. . . looking inside the “black box” of implementation.

Behavioral interventions hold the promise of improving life expectancy, quality of life, health outcomes, and health care for vulnerable populations including older adults, family caregivers, and those with chronic health problems. Nevertheless, the impact of proven programs ultimately depends upon their adoption and sustained implementation by an agency or practice setting, clinician, patient, consumer, participant, and/or his or her caregivers. Only a fraction of effective behavioral interventions are fully implemented and their benefits are only partially, or not at all, realized (Rahman, Surkan, Cayetano, Rwagatare, & Dickson, 2013). This has proven to be the case for every area of investigation into health and human service problems. For example, hundreds of original studies and systematic reviews concerning the effectiveness of behavioral interventions to improve the health and care of vulnerable populations exist (Ebrahim et al., 2011).

Although many effective interventions are theory-based, have been tested using randomized clinical trial methodologies, and have yielded strong evidence for their effectiveness, few, if any, have been implemented in practice settings. It has been estimated that up to 40% of patients do not receive care according to current scientific evidence, or receive potentially harmful care (Ewing, Selassie, Lopez, & McCutcheon, 1999; Grimshaw et al., 2004). In the area of dementia caregiving, there are over 200 proven behavioral interventions for family caregivers, yet less than 3% of these interventions have been submitted for translation into real practice settings and only 4,566 caregivers have participated in a translational effort representing 0.0003% of the 15+ million caregivers in the United States (Gitlin & Hodgson, 2015; Gitlin, Marx, Stanley, & Hodgson, 2015).

Given the challenges of moving successful behavioral interventions from research into practice, new approaches to designing, evaluating, and implementing programs need to be pursued (hence this book). One approach is to understand the challenges of implementation or to begin with the end in mind, a premise introduced in Chapter 1 and explored in more depth in Part IV and specifically this chapter. Implementation science—the discipline that studies the processes of translating, implementing, disseminating, and sustaining research evidence into routine care—can provide insight into, and help understand, the “endgame.”

The purpose of this chapter is to provide an introduction to implementation science and specifically how understanding theoretical frameworks for implementation can inform intervention development. First, we examine in more detail the reasons why the gap between research and implementation exists. We then define implementation science and its commonly used terminology and summarize existing implementation frameworks that can be useful when developing an intervention and evaluating an intervention. Finally, we identify key steps to advance the field of behavioral intervention research in light of the contributions of implementation science. We seek to show how understanding and using implementation science and specifically its emerging frameworks may maximize the likelihood for effective translation/implementation and long-term adoption of behavioral interventions into clinical practice, social service, and/or community settings.

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