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FRAMEWORKS IN IMPLEMENTATION SCIENCE

Along with the rapid growth and interest in implementation science has been the development of theories and models to guide this field of inquiry. There are currently over 61 diffusion and implementation models (Tabak, Khoong, Chambers, &

TABLE 19.1 Common Lexicon in Implementation Science

Term Definition

Innovation

The object of the implementation process. It captures a broad range, including cognitive behavioral or psychoeducational interventions, a policy, a program, guidelines, educational material, and behaviors. It has multiple attributes that might influence its ability to diffuse and to be adopted.

Innovation "is the implementation of a program and infrastructure that supports evidence-based practice" (Newhouse, 2007, p. 23). Innovation is defined "as a novel set of behaviours, routines and ways of working, which are directed at improving health outcomes, administrative efficiency, cost-effectiveness, or the user experience, and which are implemented by means of planned and coordinated action" (Greenhalgh et al., 2004, p. 6).

TABLE 19.1 Common Lexicon in Implementation Science (Continued)

Term

Definition

Diffusion

The passive spread of an innovation.

Diffusion "refers to the spread and use of new ideas, behaviors, practices, or organizational forms, which may include unplanned or spontaneous spread, as well as dissemination" (Mendel, Meredith, Schoenbaum, Sherbourne, & Wells, 2008, p. 25).

Dissemination

The active spread of an innovation, usually through specific distribution channels and plans.

Dissemination is "the targeted distribution of information on evidence- based health interventions" (Mendel et al., 2008, p. 22).

Dissemination "is the purposive distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread information and the associated evidence-based interventions. Research on dissemination addresses how information about health promotion and care interventions is created, packaged, transmitted, and interpreted among a variety of important stakeholder groups" (NIH, 2011).

Implementation

The process of incorporating an intervention—ideally an evidence- based one—to a specific setting.

Implementation "is the constellation of processes intended to get an intervention into use within an organization; it is the means by which an intervention is assimilated into an organization. Implementation is the critical gateway between an organizational decision to adopt an intervention and the routine use of that intervention; the transition period during which targeted stakeholders become increasingly skillful, consistent, and committed

in their use of an intervention" (Damschroder et al., 2009, p. 3). Implementation is defined as "a specified set of activities designed to put into practice an activity or program of known dimensions. According to this definition, implementation processes are purposeful and are described in sufficient detail such that independent observers can detect the presence and strength of the ‘specific set of activities' related to implementation. In addition, the activity or program being implemented is described in sufficient detail so that independent observers can detect its presence and strength" (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005, p. 5).

Implementation

strategy

The collection of systematically organized resources, processes, and activities that are deployed to achieve a successful implementation.

"Implementation strategies can be defined as methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice" (Proctor, Powell, & McMillen, 2013, p. 2).

Adoption

The active decision of an individual, an organization, or a community to incorporate an innovation.

Rogers (1995) defines adoption as "the decision to make full use of an innovation as the best course of action available" (p. 21).

TABLE 19.1 Common Lexicon in Implementation Science (Continued)

Term

Definition

Sustainability

An attribute of an innovation that reflects its ability to be adopted, and to produce beneficial effects, for longer periods of time and after the stimulus or support from an external agency is over.

Schell et al. (2013) "define sustainability capacity as the existence of structures and processes that allow a program to leverage resources to effectively implement and maintain evidence-based policies and activities" (p. 2).

Scheirer (2005) enumerates three operational defintions:

"(a) continuing to deliver beneficial services (outcomes) to clients

(an individual level of analysis); (b) maintaining the program

and/or its activities in an identifiable form, even if modified (an

organizational level of analysis); and (c) maintaining the capacity of

a community to deliver program activities

after an initial program created a community coalition or

similar structure (community level of analysis)" (p. 341).

Translation

Translation is defined as "the process of applying ideas, insights, and discoveries generated through basic scientific inquiry to the treatment or prevention of human disease" (as cited in Fang & Casadevall, 2010, p. 563).

The second definition "concerns research aimed at enhancing the adoption of best practices in the community" (Stevens, 2013, p. 7).

Replication

Replication is the "process of repeating services and/or program model undertaken by someone else using the same methodology. Commonly the location and participants will be different. Replication results either support earlier findings or question the accuracy of earlier results."

