A scoping review of implementation science theories, models, and frameworks - an appraisal of purpose, characteristics, usability, applicability, and testability

[From evidence to practice: The Disemination and Implementation Science in primary care]

Dissemination and Implementation Science focuses on bridging the gap between scientific research and its practical application in the real world. By identifying and promoting effective strategies, the Science of Dissemination and Implementation disseminates and implements evidence-based interventions in healthcare settings, taking into account the needs, barriers, context, resources, and end users. This special article introduces and debates the most recent advances in this field, highlighting key approaches, theoretical frameworks, as well as specific challenges and opportunities applied to primary and community care. Additionally, concrete examples tailored to the Spanish context are presented. Given the nascent state of the use of the Dissemination and Implementation Science in Spain, the authors recommend strategically adopting this approach and its principles in primary and community care to expedite the adoption of effective interventions that promote health.

Organization Theory for Implementation Science (OTIS): reflections and recommendations

Organizations exert influence on the implementation of evidence-based practices and other innovations that are independent of the influence of organizations' individual constituents. Despite their influence, nuanced explanations of organizations' influence remain limited in implementation science. Organization theories are uniquely suited to offer insights and explain organizational influences on implementation. In this paper, we describe the efforts of the Cancer Prevention and Control Research Network's (CPCRN) Organization Theory for Implementation Science (OTIS) workgroup to equip implementation scientists with theory-guided understanding of organizational influences on implementation. We provide a set of recommendations for future efforts to enhance implementation through the use of organization theories and OTIS tools.

Applying health equity implementation science frameworks to population genetic screening

Introduction

Implementation science frameworks with a focus on health equity have emerged to help guide the introduction of new interventions into healthcare and community settings while limiting health disparities. The purpose of this research was to explore the applicability of such frameworks to guide the equitable implementation of population genetic screening programs.

Methods

We searched PubMed and reference lists for relevant frameworks and examples of their use in health settings. We then assessed if and how selected frameworks provide guidance for different stages of population genetic screening: recruitment, sample collection, result return, follow-up care and long-term management, and cascade screening. Findings were synthesized into a list of health equity considerations specific to each stage.

Results

We identified 5 implementation frameworks that focus on health equity. Guidance varied by framework type: determinant (explaining what affects implementation outcomes), process (translating research into practice), or evaluation (assessing implementation). Common characteristics included focusing implementation efforts on populations who have historically experienced health inequities and adapting interventions to fit local contexts. Process models also highlighted the importance of community partnerships.

Discussion

Overall, frameworks offered broad recommendations applicable to population genetic screening program implementation. However, gaps still exist in guidance provided for later stages of population genetic screening. To improve the equitable implementation of genetic screening, future programs may benefit from utilizing one or more of these frameworks or by incorporating the health equity considerations and outcomes compiled in this analysis.

The Implementation Process Assessment Tool: translation, contextualization, and psychometric evaluation of a Swedish version in a municipal elderly care context

BACKGROUND

The number of older adults with complex healthcare needs is growing alongside limited resources available in health services. To meet this challenge, it is urgent that healthcare staff are motivated and able to continuously translate new knowledge and working methods into daily practice. To facilitate such implementation, supportive measures responding to the healthcare personnel's needs seem essential. The present study aims to translate, contextualize and test a Swedish version of the Implementation Process Assessment Tool (IPAT) for measuring the facilitation needs among staff implementing a new working process in municipal elderly care.

METHODS

A mixed-method design was used. First, the existing instrument was translated into Swedish. Thereafter, twelve staff members with different professions working in healthcare and at the municipal elderly care were interviewed using Think-aloud interviews to contextualize and test the face validity of the translated instrument. Lastly, the adjusted instrument (Swe-IPAT) was psychometrically evaluated through a cross-sectional survey among 305 staff members working in municipal elderly care.

RESULTS

The psychometric evaluation of the Swe-IPAT revealed satisfying properties. Three factors, largely in line with the original IPAT, are suggested. Internal consistency assessed using Cronbach's alpha was 0.93 for the factor individual phases for behavioral change and perception of the intervention, 0.84 for the factor individual activities, and 0.95 for the factor collective readiness and support.

CONCLUSIONS

The 27-item Swe-IPAT, translated into Swedish and contextualized, demonstrated satisfactory psychometric properties when tested in an elderly care context. The instrument is suggested to be useful in providing feedback to managers in tailoring support and assessing implementation efforts among healthcare staff in elderly care. However, more research is needed to evaluate its properties throughout the entire implementation process and to test the usability of Swe-IPAT in other settings.

Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA): a consensus-based framework for designing, conducting, and reporting

BACKGROUND

The use of rapid qualitative methods has increased substantially over the past decade in quality improvement and health services research. These methods have gained traction in implementation research and practice, wherein real-time adjustments are often made to optimize processes and outcomes. This brisk increase begs the questions: what does rigor entail in projects that use rapid qualitative analysis (RQA)? How do we define a pragmatic framework to help research teams design and conduct rigorous and valid rapid qualitative projects? How can authors articulate rigor in their methods descriptions? Lastly, how can reviewers evaluate the rigor of rapid qualitative projects?.

METHODS

A team of seven interdisciplinary qualitative methods experts developed a framework for ensuring rigor and validity in RQA and methods suitable for this analytic approach. We conducted a qualitative evidence synthesis to identify gaps in the literature and then drew upon literature, standard procedures within our teams, and a repository of rapid qualitative training materials to create a planning and reporting framework. We iteratively refined this framework through 11 group working meetings (60-90 minutes each) over the course of one year and invited feedback on items to ensure their completeness, clarity, and comprehensibility.

RESULTS

The Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA) framework is organized progressively across phases from design to dissemination, as follows: 1) rigorous design (rationale and staffing), 2) semi-structured data collection (pilot and planning), 3) RQA: summary template development (accuracy and calibration), 4) RQA: matrix analysis (matrices), and 5) rapid qualitative data synthesis. Eighteen recommendations across these sections specify best practices for rigor and validity.

CONCLUSIONS

Rapid qualitative methods play a central role in implementation evaluations, with the potential to yield prompt information and insights about context, processes, and relationships. However, guidance on how to assess rigor is nascent. The PARRQA framework enhances the literature by offering criteria to ensure appropriate planning for and assessment of rigor in projects that involve RQA. This framework provides a consensus-based resource to support high-level qualitative methodological rigor in implementation science.

Applying Implementation Science in the Field of Transplant and Cellular Therapy

Implementation science (IS) is a systematic way to approach the broader adoption of evidence-based practices and has as its goal to understand and address the gap between research and practice, ensuring that research findings are effectively translated into practice and policy to improve health outcomes and service. We describe the various facets of IS and their relevance to the field of hematopoietic cell transplantation and cellular therapy (HCT/CT) with an emphasis on health equity, community engagement, and systems approach. We also review the similarities and differences among clinical research, quality improvement, and IS. Additionally, we describe how the Center for International Blood and Marrow Transplant Research applies IS across various phases: dissemination, analyzing current practices, and developing implementation intervention strategies. This includes designing studies and evaluations, scaling up operations, and ensuring sustainability. Lastly, we discuss further applications of IS in HCT/CT including the application to prospective research studies, collaboration across the field, and standardization and adoption of best practices. The application of IS in HCT/CT is pivotal to bringing research benefits directly to all patients. Through partnership, open-mindedness, and a commitment to evidence-based practice, we can collectively ensure the greatest impact of research on improving patient outcomes following HCT/CT.

"Allowing space for voice…all our voices:" Understanding Ho'ouna Pono implementation through educational leadership perspectives in rural Hawai'i schools

Epidemiological research over the past two decades has highlighted substance use disparities that affect Native Hawaiian and Pacific Islander youth, and the lack of effective approaches to address such disparities (Okamoto et al., 2019). The Ho'ouna Pono curriculum is a culturally grounded, teacher-implemented, video-enhanced substance use prevention program that has demonstrated efficacy in rural Hawai'i in a large-scale trial (Okamoto et al., 2019). Despite its potential to ameliorate health disparities and address youth substance use, prevention programs such as Ho'ouna Pono have been poorly disseminated and implemented across Hawai'i, raising the question: Why are effective prevention programs not used in communities that most need them? The present study used concept mapping to understand previously identified implementation barriers and develop implementation strategies for Ho'ouna Pono. Seven Hawai'i Department of Education (HIDOE) educational leaders and administrators sorted Ho'ouna Pono implementation barriers (e.g., "There is a lack of HIDOE funding to support prevention curricula"), named concepts, and rated barriers' perceived impact and difficulty. Multidimensional scaling and cluster analysis yielded a five-cluster solution: (1) Kumu (Hawaiian word for teacher) Controlled, (2) School Level Buy-in, (3) Curriculum, (4) Student Attitudes + Mindsets (Family + Community), and (5) Policy. Participant ratings identified eight high-impact and low-difficulty barriers. Discussion revealed important intersections among barriers indicating the need for coordinated and cross-level implementation strategies to support Ho'ouna Pono sustainment. Brainstormed implementation strategies using participants' own language highlighted a need for participatory methods in school settings to bidirectionally share ways to best sustain substance use prevention programs.

