequentially to progress the field. Following the provided ten recommendations, we hope to assist researchers, intermediaries, and practitioners to improve the use of implementation science frameworks.

What Is Dissemination and Implementation Science?: An Introduction and Opportunities to Advance Behavioral Medicine and Public Health Globally

There has been a well-documented gap between research (e.g., evidence-based programs, interventions, practices, policies, guidelines) and practice (e.g., what is routinely delivered in real-world community and clinical settings). Dissemination and implementation (D&I) science has emerged to address this research-to-practice gap and accelerate the speed with which translation and real-world uptake and impact occur. In recent years, there has been tremendous development in the field and a growing global interest, but much of the introductory literature has been U.S.-centric. This piece provides an introduction to D&I science and summarizes key concepts and progress of the field for a global audience, provides two case studies that highlight examples of D&I research globally, and identifies opportunities and innovations for advancing the field of D&I research globally.

Implementation of lung cancer multidisciplinary teams: a review of evidence-practice gaps

Multidisciplinary care (MDC) is considered best practice in lung cancer care. Health care services have made significant investments in MDC through the establishment of multidisciplinary team (MDT) meetings. This investment is likely to be sustained in future. It is imperative that MDT meetings are efficient, effective, and sufficiently nimble to introduce new innovations to enable best practice. In this article, we consider the ‘evidence-practice gaps’ in the implementation of lung cancer MDC. These gaps were derived from the recurrent limitations outlined in existing studies and reviews. We address the contributions that implementation science and quality improvement can make to bridge these gaps by increasing translation and improving the uptake of innovations by teams.

Knowledge translation in the reality of Brazilian public health

The term knowledge translation has been used to describe the process of applying research results to the real world, in order to enhance the quality and effectiveness of health care and services. The aim of this article is to discuss the incorporation of knowledge translation in the Brazilian public health. The article addresses the basic activities of knowledge translation and lists challenges and perspectives in Brazilian scenario. Brazil began to move towards understanding the process of translating scientific knowledge into practice. Investing in pilot studies to adapt the so-called effective interventions to the Brazilian scenario may be an alternative. Increasing the qualification of Brazilian researchers in the design and evaluation of implementation studies is relevant to improve this field in the country.

Doing What We Know, Knowing What to Do: Californians Linking Action with Science for Prevention of Breast Cancer (CLASP-BC)

Given the lack of progress in breast cancer prevention, the California Breast Cancer Research Program (CBCRP) plans to apply current scientific knowledge about breast cancer to primary prevention at the population level. This paper describes the first phase of Californians Linking Action with Science for Prevention of Breast Cancer (CLASP-BC). The foci of Phase 1 are building coalitions and coalition capacity building through community engagement in community-based participatory research (CBPR) and dissemination and implementation (D&I) research training. Based on the successful implementation and evaluation of Phase 1, the foci of Phase 2 (presented separately in this special issue) will be to translate the California Breast Cancer Prevention Plan overarching goal and specific intervention goals for 23 breast cancer risk and protective factors strategies into evidence-informed interventions (EIIs) that are disseminated and implemented across California. CLASP-BC is designed to identify, disseminate and implement high-impact, population-based prevention approaches by funding large scale EIIs, through multi-jurisdictional actions, with the intent to decrease the risk of breast cancer and other chronic diseases (sharing common risk factors), particularly among racial/ethnic minorities and medically underserved populations in California.

The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review

BACKGROUND

Identifying factors that influence sustained implementation of hospital-based interventions is key to ensuring evidence-based best practice is maintained across the NHS. This study aimed to identify, appraise and synthesise the barriers and facilitators that influenced the delivery of sustained healthcare interventions in a hospital-based setting.

METHODS

A systematic review reported in accordance with PRISMA. Eight electronic databases were reviewed in addition to a hand search of Implementation Science journal and reference lists of included articles. Two reviewers were used to screen potential abstracts and full text papers against a selection criteria. Study quality was also independently assessed by two reviewers. Barriers and facilitators were extracted and mapped to a consolidated sustainability framework.

RESULTS

Our searching identified 154,757 records. We screened 14,626 abstracts and retrieved 431 full text papers, of which 32 studies met the selection criteria. The majority of studies employed a qualitative design (23/32) and were conducted in the UK (8/32) and the USA (8/32). Interventions or programmes were all multicomponent, with the majority aimed at improving the quality of patient care and/ or safety (22/32). Sustainability was inconsistently reported across 30 studies. Barriers and facilitators were reported in all studies. The key facilitators included a clear accountability of roles and responsibilities (23/32); ensuring the availability of strong leadership and champions advocating the use of the intervention (22/32), and provision of adequate support available at an organisational level (21/32). The most frequently reported barrier to sustainability was inadequate staff resourcing (15/32). Our review also identified the importance of inwards spread and development of the initiative over time, as well as the unpredictability of sustainability and the need for multifaceted approaches.

