http://www.implementationscience.com The latest research articles published by Implementation Science 2012-05-16T00:00:00Z Background: Government-sponsored science, technology, and innovation (STI) programs support thesocioeconomic aspects of public policies, in addition to expanding the knowledge base. Forexample, beneficial healthcare services and devices are expected to result from investmentsin research and development (R&D) programs, which assume a causal link to commercialinnovation. Such programs are increasingly held accountable for evidence of impact--that is,innovative goods and services resulting from R&D activity. However, the absence ofcomprehensive models and metrics skews evidence gathering toward bibliometrics aboutresearch outputs (published discoveries), with less focus on transfer metrics aboutdevelopment outputs (patented prototypes) and almost none on econometrics related toproduction outputs (commercial innovations). This disparity is particularly problematic forthe expressed intent of such programs, as most measurable socioeconomic benefits resultfrom the last category of outputs. Methods: This paper proposes a conceptual framework integrating all three knowledge-generatingmethods into a logic model, useful for planning, obtaining, and measuring the intendedbeneficial impacts through the implementation of knowledge in practice. Additionally, theintegration of the Context-Input-Process-Product (CIPP) model of evaluation proactivelybuilds relevance into STI policies and programs while sustaining rigor. Results: The resulting logic model framework explicitly traces the progress of knowledge from inputs,following it through the three knowledge-generating processes and their respectiveknowledge outputs (discovery, invention, innovation), as it generates the intended sociobeneficialimpacts. It is a hybrid model for generating technology-based innovations, wherebest practices in new product development merge with a widely accepted knowledgetranslationapproach. Given the emphasis on evidence-based practice in the medical andhealth fields and "bench to bedside" expectations for knowledge transfer, sponsors andgrantees alike should find the model useful for planning, implementing, and evaluatinginnovation processes. Conclusions: High-cost/high-risk industries like healthcare require the market deployment of technologybasedinnovations to improve domestic society in a global economy. An appropriate balanceof relevance and rigor in research, development, and production is crucial to optimize thereturn on public investment in such programs. The technology-innovation process needs acomprehensive operational model to effectively allocate public funds and thereby deliberatelyand systematically accomplish socioeconomic benefits. http://www.implementationscience.com/content/7/1/44 Vathsala Stone Joseph Lane Implementation Science 2012, null:44 2012-05-16T00:00:00Z doi:10.1186/1748-5908-7-44 /content/figures/1748-5908-7-44-toc.gif Implementation Science 1748-5908 ${item.volume} 44 2012-05-16T00:00:00Z PDF This paper presents the rationale and methods for a randomized controlled evaluation of webbasedtraining in motivational interviewing, goal setting, and behavioral task assignment.Web-based training may be a practical and cost-effective way to address the need for largescalemental health training in evidence-based practice; however, there is a dearth of wellcontrolledoutcome studies of these approaches. For the current trial, 168 mental healthproviders treating post-traumatic stress disorder (PTSD) were assigned to web-based trainingplus supervision, web-based training, or training-as-usual (control). A novel standardizedpatient (SP) assessment was developed and implemented for objective measurement ofchanges in clinical skills, while on-line self-report measures were used for assessing changesin knowledge, perceived self-efficacy, and practice related to cognitive behavioral therapy(CBT) techniques. Eligible participants were all actively involved in mental health treatmentof veterans with PTSD. Study methodology illustrates ways of developing training content,recruiting participants, and assessing knowledge, perceived self-efficacy, and competencybasedoutcomes, and demonstrates the feasibility of conducting prospective studies oftraining efficacy or effectiveness in large healthcare systems. http://www.implementationscience.com/content/7/1/43 Josef Ruzek Raymond Rosen Lisa Marceau Mary Jo Larson Donn Garvert Lauren Smith Anne Stoddard Implementation Science 2012, null:43 2012-05-14T00:00:00Z doi:10.1186/1748-5908-7-43 /content/figures/1748-5908-7-43-toc.gif Implementation Science 1748-5908 ${item.volume} 43 2012-05-14T00:00:00Z PDF Background: Clinical practice guidelines are developed to improve the quality of healthcare. However,clinical guidelines may contribute to health inequities experienced by disadvantaged groups.This study uses an equity lens developed by the International Clinical Epidemiology Network(INCLEN) to examine how well clinical guidelines address inequities experienced byindividuals with intellectual disabilities. Methods: Nine health problems relevant to the health inequities experienced by persons withintellectual disabilities were selected. Clinical guidelines on these disorders were identifiedfrom across the world. The INCLEN equity lens was used as the basis for a purposedesigned,semistructured data collection tool. Two raters independently examined eachguideline and completed the data collection tool. The data extracted by each rater werediscussed at a research group consensus conference and agreement was reached on a finalequity