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A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations

Implementation Sciencevolume 5, Article number: 14 (2010) | Download Citation

Abstract

Background

There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain.

Methods

We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used) and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation).

Results

Fifty-three of 235 studies (22.5%) were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42) used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation), diffusion of innovations, information overload and social marketing (academic detailing).

Conclusions

There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.

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Background

There is growing interest in the use of cognitive, behavioural, and organisational theories to understand barriers to implementation, to inform the design of interventions to improve professional practice, and to explore the mediating mechanisms and potential moderators of such interventions in the context of rigorous evaluations [1, 2]. However, despite this interest, the extent to which theory has been used in implementation research is unclear. To address this issue, we conducted a systematic review of the use of theory linked to a large systematic review of the effects of guideline dissemination and implementation strategies [3]. Specifically, we were interested in the extent that theory was used in the design of guideline dissemination and implementation interventions, and interpretation of their controlled evaluations.

Methods

We examined the use of theory in studies identified in a systematic review of rigorous evaluations of clinical practice guideline dissemination and implementation strategies. The full methods and results of the systematic review are available elsewhere [3]. Briefly, we searched Medline, EMBASE, Health Star, the Cochrane Controlled Trials Register, and SIGLE (System for Information on Grey Literature in Europe) using a highly sensitive search strategy developed for the Cochrane Effective Practice and Organisation of Care (EPOC) group between 1976 and 1998 [4]. Searches were not restricted by language or publication type. We included cluster and individual randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series that evaluated any guideline dissemination or implementation strategy targeting physicians and that reported an objective measure of provider behavior and/or patient outcome. Two reviewers independently screened the search results and assessed studies against the inclusion criteria. Disagreements were resolved by consensus. The final sample included 285 reports of 235 studies yielding 309 comparisons of guideline dissemination and implementation strategies.

For the purposes of the current study, we identified whether included studies had used a theory to inform the design of an intervention and/or the interpretation of the results. A study was considered to have used a theory if the authors stated that they had done so within the report of the study, preferably with a source reference and/or an explanation of how the theory was proposed to explain the phenomenon to which it had been applied. Where a study described a framework or approach that appeared to be theoretically based, but the authors had not explicitly stated that they had used a theory, a decision was made by two reviewers regarding whether or not the study should be classified as theory-based or not. PD read all papers to identify whether or not they used theory. In cases of uncertainty, papers were considered by a second reviewer (AW), and a consensus was reached about whether or not these studies should be classified as having used theory or not.

We classified all papers using a descriptive framework that considered the level of theory use and the stage at which theory was used (Appendix 1). Level of theory use reflects the intensiveness of use of theory within studies. Studies judged to have used theories were classified within the first two categories ('explicitly theory based'; 'some conceptual basis'). Studies using individual constructs from theories, e.g., knowledge, attitude, self-efficacy, that were not reported within a theoretical framework were classified as 'construct(s) (unrelated to theory)'. In cases where a study employed more than one theory, each instance of theory use was classified separately using the framework. Studies in the first three categories--explicitly theory-based; some conceptual basis; constructs (unrelated to theory)--were further classified according to the stage of the research process at which the theory (or construct) was used. For the purposes of the review, the stage of use categories were treated as being mutually exclusive, i.e., each instance of theory use was assigned to one category only (the first stage of the research process at which the theory has been integrated). This is not to say that studies employing a theory at one stage could not, or did not, use the same theory at any other stage.

Results

Fifty-three of 235 studies (22.5%) were judged to have employed theories of behaviour or behaviour change (see Additional File 1) [5–67]. Of these, fourteen did so explicitly and thirty-nine were considered to have some conceptual basis. A further ten studies used individual constructs from theories only. The majority of studies (n = 42) used only one theory. The maximum number of theories employed by any study was three. The remaining 172 studies were judged to have not employed theories of behaviour or constructs and were not studied further. Brief descriptions of the identified theories are provided in Additional File 2.

