A systematic review of empirical studies examining mechanisms of implementation in health

Lewis, Cara C.; Boyd, Meredith; Walsh‐Bailey, Callie; Lyon, Aaron R.; Beidas, Rinad S.; Mittman, Brian; Aarons, Gregory A.; Weiner, Bryan J.; Chambers, David A.

doi:10.1186/s13012-020-00983-3

Cited by 202 publications

(192 citation statements)

References 112 publications

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“…Steps For step 4 (mechanisms), using the three health equity domains (added to another implementation framework, as done in the Health Equity Implementation Framework), one may develop theoretically driven hypotheses about which domains or mechanisms must change to lead to improved equity and implementation success. [61] When working on an inequitable implementation problem, this will ensure some mechanisms related to equity and implementation are investigated. For example, there may be inequity in the research-practice gap related to outer context (e.g., this intervention is only implemented in well-funded institutions that serve mostly a uent people).…”

Section: Specify Implementation Outcomes and Evaluate Implementationmentioning

confidence: 99%

A Practical Guide to Incorporating Health Equity Domains in Implementation Frameworks

Woodward

Singh

Ndebele-Ngwenya

et al. 2020

Preprint

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Background: Due to limited systematic integration of health equity and implementation science, it is imperative to provide researchers and practitioners tools to guide implementation in settings where there is inequitable implementation of an intervention. Our prior work documented and piloted the first published adaptation of an existing implementation science framework with health equity determinants to create the Health Equity Implementation Framework. We suggested how others’ might adapt their preferred implementation science frameworks with three health equity domains: 1) cultural factors of recipients, 2) clinical encounter, or patient-provider interaction, and 3) societal influences (including but not limited to social determinants of health). This manuscript is a practical guide to utilize three health equity domains in implementation research and practice.Methods: We describe in greater depth than in our previous publication domains typical in implementation determinants frameworks and three adaptations: domains known to affect health equity. For each domain, we compiled definitions with supporting literature, defined relevant subdomains, showcased an illustrative example, and suggested sample measures, both quantitative and qualitative.Results: We describe how to incorporate the three health equity domains in one’s preferred implementation science framework, or how to use the Health Equity Implementation Framework specifically. Practical guidelines follow ten published recommendations on how to use frameworks in implementation research and practice. We describe a new case study in which the framework guided evaluation.Conclusions: Incorporating health equity domains within implementation frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally, addressing, implementation and equity barriers simultaneously. The practical guidance and tools provided can assist implementation scientists and practitioners to concretely address inequity in implementation across populations to capture and analyze information used to assess health outcomes.Contributions to the LiteratureSpecific definitions of implementation and three health equity domains with examples of how they have been applied in published literature and sample measures.Practical tools, including a qualitative interview guide and codebookCase study of how the Health Equity Implementation Framework guided analysis in an implementation study

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Section: Specify Implementation Outcomes and Evaluate Implementationmentioning

confidence: 99%

A Practical Guide to Incorporating Health Equity Domains in Implementation Frameworks

Woodward

Singh

Ndebele-Ngwenya

et al. 2020

Preprint

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“…An important step of implementation strategy development is articulating their theorized mechanisms of change [5]; although these are rarely evaluated [17,18]. Theory is currently the best pathway through which to identify implementation mechanisms [5].…”

Section: Implementation Strategies Determinants and Mechanismsmentioning

confidence: 99%

The influence of a blended, theoretically-informed pre-implementation strategy on school-based clinician implementation of an evidence-based trauma intervention

