WHAT IS IMPLEMENTATION SCIENCE?
Implementation science holds the promise of disentangling the challenges of dissemination and implementation and helping to solve knowledge-practice gaps by
Figure 19.1 The implementation gap.
informing research decision making early on in the developmental process of an intervention (Brownson, Colditz, & Proctor, 2012). A relatively new discipline, implementation science has emerged in part in response to knowledge-practice gaps and to systematically move evidence to action. The primary goal of implementation science is to develop, test, and evaluate specific strategies for translating, implementing, and sustaining evidence into practice environments. Given that the effectiveness of embedding evidence into practice is influenced by multiple contextual factors (see Chapter 1, Figure 1.2), implementation science represents the domain of studies that examine these factors.
Numerous definitions of implementation science have been posited. The National Cancer Institute defines implementation research as “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings” (National Institutes of Health [NIH], 2013). Dearing and Kee (2012) provide a more restrictive definition and suggest that it is “the study of what happens after adoption occurs, especially in organizational settings. Implementation is one stage (after awareness and adoption, and before sustained use) in the over-time process diffusion” (p. 56).
We use as our referent point Eccles and Mittman’s (2006) approach, which defines implementation science as the scientific evaluation of methods to promote the systematic uptake of research findings or other evidence-based practices into routine practice and, hence, to improve the quality and effectiveness of health services and care. Implementation represents the transition period in which the ultimate end user becomes skilled, consistent, and committed to using a proven intervention.
Although implementation science has only recently gained wide recognition and is in an early developmental stage of its science, its roots are grounded in decades of research that have focused on the factors influencing sustained adoption of an effective innovation. In 1962, Rogers posed his breakthrough Diffusion of Innovations Theory. He suggested that an s-shaped innovation curve reflected the diffusion process in which a small minority group becomes early adopters of an innovation followed by rapid adoption by a majority of the population and then a period in which holdouts finally adopt. Diffusion of an innovation is influenced by the characteristics of the innovation itself, an adopter’s level of innovativeness, and social system, adoption, and diffusion processes. Similarly, medical sociology (Burt, 1973), communication studies (Rogers & Kincaid, 1981), and marketing research (Bass, 1969) produced important findings on factors that influence the adoption of innovations. However, this early work primarily focused on individual-level factors that influenced adoption such as characteristics of adopters of an intervention versus understanding the larger context such as organizational culture in which such changes occurred.
During the past two decades, the focus has shifted from diffusion to dissemination and implementation, reflecting the need for more active processes to foster long-term or sustained adoption of the research evidence. Additionally, the focus has expanded to include the broader social and contextual factors (organizational, geographical, political, and cultural) that influence long-term adoption. This is a result of the growing recognition that the sustainability of any behavioral intervention requires an understanding of complex health care and social systems and coordinated behavioral and organizational mechanisms to invoke change. Implementation is the gateway between deciding to adopt an intervention and the routine use (or the sustainability or maintenance, Phase VII) of that intervention. It therefore requires attention to the specific factors that may influence implementation of evidence in practice settings such as the culture of care, leadership, facility size, staffing support and training, organizational innovativeness, workload, resistance to change, and available resources (money and time). These factors may vary by location, type of setting, resources, and other related factors.
The shift in focus from diffusion of knowledge to dissemination and implementation into practice has revealed the lack of a common language and standard terminology. For example, dissemination and implementation research is also variably defined and referred to as “knowledge translation” or “scaling up.” The NIH defines dissemination as “the targeted distribution of information and intervention materials to a specific public health or clinical practice audience” (NIH, 2007) and is the focus of Chapter 21. Conversely, implementation is defined as “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings” (NIH, 2007). Dissemination and implementation are closely related, but not synonymous, and represent a continuum of the translation of evidence into a practice setting. For example, whereas the publication of the Centers for Disease Control and Prevention Physical Activity Guidelines of Americans (U.S. Department of Health and Human Services, 2008) can be considered dissemination of evidence, the process by which the guidelines are subsequently adopted into routine practice is considered implementation. Table 19.1 provides brief definitions of the key terms commonly used in implementation science and can serve as a quick reference.