Twenty-five different theories representing 66 occasions of theory use were found (Table 1). A small number of theories accounted for the majority of theory use. For example, PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) [68], diffusion of innovation [69], information overload [70], and social marketing (academic detailing) [71] accounted for just over half of all instances of theory use. Fourteen studies used 11 theories explicitly. Only two theories were used explicitly more than once. The PRECEDE theory was also the most commonly employed theory within the review as a whole across all levels of theory use. Thirty-nine studies used sixteen theories within some conceptual basis. For two of the most commonly employed theories (diffusion of innovation, social marketing (academic detailing)) all instances of their use were in this category. Theory was used during the intervention choice/design stage 49 times (74.2%), for process/mediator/moderator analyses seven times (10.6%) and for post hoc explanation 10 times (16.6%).

Table 1 Level of use of theory within studies (including level of theory use)
Full size table

Twenty-four studies used individual constructs from theory (Additional File 1) including knowledge (17 studies), attitude (14 studies), and self-efficacy (two studies). All studies used constructs in process/mediator/moderator analyses (although few of the studies carried out formal tests for the mediating or moderating effects of these variables). The rationale for why specific theories and constructs were used was not apparent in the majority of studies.

Discussion

This study examined the use of theories within a large sample of rigorous evaluations of guideline dissemination and implementation strategies published before 1998. We observed that the minority of studies (22.5%) reported any use of theory, although less than 6% explicitly used theory. Theory was most often used to inform the choice and design of interventions (although this may be in part due to our approach to mutually exclusive coding of the stage of theory use). Theoretical constructs were used in specific process/mediator/moderator analyses. There was poor reporting of the rationale for using specific theories and constructs. In the case of many of the theory-based studies considered in this review, it was difficult to determine the quality of theory use (i.e., the extent to which researchers had employed the theory with fidelity), although this was not one of the objectives of our review.

To our knowledge, this is the first review of the use of theory in implementation intervention studies. The use of studies identified for a rigorous systematic review of guideline dissemination and implementation strategies ensures a comprehensive and representative sample. However, we did not explicitly look for published process evaluations alongside the identified studies that might be more likely to report theoretical considerations. A further meta-synthesis of qualitative studies of general practitioners' experiences and attitudes towards the use of clinical practice guidelines only found 12 studies all published between 1998 and 2006 [72]. The focus of the original review on practice guideline and dissemination studies targeting medically qualified healthcare professionals ensures that we cannot comment on whether the use of theory was greater in dissemination and implementation studies focussing on studies of behaviour change interventions other then practice guidelines or targeting other stakeholders. Further, the timeframe of the searches for the systematic review means that we cannot comment on whether use of theory has increased in studies published since 1998. Although it is only in the last five years that there has been greater discourse about the role of theory in implementation research [2, 73]. We would encourage researchers to treat this as baseline data and replicate this review for studies published since 1998 to explore whether there have been any improvements in the use of theory in implementation research.

PD undertook the first screen of studies to identify whether or not they used theory. This could have introduced some misclassification of studies. We tried to reduce this risk by having a low threshold for consulting AW if PD was in anyway uncertain. It would clearly have been better if two reviewers had independently screened all studies. However, this was not possible given the resources available to us.

It is possible that authors may have used theory in more of the studies, but not reported it in the main study publications due to space constraints or lack of recognition of importance of explicitly outlining the rationale for interventions [1]. The increased emphasis on greater transparency in scientific reporting (for example, publishing study protocols) and the availability of online journals (such as Implementation Science) without space constraints could address this issue.

It was challenging to identify and classify theories given the paucity of description. Some readers may argue whether some of our categories of theory are actual theories. Nevertheless, removing some categories would further reduce the number of studies that provided an explicit rationale for their interventions.

Conclusion

Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators has been advocated to advance of the science of implementation research [1]. This study highlights the lack of use of theory until at least 1998.

