Implementation Phases

Theory has still yet another role in the implementation phases of behavioral intervention research (Phase V—translation/implementation; Phase VI—diffusion/dis- semination; Phase VII—sustainability). In these latter phases, theory informs an understanding of specific implementation processes such as the contextual barriers to, and supports of the adoption of, a proven intervention within settings and by interventionists and end users. Specifically, theory helps identify what components of the intervention could be modified or eliminated, the immutable elements or aspects that cannot be changed, organizational and contextual features impinging on implementation, and strategies for streamlining the intervention to enhance implementation potential. Using theory to identify and sort through contributory organizational or contextual characteristics is essential at this phase.

An exemplar is the use of Normalization Process Theory (NPT) to understand the potential of GBGB to be implemented in senior centers and other community-based agencies (May et al., 2009). This particular theory identifies four factors that can inform implementation potential. Briefly, these are “coherence” or whether an intervention is easy to describe and understand; “cognitive participation” or whether users consider it a good idea; “collective work” or how the program affects agency staff; and “reflexive monitoring” or how users of the program will perceive it.

As to the first factor, GBGB demonstrated high coherence: Staff and older African American participants alike understood and recognized the program and its benefits. As supporting positive mental health is the expressed mission of senior centers, GBGB fits within their organizational goals. With regard to cognitive participation, initially care managers responsible for screening for depressive symptoms did not value using a systematic screening tool and believed that their own appraisals were sufficient. However, through training, ongoing use, and supervisory support, care managers learned that their judgments were often incorrect and that screening afforded a more systematic and accurate approach to depression detection. Similarly, initially interventionists believed that they already practiced many of the elements of GBGB and therefore the intervention was not necessarily novel to them. This is a common reaction to behavioral interventions. However, with training and use, interventionists were able to differentiate GBGB from their own traditional mental health practices and became invested in the program. Older African American participants in the program found it highly valuable and perceived the program worthy of their investment of time and energy.

The third NPT factor, “collective work,” presents as the most challenging for GBGB. As most senior centers or community-based agencies do not have the capacity to engage in depression care, GBGB would require a change in work practices and flow. Staff training and employment of skilled professionals would be critical to implement GBGB, and this may be difficult for agencies with limited budgets and staffing.

The fourth consideration, “reflexive monitoring,” suggests that the value of GBGB was perceived positively by both interventionists and participants alike. Thus, NPT suggests two potential areas that present as critical challenges when implementing GBGB in real-world settings: accounting for and helping agencies adjust their work flow and payment mechanisms; and tweaking training efforts so that interventionists come to understand the benefits of the program sooner rather than later (Gitlin, Harris, McCoy, Hess, & Hauck, in press).

As specific theories have been developed to understand ways to embed evidence- based interventions in practice settings, Chapter 19 provides a more in-depth discussion of the role of theory in the implementation phase and specific theories that help to guide implementation processes.

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