CONCLUSIONS

This review has important implications for practice and research as it increases understanding of the factors that faciliate and hinder intervention sustainability. It also highlights the need for more consistent and complete reporting of sustainability to ensure that lessons learned can be of direct benefit to future implementation of interventions.

TRIAL REGISTRATION

The review is registered on PROSPERO ( CRD42017081992 ).

Development of an integrative coding framework for evaluating context within implementation science

BACKGROUND

This research aims to explore an identified gap in implementation science methodology, that is, how to assess context in implementation research. Context is among the strongest influences on implementation success but is a construct that is poorly understood and reported within the literature. Consequently, there is little guidance on how to research context. This study addresses this issue by developing a method to account for the active role of context during implementation research. Through use of a case study, this paper demonstrates the value of using our context coding framework.

METHODS

The developed context coding framework was guided by the sub-elements of the Consolidated Framework for Implementation Research (CFIR). Employing a constructivist approach, this framework builds on the CFIR and enables a deeper exploration of context at multiple levels of the health system. The coding framework enables the collation of various data sources such as organisational reports, culture audits, interview, survey, and observational data. It may be continuously updated as new data emerge and can be adapted by researchers as required. A pre-existing rating criterion has been integrated to the context coding framework to highlight the influence and relative strength of each contextual factor prior to and during implementation.

RESULTS

It is anticipated that the context coding framework will facilitate a standardised approach to assessing context. This will provide a deeper understanding of how to account for the influence of context, ultimately providing guidance that should increase the likelihood of implementation success. The coding framework enables implementation progress to be monitored, facilitating the identification of contextual changes and variations across settings at different levels of the healthcare system. It is expected this framework will inform the selection of appropriate implementation strategies and enable the monitoring of such strategies regarding their impact on local context.

CONCLUSIONS

This research contributes to the extant literature by advancing methodologies for the consideration and assessment of context in implementation research. This context coding framework may be used in any setting to provide insight into the characteristics of particular contexts throughout implementation processes.

Bringing Evidence into Practice in Hand Surgery

Despite the significant investment in scientific investigation to enhance clinical care, the uptake of new interventions and innovations into clinical care and policy remains slow. Understanding and examining the factors that influence the dissemination and implementation of best practices are critical to promote high-quality health care. This review provides an overview of the evidence base in hand surgery, the science that underlies dissemination and innovation, and the emergence of learning health systems in health care.

Ten recommendations for using implementation frameworks in research and practice

Background

Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.

Discussion

Ideally, an implementation framework, or multiple frameworks should be used prior to and throughout an implementation effort. This includes both in implementation science research studies and in real-world implementation projects. To guide this application, outlined are ten recommendations for using implementation frameworks across the implementation process. The recommendations have been written in the rough chronological order of an implementation effort; however, we understand these may vary depending on the project or context: (1) select a suitable framework(s), (2) establish and maintain community stakeholder engagement and partnerships, (3) define issue and develop research or evaluation questions and hypotheses, (4) develop an implementation mechanistic process model or logic model, (5) select research and evaluation methods (6) determine implementation factors/determinants, (7) select and tailor, or develop, implementation strategy(s), (8) specify implementation outcomes and evaluate implementation, (9) use a framework(s) at micro level to conduct and tailor implementation, and (10) write the proposal and report. Ideally, a framework(s) would be applied to each of the recommendations. For this article, we begin by discussing each recommendation within the context of frameworks broadly, followed by specific examples using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Summary

The use of conceptual and theoretical frameworks provides a foundation from which generalizable implementation knowledge can be advanced. On the contrary, superficial use of frameworks hinders being able to use, learn from, and work sequentially to progress the field. Following the provided ten recommendations, we hope to assist researchers, intermediaries, and practitioners to improve the use of implementation science frameworks.

Adaptation for Regulatory Application: A Content Analysis of FDA Risk Evaluation and Mitigation Strategies Assessment Plans (2014-2018) Using RE-AIM

Background: Risk Evaluation and Mitigation Strategies (REMS) are safety programs that U.S. Food and Drug Administration can require to ensure a drug's benefits outweigh its risks and can be considered public health interventions. FDA's 2019 draft Guidance for Industry on REMS Assessments encourages the development of “novel methods for assessing REMS [to] help advance the science of post-market assessment of effectiveness of risk mitigation strategies.”

Objective: To characterize REMS assessment plans using RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework and identify areas for advancing methods for evaluating REMS programs. RE-AIM was selected for its wide application evaluating the translation of scientific advances into practice for public health impact.

