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      Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions

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          Abstract

          Background

          A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers.

          Methods

          Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices.

          Results

          Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD = 4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants.

          Conclusions

          The wide heterogeneity of endorsements obtained in this study’s task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study’s results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.

          Electronic supplementary material

          The online version of this article (10.1186/s13012-019-0892-4) contains supplementary material, which is available to authorized users.

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          Most cited references33

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          A compilation of strategies for implementing clinical innovations in health and mental health.

          Efforts to identify, develop, refine, and test strategies to disseminate and implement evidence-based treatments have been prioritized in order to improve the quality of health and mental health care delivery. However, this task is complicated by an implementation science literature characterized by inconsistent language use and inadequate descriptions of implementation strategies. This article brings more depth and clarity to implementation research and practice by presenting a consolidated compilation of discrete implementation strategies, based on a review of 205 sources published between 1995 and 2011. The resulting compilation includes 68 implementation strategies and definitions, which are grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality, and attending to the policy context. This consolidated compilation can serve as a reference to stakeholders who wish to implement clinical innovations in health and mental health care and can facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts.
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            Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study

            Background Poor terminological consistency for core concepts in implementation science has been widely noted as an obstacle to effective meta-analyses. This inconsistency is also a barrier for those seeking guidance from the research literature when developing and planning implementation initiatives. The Expert Recommendations for Implementing Change (ERIC) study aims to address one area of terminological inconsistency: discrete implementation strategies involving one process or action used to support a practice change. The present report is on the second stage of the ERIC project that focuses on providing initial validation of the compilation of 73 implementation strategies that were identified in the first phase. Findings Purposive sampling was used to recruit a panel of experts in implementation science and clinical practice (N = 35). These key stakeholders used concept mapping sorting and rating activities to place the 73 implementation strategies into similar groups and to rate each strategy’s relative importance and feasibility. Multidimensional scaling analysis provided a quantitative representation of the relationships among the strategies, all but one of which were found to be conceptually distinct from the others. Hierarchical cluster analysis supported organizing the 73 strategies into 9 categories. The ratings data reflect those strategies identified as the most important and feasible. Conclusions This study provides initial validation of the implementation strategies within the ERIC compilation as being conceptually distinct. The categorization and strategy ratings of importance and feasibility may facilitate the search for, and selection of, strategies that are best suited for implementation efforts in a particular setting. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0295-0) contains supplementary material, which is available to authorized users.
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              From Classification to Causality: Advancing Understanding of Mechanisms of Change in Implementation Science

              Background The science of implementation has offered little toward understanding how different implementation strategies work. To improve outcomes of implementation efforts, the field needs precise, testable theories that describe the causal pathways through which implementation strategies function. In this perspective piece, we describe a four-step approach to developing causal pathway models for implementation strategies. Building causal models First, it is important to ensure that implementation strategies are appropriately specified. Some strategies in published compilations are well defined but may not be specified in terms of its core component that can have a reliable and measureable impact. Second, linkages between strategies and mechanisms need to be generated. Existing compilations do not offer mechanisms by which strategies act, or the processes or events through which an implementation strategy operates to affect desired implementation outcomes. Third, it is critical to identify proximal and distal outcomes the strategy is theorized to impact, with the former being direct, measurable products of the strategy and the latter being one of eight implementation outcomes (1). Finally, articulating effect modifiers, like preconditions and moderators, allow for an understanding of where, when, and why strategies have an effect on outcomes of interest. Future directions We argue for greater precision in use of terms for factors implicated in implementation processes; development of guidelines for selecting research design and study plans that account for practical constructs and allow for the study of mechanisms; psychometrically strong and pragmatic measures of mechanisms; and more robust curation of evidence for knowledge transfer and use.
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                Author and article information

                Contributors
                laura.damschroder@va.gov
                Journal
                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                1748-5908
                29 April 2019
                29 April 2019
                2019
                : 14
                : 42
                Affiliations
                [1 ]ISNI 0000000106743006, GRID grid.255399.1, Eastern Michigan University, ; Ypsilanti, USA
                [2 ]ISNI 0000 0000 8603 8958, GRID grid.497654.d, Ann Arbor VA Center for Clinical Management Research, ; P.O. Box 130170, Ann Arbor, MI 48113-0170 USA
                [3 ]ISNI 0000000122483208, GRID grid.10698.36, Department of Health Policy and Management, Gillings School of Global Public Health, , University of North Carolina at Chapel Hill, ; Chapel Hill, USA
                [4 ]ISNI 0000 0000 9206 2401, GRID grid.267308.8, Center for Health Promotion and Prevention Research, School of Public Health, , University of Texas Health Science Center at Houston, ; Houston, USA
                Author information
                http://orcid.org/0000-0002-3657-8459
                Article
                892
                10.1186/s13012-019-0892-4
                6489173
                31036028
                d1447ad6-2da3-4c64-acd8-d54feb0b0aed
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 20 September 2018
                : 12 April 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000738, U.S. Department of Veterans Affairs;
                Award ID: QLP 92-025; QUERI DM, DIB 98-001
                Categories
                Research
                Custom metadata
                © The Author(s) 2019

                Medicine
                consolidated framework for implementation research,expert recommendations for implementing change,implementation,intervention mapping,implementation strategies

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