Context

Horner, Blitz, and Ross (2014) "define contextual fit as the match between the strategies, procedures, or elements of an intervention and the values, needs, skills, and resources available in a setting"

(p. 1).

Context "is the set of circumstances or unique factors that surround a particular implementation effort. Examples of contextual factors include a provider's perception of the evidence supporting the use of a clinical reminder for obesity, local and national policies about how to integrate that reminder into a local electronic medical record, and characteristics of the individuals involved in the implementation effort. In this paper, we use the term context to connote this broad scope of circumstances and characteristics. The ‘setting' includes the environmental characteristics in which implementation occurs. Most implementation theories in the literature use the term context both to refer to broad context, as described above, and also the specific setting" (Damschroder et al., 2009, p. 3).

Brownson, 2012), suggesting an increasingly robust conceptual grounding for this area of science. Theories and models are used to guide implementation studies and to explain how, why, and when a proven intervention is adopted (see Chapter 4). Table 19.2 provides a summary of 13 key and commonly used implementation theories and models that have high relevance to the conduct of behavioral intervention research. Familiarity with these models is an important first step in helping to advance the

TABLE 19.2 Implementation Science Models and Frameworks

Theory and Key Citation

Brief Description

Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM)

Glasgow, Vogt, & Boles (1999)

Each letter of the acronym represents one construct of the theory, which collectively aims to explain the public health impact of a given intervention using individual and organizational domains. Reach refers to who received the intervention—in terms of numbers, demographic characteristics, biopsychosocial history, and set of risk and protective factors. Efficacy refers to reporting on both the positive and negative outcomes of an intervention, as well as measuring the physiologic, behavioral, and quality of life metrics of both the participant and the interventionist. Adoption refers to the setting(s) that carries out the intervention. Implementation refers to participant adherence and interventionist fidelity, both of which help determine if the intervention was delivered as intended. Maintenance refers to the extent to which individuals relapse (cf. attrition) and if programs continue an intervention as part of an enduring policy.

Promoting Action on Research Implementation in Health Services (PARiHS) Model Kitson et al. (2008)

To explain the complexities of implementation, the PARiHS model has three core elements—(1) evidence, (2) context, and (3) facilitation—that all have subelements. Evidence includes research (e.g., is there sufficient evidence?), clinical experience (e.g., does experience fit the data?), patient experience (e.g., are we gathering patient opinions?), and information from local context (e.g., are the key messages tailored to the environment?). Context includes receptive contact (e.g., are professional networks and human resources in place?), culture (e.g., does the organization value collaborative partnerships?), leadership (e.g., are the roles clear?), and evaluation (will data be collected that will routinely improve and change practice?). Facilitation includes the skills, knowledge, and expertise of the facilitator(s) designated to carry out the implementation goal.

PRECEDE-PROCEED

Model

Green & Krueter (1999)

PRECEDE-PROCEED is a heuristic framework that can help guide the development of an intervention. Importantly, the target population is included in the planning processes, as an underlying tenet is that health behavior change is voluntary and interventions are most effective if the community context is considered.

It is divided into two components: (1) PRECEDE (an "educational diagnosis" or description of the problem) and (2) PROCEED (an "ecological diagnosis" or consideration of the environmental factors necessary for health change). Each arm of the model contains sub elements: PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) and PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development).

TABLE 19.2 Implementation Science Models and Frameworks (Continued)

Theory and Key Citation

Brief Description

CFIR (Consolidated Framework for Implementation Research)

Damschroder et al. (2009)

CFIR was the result of a comprehensive review (Damschroder et al., 2009) that aimed at consolidating various implementation frameworks. This model consists of five themes: intervention characteristics, outer setting, inner setting, characteristics of the individuals, and process. Each theme is also composed of additional constructs related to the theme. For example, the intervention characteristics theme contains the intervention source, evidence strength, relative advantage, adaptability, trialability, complexity, design quality, and cost.

Technology Acceptance Model (TAM)

Legris, Ingham, & Collerette (2003)

TAM is a model that aims to explain why individuals use (or reject) information technology. The core tenet is that external variables impact individual beliefs and intentions through two core-mediating constructs: perceived usefulness and perceived ease of use. Perceived usefulness includes the perception that a given technology increases productivity, performance, and effectiveness. Perceived ease of use includes the perception that learning to operate the technology is easy and that it is learnable and flexible.