Methods: A content analysis of REMS assessment plans (N = 18) and measures(n = 540) was conducted for REMS programs approved by FDA between 1/1/2014–12/31/2018. Eligibility criteria were: a new drug application or biologic license application, included FDA-mandated mitigation strategies called elements to assure safe use (ETASU), and represented a single product REMS program. Assessment plans were collected from publicly available regulatory approval letters from REMS@FDA website. Blinded reviewers categorized each REMS assessment measure to a RE-AIM dimension, adjudicated their application (average IRR 75%), and refined the adapted dimensions' definitions. Dimensions were also mapped to REMS Assessment guidance categories.

Results: The median number of assessment measures per REMS assessment plan was 31 (IQR: 21–36). Frequency of measures per RE-AIM criteria per REMS program was: Reach (median = 2; IQR: 2–4); Effectiveness (median = 2.5; IQR:1–4); Adoption (median = 3.5; IQR: 2–5); Implementation (median = 18; IQR: 15–24); Maintenance (median = 0; IQR: 0–1). Adoption (among prescriber, health system agents of implementation) was more commonly assessed than Reach (population-attributable number of patients affected). Assessment of heterogeneity of Adoption and Reach was generally absent. Implementation assessment measures were most common among drugs requiring evidence of safe-use conditions before dispensing or administering the drug. Patient-level Effectiveness and Maintenance assessments were most common among drugs requiring patient monitoring.

Discussion: Implementation science frameworks, such as RE-AIM, can be applied to characterize REMS assessment measures and identify opportunities for standardizing and strengthening their evaluation. Methods to measure Maintenance are needed to provide real-world evidence of REMS integration into the healthcare system.

Designing high-quality implementation research: development, application, feasibility and preliminary evaluation of the implementation science research development (ImpRes) tool and guide

Background

Designing implementation research can be a complex and daunting task, especially for applied health researchers who have not received specialist training in implementation science. We developed the Implementation Science Research Development (ImpRes) tool and supplementary guide to address this challenge and provide researchers with a systematic approach to designing implementation research.

Methods

A multi-method and multi-stage approach was employed. An international, multidisciplinary expert panel engaged in an iterative brainstorming and consensus-building process to generate core domains of the ImpRes tool, representing core implementation science principles and concepts that researchers should consider when designing implementation research. Simultaneously, an iterative process of reviewing the literature and expert input informed the development and content of the tool. Once consensus had been reached, specialist expert input was sought on involving and engaging patients/service users; and economic evaluation. ImpRes was then applied to 15 implementation and improvement science projects across the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, a research organisation in London, UK. Researchers who applied the ImpRes tool completed an 11-item questionnaire evaluating its structure, content and usefulness.

Results

Consensus was reached on ten implementation science domains to be considered when designing implementation research. These include implementation theories, frameworks and models, determinants of implementation, implementation strategies, implementation outcomes and unintended consequences. Researchers who used the ImpRes tool found it useful for identifying project areas where implementation science is lacking (median 5/5, IQR 4–5) and for improving the quality of implementation research (median 4/5, IQR 4–5) and agreed that it contained the key components that should be considered when designing implementation research (median 4/5, IQR 4–4). Qualitative feedback from researchers who applied the ImpRes tool indicated that a supplementary guide was needed to facilitate use of the tool.

Conclusions

We have developed a feasible and acceptable tool, and supplementary guide, to facilitate consideration and incorporation of core principles and concepts of implementation science in applied health implementation research. Future research is needed to establish whether application of the tool and guide has an effect on the quality of implementation research.

Implementing a School-Based Sleep Intervention in the First Year of Elementary School: Voices of the School Nurses as Intervention Deliverers

OBJECTIVE/BACKGROUND

Elementary school nurses are an important component of health care systems. However, translational research of their role in interventions is limited. This study aimed to determine the feasibility, acceptability and sustainability of training the school nursing workforce to deliver a brief behavioral sleep intervention and the associated delivery costs.

PARTICIPANTS

Twenty-four primary school nurses from the Victorian Department of Education and Training, Melbourne, Australia, involved in delivering the school-based sleep intervention as part of the Sleep Well - Be Well trial participated in three surveys and a focus group over 30 months.

METHODS

An embedded mixed methods design utilizing quantitative and qualitative data sources was used.

RESULTS

Qualitative and quantitative evidence demonstrated training school nurses to deliver a brief sleep intervention was feasible and acceptable. Competence and confidence levels were maintained 12 months after the completion of intervention delivery demonstrating sustainability for this low cost model. Benefits of school nurses' participation in translational research projects were also identified.

CONCLUSIONS

These findings highlight the potential for utilizing school nurses directly in interventions at the health and education interface. Further research is required to address the challenges of intervention implementation and to identify policy implications for other intervention opportunities which may exist.