lens rating for each guideline. Results: Thirty-six guidelines were identified, one of which (2.8%) explicitly excluded persons withintellectual disabilities. Of the remaining 35, six (17.1%) met the first criterion of the equitylens, identifying persons with intellectual disabilities at high risk for the specific healthproblem. Eight guidelines (22.9%) contained any content on intellectual disabilities. Sixguidelines addressed the fourth equity lens criterion, by giving specific consideration to thebarriers to implementation of the guideline in disadvantaged populations. There were noguidelines that addressed the second, third, and fifth equity lens criteria. Conclusions: The equity lens is a useful tool to systematically examine whether clinical guidelines addressthe health needs and inequities experienced by disadvantaged groups. Clinical guidelines arelikely to further widen the health inequities experienced by persons with intellectualdisabilities, and other disadvantaged groups, by being preferentially advantageous to thegeneral population. There is a need to systematically incorporate methods to considerdisadvantaged population groups into the processes used to develop clinical guidelines. http://www.implementationscience.com/content/7/1/42 Lindsay Mizen Marjorie Macfie Linda Findlay Sally-Ann Cooper Craig Melville Implementation Science 2012, null:42 2012-05-11T00:00:00Z doi:10.1186/1748-5908-7-42 /content/figures/1748-5908-7-42-toc.gif Implementation Science 1748-5908 ${item.volume} 42 2012-05-11T00:00:00Z PDF Background: Since 2003, the United States National Institutes of Health (NIH) has sought to restructurethe clinical research enterprise in the United States by promoting collaborative researchpartnerships between academically-based investigators and community-based physicians. Byincreasing community-based provider participation in research (CBPPR), the NIH seeks toadvance the science of discovery by conducting research in clinical settings where mostpeople get their care, and accelerate the translation of research results into everyday clinicalpractice. Although CBPPR is seen as a promising strategy for promoting the use of evidencebasedclinical services in community practice settings, few empirical studies have examinedthe organizational factors that facilitate or hinder the implementation of CBPPR. The purposeof this study is to explore the organizational start-up and early implementation of CBPPR incommunity-based practice. Methods: We used longitudinal, case study research methods and an organizational model ofinnovation implementation to theoretically guide our study. Our sample consisted of threecommunity practice settings that recently joined the National Cancer Institute's (NCI)Community Clinical Oncology Program (CCOP) in the United States. Data were gatheredthrough site visits, telephone interviews, and archival documents from January 2008 to May2011. Results: The organizational model for innovation implementation was useful in identifying andinvestigating the organizational factors influencing start-up and early implementation ofCBPPR in CCOP organizations. In general, the three CCOP organizations varied in the extentto which they achieved consistency in CBPPR over time and across physicians. All threeCCOP organizations demonstrated mixed levels of organizational readiness for change.Hospital management support and resource availability were limited across CCOPorganizations early on, although they improved in one CCOP organization. As a result ofweak IPPs, all three CCOPs created a weak implementation climate. Patient accrual becameconcentrated over time among those groups of physicians for whom CBPPR exhibited astrong innovation-values fit. Several external factors influenced innovation use, complicatingand enriching our intra-organizational model of innovation implementation. Conclusion: Our results contribute to the limited body of research on the implementation of CBPPR. Theyinform policy discussions about increasing and sustaining community clinician involvementin clinical research and expand on theory about organizational determinants ofimplementation effectiveness. http://www.implementationscience.com/content/7/1/41 Randall Teal Dawn Bergmire Matthew Johnston Bryan Weiner Implementation Science 2012, null:41 2012-05-08T00:00:00Z doi:10.1186/1748-5908-7-41 /content/figures/1748-5908-7-41-toc.gif Implementation Science 1748-5908 ${item.volume} 41 2012-05-08T00:00:00Z PDF Background: To address the problem of translation from research-based evidence to routine healthcare practice, the Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire, and Lincolnshire (CLAHRC-NDL) was funded by the National Institute for Health Research as one of nine CLAHRCs across England. This paper outlines the underlying theory and its application that CLAHRC-NDL has adopted, as a case example that might be generalised to practice outside the CLAHRC, in comparison to alternative models of implementation.DiscussionConventional approaches to health research frequently generate evidence in isolation from the environment in which it is intended for use. The premise of the CLAHRC-NDL model is that barriers to implementation can be overcome if knowledge is co-produced by academic and clinical service staff, taking account of the organisational context in which it is to be applied. This approach is founded on organisational learning theory, recognising that change is a social and political phenomenon. Evidence is produced in real time, taking full account of the environment in which it is to be implemented. To support this process, senior health service