THE CHALLENGE OF CONTEXT
A key challenge when introducing a new intervention into a setting concerns the characteristics of that setting, which may or may not support the adoption of the intervention (Burke & Gitlin, 2012; Gitlin, 2013). As previous research has shown, the fit between an intervention (e.g., its delivery characteristics, purpose, targeted population) and the values and goals of a practice or social service setting is associated with the dissemination potential of the intervention (discussed in Chapter 21) and whether the intervention is adopted; the better or stronger the fit, the greater the potential for adoption to occur and for the new intervention to be sustained (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Horner & Blitz, 2014). Unfortunately, most researchers lack a clear understanding of the “contexts” in which their interventions may eventually be implemented, the aspects of contexts that may impact implementation, and the degree of “fit” between their interventions and these contexts (Fixsen et al. 2005; Wilson, Brady, & Lesesne, 2011).
Although there is no doubt as to the importance of “context,” the term does not have a clear conceptual and operational definition or measurement approach— what do we mean by “context” and how should we measure it? Undoubtedly, context should be considered as a multifaceted construct. Many aspects of context have been identified as potentially influencing the implementation, dissemination, and wide-scale adoption of proven interventions (Greenhalgh, 2005). These include but are not limited to contextual characteristics such as staffing, resources, payment structures, beliefs and long-held routines, habits or practices, perceptions of benefits, and so forth (Jacobs, Weiner, & Bunger, 2014). Central to the development of a conceptual and measurement approach to context are the questions: Are there specific aspects of contexts that are more important than others to understand, identify, and measure? Are contextual considerations global and do they transcend any type of intervention? Are contextual factors of importance intervention-specific? These are important questions for which more research and measurement development are warranted and very much needed.
One approach to understanding context is reflected in the construct of “implementation climate,” which refers to the perceptions and expectations of an organization concerning the rewards and supports that might be derived from a new intervention. As measurement of this construct is in development, it is not clear if one factor, such as support, is more important than another factor, say rewards, for the implementation of an intervention by an organization (Jacobs et al., 2014). A related question is whether perceptions or behaviors of an organization or both drive the “climate” of implementation.
Fixsen and colleagues (2005) have tackled this issue by identifying six core components of interventions that enhance their implementation potential. These include having a clear description of the who, what, when, and where of the intervention; a practical measure of fidelity; a fully operationalized intervention (e.g., what to say and when); and an intervention that has been field tested and revised and which can be contextualized or fit a system of care or organization and be perceived as effective (e.g., it is worth the effort). Despite the identification of these core components, the construct of “context” itself is not fully articulated nor its measurement properties discerned. An intervention that possesses these core components also enhances its dissemination potential for distribution and wide-scale adoption by organizations, as discussed in Chapter 21.
Other approaches for understanding context are embedded in more than 60 implementation theories or conceptual frameworks that have been developed to examine implementation processes (see Chapter 19 for a discussion of select theories). Although critical for guiding translation/implementation efforts, most of these conceptual frameworks do not provide an explicit operational framework for, nor clearly delineate, this notion of context.