Models and frameworks for assessing the implementation of clinical practice guidelines: a systematic review

BACKGROUND

The implementation of clinical practice guidelines (CPGs) is a cyclical process in which the evaluation stage can facilitate continuous improvement. Implementation science has utilized theoretical approaches, such as models and frameworks, to understand and address this process. This article aims to provide a comprehensive overview of the models and frameworks used to assess the implementation of CPGs.

METHODS

A systematic review was conducted following the Cochrane methodology, with adaptations to the "selection process" due to the unique nature of this review. The findings were reported following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. Electronic databases were searched from their inception until May 15, 2023. A predetermined strategy and manual searches were conducted to identify relevant documents from health institutions worldwide. Eligible studies presented models and frameworks for assessing the implementation of CPGs. Information on the characteristics of the documents, the context in which the models were used (specific objectives, level of use, type of health service, target group), and the characteristics of each model or framework (name, domain evaluated, and model limitations) were extracted. The domains of the models were analyzed according to the key constructs: strategies, context, outcomes, fidelity, adaptation, sustainability, process, and intervention. A subgroup analysis was performed grouping models and frameworks according to their levels of use (clinical, organizational, and policy) and type of health service (community, ambulatorial, hospital, institutional). The JBI's critical appraisal tools were utilized by two independent researchers to assess the trustworthiness, relevance, and results of the included studies.

RESULTS

Database searches yielded 14,395 studies, of which 80 full texts were reviewed. Eight studies were included in the data analysis and four methodological guidelines were additionally included from the manual search. The risk of bias in the studies was considered non-critical for the results of this systematic review. A total of ten models/frameworks for assessing the implementation of CPGs were found. The level of use was mainly policy, the most common type of health service was institutional, and the major target group was professionals directly involved in clinical practice. The evaluated domains differed between the models and there were also differences in their conceptualization. All the models addressed the domain "Context", especially at the micro level (8/12), followed by the multilevel (7/12). The domains "Outcome" (9/12), "Intervention" (8/12), "Strategies" (7/12), and "Process" (5/12) were frequently addressed, while "Sustainability" was found only in one study, and "Fidelity/Adaptation" was not observed.

CONCLUSIONS

The use of models and frameworks for assessing the implementation of CPGs is still incipient. This systematic review may help stakeholders choose or adapt the most appropriate model or framework to assess CPGs implementation based on their specific health context.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) registration number: CRD42022335884. Registered on June 7, 2022.

Design and implementation of electronic health record-based tools to support a weight management program in primary care

Objectives

This paper reports on a mixed methods formative evaluation to support the design and implementation of information technology (IT) tools for a primary care weight management intervention delivered through the patient portal using primary care staff as coaches.

Methods

We performed a qualitative needs assessment, designed the IT tools to support the weight management program, and developed implementation tracking metrics. Implementation tracking metrics were designed to use real world electronic health record (EHR) data.

Results

The needs assessment revealed IT requirements as well as barriers and facilitators to implementation of EHR-based weight management interventions in primary care. We developed implementation metrics for the IT tools. These metrics were used in weekly project team calls to make sure that project resources were allocated to areas of need.

Conclusion

This study identifies the important role of IT in supporting weight management through patient identification, weight and activity tracking in the patient portal, and the use of the EHR as a population management tool. An intensive multi-level implementation approach is required for successful primary care-based weight management interventions including well-designed IT tools, comprehensive involvement of clinic leadership, and implementation tracking metrics to guide the process of workflow integration. This study helps to bridge the gap between informatics and implementation by using socio-technical formative evaluation methods early in order to support the implementation of IT tools.

Trial registration

clinicaltrials.gov, NCT04420936. Registered June 9, 2020.

Development and usability testing of an online support tool to identify models and frameworks to inform implementation

BACKGROUND

Theories, models and frameworks (TMFs) are useful when implementing, evaluating and sustaining healthcare evidence-based interventions. Yet it can be challenging to identify an appropriate TMF for an implementation project. We developed and tested the usability of an online tool to help individuals who are doing or supporting implementation practice activities to identify appropriate models and/or frameworks to inform their work.

METHODS

We used methods guided by models and evidence on implementation science and user-centered design. Phases of tool development included applying findings from a scoping review of TMFs and interviews with 24 researchers/implementers on barriers and facilitators to identifying and selecting TMFs. Based on interview findings, we categorized the TMFs by aim, stage of implementation, and target level of change to inform the tool's algorithm. We then conducted interviews with 10 end-users to test the usability of the prototype tool and administered the System Usability Scale (SUS). Usability issues were addressed and incorporated into the tool.