Lyon¹,

Cook²,

Duong³

et al. 2019

Preprint

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BackgroundIndividual-level implementation determinants, such as clinician attitudes, commonly influence the successful adoption of evidence-based practices, but few explicit strategies have been tested with regard to their ability to impact these key mechanisms of change. This paper reports on an initial test of a blended, theoretically informed pre-implementation strategy designed to target malleable individual-level determinants of behavior change. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a brief and pragmatic pre-implementation strategy that uses strategic education, social influence techniques, and group-based motivational interviewing to target implementation attitudes, perceived social norms, perceived behavioral control, and behavioral intentions to implement among mental health clinicians working in the education sector.MethodsAs part of a pilot trial, 25 school mental health clinicians were randomized to BASIS (n = 12) or an attention control placebo (n = 13), with both conditions receiving training and consultation in an evidence-based intervention for youth experiencing trauma (the Cognitive Behavioral Intervention for Trauma in Schools). Theorized mechanisms of change (attitudes, perceived social norms, perceived behavioral control, and behavioral intentions) were assessed at baseline, post-training, and 4-month follow-up. Clinician participation in post-training consultation and intervention adoption were also tracked.ResultsA series of regression models and independent sample t tests indicated that BASIS had significant, medium to large effects on the majority of its proximal mechanisms from baseline to post-training. BASIS was also associated with a greater latency between initial training in the intervention and discontinuation of participation in post-training consultation, with clinicians in the BASIS condition persisting in consultation for an average of 134 days versus 32 days for controls, but this difference was not statistically significant. At 4-month follow-up, most differences in the theorized mechanisms had attenuated, and approximately the same small number of BASIS clinicians adopted the trauma intervention as controls.ConclusionFindings suggest that the brief BASIS pre-implementation strategy had a significant influence on its proximal mechanisms of change, but that these changes did not persist over time or translate into adoption of the trauma intervention. Implications for theory refinement, revisions to the BASIS protocol, and next steps for research surrounding individual-level implementation strategies are discussed.Methods. As part of a pilot trial, 25 school mental health clinicians were randomized to BASIS (n = 12) or an attention control placebo (n = 13), with both conditions receiving training and consultation in an evidence-based intervention for youth experiencing trauma. Theorized mechanisms of change (attitudes, perceived social norms, perceived behavioral control, and behavioral intentions) were assessed at baseline, post-training, and four-month follow-up. Clinician participation in post-training consultation and intervention adoption were also tracked. Results. A series of regression models and independent sample t-tests indicated that BASIS had significant, medium to large effects on the majority of its proximal mechanisms from baseline to post-training. BASIS was also associated with a greater latency between initial training in the intervention and discontinuation of participation in post-training consultation, with clinicians in the BASIS condition persisting in consultation for an average of 134 days versus 32 days for controls, but this difference was not statistically significant. At four-month follow-up, most differences in the theorized mechanisms had attenuated, and approximately the same small number of BASIS clinicians adopted the trauma intervention as controls. Conclusion. Findings suggest that the brief BASIS pre-implementation strategy had a significant influence on its proximal mechanisms of change, but that these changes did not persist over time or translate into adoption of the trauma intervention. Implications for theory refinement, revisions to the BASIS protocol, and next steps for research surrounding individual-level implementation strategies are discussed.

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“…Improving the efficiency, speed, and sustainment of EBP implementation requires research on the mechanisms through which multiple organizations impact implementation outcomes, yet no empirical evidence on these mechanisms exists to date [ 2 , 14 , 68 , 69 ]. However, candidate mechanisms for IOA at the organizational and individual levels can be identified to facilitate research, tailor implementations to context, or identify core components to increase the precision of implementation strategies [ 70 ]. When considering the partnership between two organizations, mechanisms may include group-level processes drawn from established organizational frameworks, such as inter-organizational fragmentation or cohesion [ 71 , 72 ].…”

Section: Introductionmentioning

confidence: 99%

The impact of inter-organizational alignment (IOA) on implementation outcomes: evaluating unique and shared organizational influences in education sector mental health

et al. 2018

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BackgroundIntegrated healthcare delivered by work groups in nontraditional service settings is increasingly common, yet contemporary implementation frameworks typically assume a single organization—or organizational unit—within which system-level processes influence service quality and implementation success. Recent implementation frameworks predict that inter-organizational alignment (i.e., similarity in values, characteristics, activities related to implementation across organizations) may facilitate the implementation of evidence-based practices (EBP), but few studies have evaluated this premise. This study’s aims examine the impact of overlapping organizational contexts by evaluating the implementation contexts of externally employed mental health clinicians working in schools—the most common integrated service delivery setting for children and adolescents. Aim 1 is to estimate the effects of unique intra-organizational implementation contexts and combined inter-organizational alignment on implementation outcomes. Aim 2 is to examine the underlying mechanisms through which inter-organizational alignment facilitates or hinders EBP implementation.Methods/designThis study will conduct sequential, exploratory mixed-methods research to evaluate the intra- and inter-organizational implementation contexts of schools and the external community-based organizations that most often employ school-based mental health clinicians, as they relate to mental health EBP implementation. Aim 1 will involve quantitative surveys with school-based, externally-employed mental health clinicians, their supervisors, and proximal school-employed staff (total n = 120 participants) to estimate the effects of each organization’s general and implementation-specific organizational factors (e.g., climate, leadership) on implementation outcomes (fidelity, acceptability, appropriateness) and assess the moderating role of the degree of clinician embeddedness in the school setting. Aim 2 will explore the mechanisms through which inter-organizational alignment influences implementation outcomes by presenting the results of Aim 1 surveys to school-based clinicians (n = 30) and conducting semi-structured qualitative interviews. Qualitative data will be evaluated using an integrative inductive and deductive approach.DiscussionThe study aims are expected to identify intra- and inter-organizational constructs that are most instrumental to EBP implementation success in school-based integrated care settings and illuminate mechanisms that may account for the influence of inter-organizational alignment. In addition to improving school-based mental health, these findings will spur future implementation science that considers the relationships across organizations and optimize the capacity of implementation science to guide practice in increasingly complex systems of care.

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A systematic review of empirical studies examining mechanisms of implementation in health

Cited by 202 publications

References 112 publications

A Practical Guide to Incorporating Health Equity Domains in Implementation Frameworks

A Practical Guide to Incorporating Health Equity Domains in Implementation Frameworks

The influence of a blended, theoretically-informed pre-implementation strategy on school-based clinician implementation of an evidence-based trauma intervention

The impact of inter-organizational alignment (IOA) on implementation outcomes: evaluating unique and shared organizational influences in education sector mental health

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