THE BLACK BOX OF IMPLEMENTATION
Although there are a sufficient range and number of implementation theories/models for guiding implementation of behavioral intervention research, there is a lack of measures to evaluate readiness of stakeholders, the process of uptake, and actual implementation of an intervention. Two areas, in particular, warrant measurement development, organizational readiness, and contextual fit. As features of an organization (team, department, organization) affect adoption of an evidence-based program, gauging the level of readiness could help guide what organizations to target first and how to better prepare and support a setting for changing their practices (Shea, Jacobs, Esserman, Bruce, & Weiner, 2014). Similarly, the successful implementation of a proven intervention depends upon the fit with the context (Horner et al., 2014). A measure of “contextual fit” would provide critical information even early on in the development of an intervention as to its potential for implementation. This is discussed in more depth in Chapter 20.
As a consequence of the lack of adequate measures, there is still a “black box” regarding the mechanisms that may influence intervention “uptake” (e.g., the optimal timing of dose and duration of the intervention) and there remains a critical need to develop and test measures of implementation outcomes (e.g., barriers assessment, knowledge use, impact, sustainability). Nevertheless, even in the initial steps in designing an intervention, it is important to consider the ultimate end us- er(s) and to document the contextual factors and the characteristics of an organization that could use the intervention in order to boost the potential for adoption of an intervention, if proven to be effective.
A formative evaluation that is designed to elicit the organizational culture and the perceptions of the end user is an important initial step that can be accomplished early on in the developmental phase of the intervention pipeline. Intervention projects targeted at evaluating obstacles to change using one or more of the theories of implementation may be more effective than intervention efforts that do not follow this approach. If resources permit, early examination of processes and outcomes at every level (e.g., targeted person as well as practitioner and organizational level) could be helpful. Data could be used to answer questions such as: What aspects of the intervention were successful in promoting improvements in practice, in what environments, and why? and What are the barriers to overcome? Process information collected early on using mixed methodologies (see Chapter 11) on how the intervention has effected or changed the standard of practice and whether this is associated with measurably improved patient outcomes could potentially shorten the elongated pipeline of bringing interventions to practice.
Since most behavioral interventions are complex and multicomponent, it is essential to identify the delivery characteristics (see Chapter 5) of the intervention that are absolutely necessary for treatment benefits to occur and those elements that are potentially modifiable (e.g., the scheduling of treatment sessions, or whether a session can be shorter or longer).
Consideration of the cost and potential cost savings of behavioral interventions is another important requisite in intervention development (see Chapter 18). What can be scalable or generalized, and at what cost? Rigorous evaluations of behavioral interventions increasingly need to include measurement of costs to argue that insurance programs should cover such interventions and thus are able to be implemented on a large scale.