RESULTS

We developed Find TMF, an online tool consisting of 3-4 questions about the user's implementation project. The tool's algorithm matches key characteristics of the user's project (aim, stage, target change level) with characteristics of different TMFs and presents a list of candidate models/frameworks. Ten individuals from Canada or Australia participated in usability testing (mean SUS score 84.5, standard deviation 11.4). Overall, participants found the tool to be simple, easy to use and visually appealing with a useful output of candidate models/frameworks to consider for an implementation project. Users wanted additional instruction and guidance on what to expect from the tool and how to use the information in the output table. Tool improvements included incorporating an overview figure outlining the tool steps and output, displaying the tool questions on a single page, and clarifying the available functions of the results page, including adding direct links to the glossary and to complementary tools.

CONCLUSIONS

Find TMF is an easy-to-use online tool that may benefit individuals who support implementation practice activities by making the vast number of models and frameworks more accessible, while also supporting a consistent approach to identifying and selecting relevant TMFs.

School-Based Mental Health Interventions: Recommendations for Selecting and Reporting Implementation Strategies. THE JOURNAL OF SCHOOL HEALTH 2024;94:581-585. [PMID: 38627895 PMCID: PMC11618845 DOI: 10.1111/josh.13458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Mental health is a key component of overall student health and well-being. Schools are a primary setting in which youth receive mental health services. Although there is an extensive research literature about school mental health services that examines the effectiveness of prevention programs and interventions, studies rarely focus on the strategies that are used to support the implementation of these interventions in schools. In this commentary, we draw on the Exploration Preparation Implementation Sustainment (EPIS) framework to make recommendations regarding the selection and reporting of implementation strategies (i.e., the techniques used to enhance the adoption, implementation, and/or sustainment of interventions) in the school mental health literature. We focus on three specific recommendations for school mental health research and practice. First, we urge researchers and practitioners in the field of school mental health services to recognize the crucial roles of the Exploration and Preparation phases for implementation success, and to collaboratively develop implementation strategies for these overlooked phases. Second, we encourage researchers and practitioners to consider implementation strategies in addition to time- and resource-intensive training and coaching at the Implementation phase. Third, we argue for the importance of employing and reporting implementation strategies to plan for Sustainment . In doing so, we highlight the utility of frameworks such as EPIS for synthesizing research in the school health field, and the critical role of authentic community partnerships and participatory research for optimizing the mental health, and ultimately the overall health, of students.

Food is Medicine and implementation science: A recipe for health equity

Diet-related chronic diseases such as Type II diabetes, cardiometabolic diseases, and cancer are among the leading causes of death in the USA. Nutrition security has emerged as a target outcome and a national priority for preventative medicine and the treatment of diet-related chronic diseases. Food is Medicine (FIM) initiatives encompass programs and interventions to meet priority population's needs across food and nutrition security continuums as a mechanism to address persistent food and nutrition inequities. In this position statement, we draw on implementation science, specifically the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework and health equity principles to provide guidance on FIM initiatives. As the FIM evidence base continues to grow, we encourage the EPIS framework be applied as one lens through which we can improve our understanding of FIM implementation among multiple contexts to understand what works, for whom, and under what circumstances. Ultimately, this position statement aims to call to action the incorporation of implementation science and equity principles into FIM efforts.

Getting cozy with causality: Advances to the causal pathway diagramming method to enhance implementation precision

Background

Implementation strategies are theorized to work well when carefully matched to implementation determinants and when factors-preconditions, moderators, etc.-that influence strategy effectiveness are prospectively identified and addressed. Existing methods for strategy selection are either imprecise or require significant technical expertise and resources, undermining their utility. This article outlines refinements to causal pathway diagrams (CPDs), a method for articulating the causal process through which implementation strategies work and offers illustrations of their use.

Method

CPDs are a visualization tool to represent an implementation strategy, its mechanism(s) (i.e., the processes through which a strategy is thought to operate), determinants it is intended to address, factors that may impede or facilitate its effectiveness, and the series of outcomes that should be expected if the strategy is operating as intended. We offer principles for constructing CPDs and describe their key functions.

Results

Applications of the CPD method by study teams from two National Institute of Health-funded Implementation Science Centers and a research grant are presented. These include the use of CPDs to (a) match implementation strategies to determinants, (b) understand the conditions under which an implementation strategy works, and (c) develop causal theories of implementation strategies.

Conclusions

CPDs offer a novel method for implementers to select, understand, and improve the effectiveness of implementation strategies. They make explicit theoretical assumptions about strategy operation while supporting practical planning. Early applications have led to method refinements and guidance for the field.