staff are seconded to the CLAHRC as 'diffusion fellows' (DFs) to actively bridge the research to practice gap by being a full member of both the research team and their area of clinical practice. To facilitate innovation and embed change in the local health community, existing communities of practice are enhanced and new ones are fostered around specific themes. Our approach has been adopted by 16 clinical research studies in the areas of mental health, children and young people, primary care, and stroke rehabilitation.SummaryThe CLAHRC-NDL model of implementation applies organisational learning theory by addressing the social and situational barriers and enablers to implementation, and adopting a philosophy of co-production. Two key mechanisms for translation of innovation have been utilised: DFs, to actively bridge the research to practice gap, and communities of practice, to underpin and sustain improvements in healthcare. The model shows promising results in putting research into practice, which may be transferable to other healthcare contexts. http://www.implementationscience.com/content/7/1/40 Emma Rowley Richard Morriss Graeme Currie Justine Schneider Implementation Science 2012, null:40 2012-05-03T00:00:00Z doi:10.1186/1748-5908-7-40 /content/figures/1748-5908-7-40-toc.gif Implementation Science 1748-5908 ${item.volume} 40 2012-05-03T00:00:00Z PDF Background: A growing body of work on knowledge translation (KT) reveals significant gaps betweenwhat is known to improve health, and what is done to improve health. The literature andpractice also suggest that KT has the potential to narrow those gaps, leading to moreevidence-informed healthcare. In response, Canadian health research funders and agencieshave made KT a priority. This article describes how one funding agency determined its KTrole and in the process developed a model that other agencies could use when considering KTprograms.DiscussionWhile 'excellence' is an important criterion by which to evaluate and fund health research, italone does not ensure relevance to societal health priorities. There is increased demand forreturn on investments in health research in the form of societal and health system benefits.Canadian health research funding agencies are responding to these demands by emphasizingrelevance as a funding criterion and supporting researchers and research users to use theevidence generated.Based on recommendations from the literature, an environmental scan, broad circulation ofan iterative discussion paper, and an expert working group process, our agency developed aplan to maximize our role in KT. Key to the process was development of a model comprisingfive key functional areas that together create the conditions for effective KT: advancing KTscience; building KT capacity; managing KT projects; funding KT activities; and advocatingfor KT. Observations made during the planning process of relevance to the KT enterprise are:the importance of delineating KT and communications, and information and knowledge;determining responsibility for KT; supporting implementation and evaluation; and promotingthe message that both research and KT take time to realize results.SummaryChallenges exist in fulfilling expectations that research evidence results in beneficial impactsfor society. However, health agencies are well placed to help maximize the use of evidence inhealth practice and policy. We propose five key functional areas of KT for health agencies,and encourage partnerships and discussion to advance the field. http://www.implementationscience.com/content/7/1/39 Bev Holmes Gayle Scarrow Megan Schellenberg Implementation Science 2012, null:39 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-39 /content/figures/1748-5908-7-39-toc.gif Implementation Science 1748-5908 ${item.volume} 39 2012-04-24T00:00:00Z PDF Background: There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. Methods: The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? Results: A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. Conclusions: We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process. http://www.implementationscience.com/content/7/1/38 Simon French Sally Green Denise O'Connor Joanne McKenzie Jill Francis Susan Michie Rachelle Buchbinder Peter Schattner Neil Spike Jeremy Grimshaw Implementation Science 2012, null:38 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-38 /content/figures/1748-5908-7-38-toc.gif Implementation Science 1748-5908 ${item.volume} 38 2012-04-24T00:00:00Z PDF Background: An integrative theoretical framework, developed for cross-disciplinary implementation and other behaviour change research, has been applied across a wide range of clinical situations. This study tests the validity of this framework. Methods: Validity was investigated by behavioural experts sorting 112 unique theoretical constructs using closed and open sort tasks. The extent of replication was tested by Discriminant Content Validation and Fuzzy Cluster Analysis. Results: There was good support for a refinement of the framework comprising 14 domains of theoretical constructs (average silhouette value 0.29): 'Knowledge', 'Skills', 'Social/Professional Role and Identity', 'Beliefs about Capabilities', 'Optimism', 'Beliefs about Consequences', 'Reinforcement', 'Intentions', 'Goals', 'Memory, Attention and Decision Processes', 'Environmental Context and Resources', 'Social Influences', 'Emotions', and 'Behavioural Regulation'. Conclusions: The refined Theoretical Domains Framework has a strengthened empirical base and provides a method for theoretically assessing implementation problems, as well as professional