Normalization Process Theory (NPT)

May (2006); May et al. (2007, 2009); May & Finch (2009)

A theory that aims to explain the sociological mechanisms that lead to (or inhibit) the implementation, embedding, and integration of an intervention or policy. The most recent iteration of the theory (May & Finch, 2009) has four core constructs: coherence, cognitive participation, collective action, and reflexive monitoring. Coherence asks, "what is the work?" Cognitive participation asks, "who does the work?" Collective action asks, "how does the work get done?" Reflexive monitoring asks, "how is the work understood?"

General Theory of Implementation

May (2013)

Building on NPT, the General Theory of Implementation has four interactive core constructs: potential, capacity, capability, and contribution. Potential includes individual intentions and collective commitment. Capacity includes material resources, social roles, social norms, and cognitive resources. Capability includes workability and integration. Contribution includes coherence, cognitive participation, collective action, and reflexive monitoring.

Theoretical Domains Framework (TDF)

Michie et al. (2005); Cane, O'Connor, & Michie (2012); French et al. (2012)

In response to the large body of theories seeking to explain behavior change, the TDF was created to provide an organizational heuristic of the extant theories. Overall, 33 theories encompassing a total of 128 core constructs were distilled into 12 theoretical domains that explain behavior change and inform implementation efforts. The 12 domains identified include (1) knowledge; (2) skills; (3) social/professional role identify; (4) belief about capabilities; (5) beliefs about consequences; (6) motivation and goals; (7) memory, attention, and decision processes; (8) environmental context and resources; (9) social influences; (10) emotion regulation; (11) behavior regulation; and (12) nature of the behavior.

TABLE 19.2 Implementation Science Models and Frameworks (Continued)

Theory and Key Citation

Brief Description

Diffusion of Innovations Theory

Rogers (2003); Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou (2004)

Proposes that four elements account for an idea being spread throughout a system or a society and among members of each group: (1) innovation (i.e., a novel idea); (2) communication channels (i.e., transmitting messages to one another); (3) time (i.e., how fast a given system or society adopts the new practice); and (4) social system (i.e., the stakeholders).

Social Constructivist Theory

Thomas, Menon, Boruff, Rodriguez, & Ahmed (2014)

A sociological theory that proposes that knowledge is created ("meaning-making") in the context of other human beings—that is, it is a collectivist, rather than individualist, effort.

Replicating Effective Programs

Kilbourne, Neumann, Pincus, Bauer, & Stall (2007)

Four steps: (1) preconditions (identify the need, identify an effective intervention, identify barriers, draft a package for training and assessment purposes); (2) preimplementation (orient community groups in core elements, customize delivery, plan logistics, train staff, provide technical assistance); (3) implementation (continue partnership with community organization, provide booster trainings, perform process evaluations, provide feedback and refinement of intervention package/training); and (4) maintenance and evolution (make organizational and financial changes to sustain intervention, prepare package for national dissemination, recustomize delivery as needed).

Translating Evidence into Practice (TRIP) Model

Pronovost, Berenholtz, & Needham (2008)

Four components: (1) summarize the evidence; (2) identify barriers to implementation at the local level; (3) measure performance; and (4) ensure all patients receive the interventions. The fourth component is further broken down into the "four Es": engage (explain why the interventions are important), educate (provide evidence as to the interventions' efficacy), execute (design a toolkit), and evaluate (provide ongoing assessment for performance measures).

PRISM (Practical, Robust Implementation and Sustainability Model)

Feldstein & Glasgow (2008)

PRISM establishes a basic and practical approach to define the elements that influence a successful implementation. This model states that the factors are the program (or intervention), which has an organizational and a patient perspective, the recipients (with also an organizational and a patient perspective), the external environment, and the implementation and sustainability infrastructure.

development of an intervention when the ultimate goal is its implementation, dissemination, and wide-scale adoption in a real-world setting. Understanding downstream (e.g., implementation) considerations, as expressed in these theories/models upfront in the developmental process for an intervention, may ultimately positively impact the implementation potential of an intervention once it is proven to be effective. Common frameworks that have been used to inform behavioral intervention research include but are not limited to RE-AIM, PRECEDE-PROCEED, PARiHS, and Rogers’s Diffusion of Innovations Theory (see Table 19.2 for others).

 
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