and other health-related behaviours as a basis for intervention development. http://www.implementationscience.com/content/7/1/37 James Cane Denise O'Connor Susan Michie Implementation Science 2012, null:37 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-37 /content/figures/1748-5908-7-37-toc.gif Implementation Science 1748-5908 ${item.volume} 37 2012-04-24T00:00:00Z PDF Background: Around 5,000 miscarriages and 300 perinatal deaths per year result from maternal smoking in the United Kingdom. In the northeast of England, 22% of women smoke at delivery compared to 14% nationally. Midwives have designated responsibilities to help pregnant women stop smoking. We aimed to assess perceived implementation difficulties regarding midwives' roles in smoking cessation in pregnancy. Methods: A self-completed, anonymous survey was sent to all midwives in northeast England (n = 1,358) that explores the theoretical explanations for implementation difficulties of four behaviours recommended in the National Institute for Health and Clinical Excellence (NICE) guidance: (a) asking a pregnant woman about her smoking behaviour, (b) referring to the stop-smoking service, (c) giving advice about smoking behaviour, and (d) using a carbon monoxide monitor. Questions covering Michie et al.'s theoretical domain framework (TDF), describing 11 domains of hypothesised behavioural determinants (i.e., 'knowledge', 'skills', 'social/professional role/identity', 'beliefs about capabilities', 'beliefs about consequences', 'motivation and goals', 'memory', 'attention and decision processes', 'environmental context and resources', 'social influences', 'emotion', and 'self-regulation/action planning'), were used to describe perceived implementation difficulties, predict self-reported implementation behaviours, and explore relationships with demographic and professional variables. Results: The overall response rate was 43% (n = 589). The number of questionnaires analysed was 364, following removal of the delivery-unit midwives, who are not directly involved in providing smoking-cessation services. Participants reported few implementation difficulties and high levels of motivation for all four behaviours and identified smoking-cessation work with their role. Midwives were less certain about the consequences of, and the environmental context and resources available for, engaging in this work relative to other TDF domains. All domains were highly correlated. A principal component analysis showed that a single factor ('propensity to act'), derived from all domains, explained 66% of variance in theoretical domain measures. The 'propensity to act' was predictive of the self-reported behaviour 'Refer all women who smoke......to NHS Stop Smoking Services' and mediated the relationship between demographic variables, such as midwives' main place of work, and behaviour. Conclusions: Our findings advance understanding of what facilitates and inhibits midwives' guideline implementation behaviours in relation to smoking cessation and will inform the development of current practice and new interventions. Using the TDF as a self-completion questionnaire is innovative, and this study supports previous research that the TDF is an appropriate tool to understand the behaviour of healthcare professionals. http://www.implementationscience.com/content/7/1/36 Jane Beenstock Falko Sniehotta Martin White Ruth Bell Eugene Milne Vera Araujo-Soares Implementation Science 2012, null:36 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-36 /content/figures/1748-5908-7-36-toc.gif Implementation Science 1748-5908 ${item.volume} 36 2012-04-24T00:00:00Z PDF Behaviour change is key to increasing the uptake of evidence into healthcare practice. Designing behaviour-change interventions first requires problem analysis, ideally informed by theory. Yet the large number of partly overlapping theories of behaviour makes it difficult to select the most appropriate theory. The need for an overarching theoretical framework of behaviour change was addressed in research in which 128 explanatory constructs from 33 theories of behaviour were identified and grouped. The resulting Theoretical Domains Framework (TDF) appears to be a helpful basis for investigating implementation problems. Research groups in several countries have conducted TDF-based studies. It seems timely to bring together the experience of these teams in a thematic series to demonstrate further applications and to report key developments. This overview article describes the TDF, provides a brief critique of the framework, and introduces this thematic series.In a brief review to assess the extent of TDF-based research, we identified 133 papers that cite the framework. Of these, 17 used the TDF as the basis for empirical studies to explore health professionals' behaviour. The identified papers provide evidence of the impact of the TDF on implementation research. Two major strengths of the framework are its theoretical coverage and its capacity to elicit beliefs that could signify key mediators of behaviour change. The TDF provides a useful conceptual basis for assessing implementation problems, designing interventions to enhance healthcare practice, and understanding behaviour-change processes. We discuss limitations and research challenges and introduce papers in this series. http://www.implementationscience.com/content/7/1/35 Jill Francis Denise O'Connor Janet Curran Implementation Science 2012, null:35 2012-04-24T00:00:00Z doi:10.1186/1748-5908-7-35 /content/figures/1748-5908-7-35-toc.gif Implementation Science 1748-5908 ${item.volume} 35 2012-04-24T00:00:00Z PDF