It is recommended that researchers conducting theory-based studies give careful consideration to the choice of theory used and develop a clear rationale of how the theory is proposed to operate within the study. Where possible, hypotheses deduced from the theory to design the study should be explicitly examined. Reports of theory-based research should be explicit about all theories used including, where appropriate, citations to original literature relating to the theories. The way in which the theory is proposed to explain that to which it has been applied should be clearly stated, as should methodological detail relating to the way in which the theory has been operationalised and analysed.

Appendix 1. Descriptive framework used to classify studies

Level of use

Explicitly theory-based

Study explicitly stated a theory and provided a direct test of one or more of the hypotheses deduced from a named theory in order to design the study. Hence, it was possible to examine the suitability of the explanation provided by the theory for the intervention to which it had been applied.

Some conceptual basis

Studies classified as having some conceptual basis were those where a theory was judged to have been used within the study, but where the study did not provide a test of any of the hypotheses deduced from the theory in order to design the study. Studies included in this category were those where the authors stated that they had employed a theory within the study, or where the study described a framework or approach that appeared to be theoretically-based and two reviewers (PD, AW) agreed that the study should be considered to be theory-based.

Theoretical construct used

Studies included in this category are those where one or more constructs were examined within the study, but the use of constructs was not embedded within the framework of a theory. Where a construct was referred to within the context of a theory, but was the only component of the theory that was measured and considered, this was considered to be use of the theory within the 'some conceptual basis' category.

Stage of use

Choice/design of intervention

The choice/design category refers to the use of theory to guide the choice of intervention, such as, for example, to understand the reasons for the observed gap between clinical practice and the guideline recommendations, or the use of theory to guide the design of the intervention used to implement the guidelines.

Process/mediators/moderators

This category refers to the use of theories or constructs for the purposes of process assessment, or to explore mediators or moderators of behaviour or the effects of the intervention. Studies classified as using constructs (unrelated to theory) were further classified as 'process,' 'mediator,' or 'moderator'. These further classifications were based on the following descriptions:

Process

Where a construct has been measured once or more (e.g., pre- and post-intervention, or post-intervention in a study group and a control group), but has not been analysed in relation to any other variables measured within the study.

Moderator

Where a construct has been measured once or more and analysed in relation to outcome variables

Mediator

In order to demonstrate the mediating effect of the construct it should be measured pre- and post-intervention (or post-intervention only in both a control and study group) and changes in the construct should be analysed in relation to changes in outcome measures obtained within the study.

Post hoc/explanation

This category refers to retrospective use of theory to explain the results of the study or to stimulate further discussion. Whilst the use of theories within this category might appear to overlap with the previous categories (i.e., a theory might be employed to reflect on the design of the intervention or potential mediators or moderators of its effectiveness), the distinguishing feature of this category is that the theory has been introduced after the intervention has been carried out.

References

  1. 1.

    The Improved linical Effectiveness through Behavioural Research Group (ICEBeRG): Designing theoretically-informed implementation interventions. Implement Sci. 2006, 1: 4-10.1186/1748-5908-1-4.

  2. 2.

    Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N: Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol. 2005, 58: 107-112. 10.1016/j.jclinepi.2004.09.002.

  3. 3.

    Grimshaw JM, Thomas RE, Maclennan G, Fraser C, Ramsay CR, Vale L: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004, 8: iii-72.

  4. 4.

    Bero L, Eccles M, Grilli R, Grimshaw J, Gruen RL, Mayhew A: Cochrane Effective Practice and Organisation of Care Group. About The Cochrane Collaboration (Cochrane Review Groups (CRGs)). 2007, Art. No.: EPOC., 4

  5. 5.

    Anonymous: CCQE-AHCPR guideline criteria project. Building and applying a guideline-based performance measurement system: develop, apply, and evaluate medical review criteria and educational outreach based upon practice guidelines: final project report. 97-N002 - 97-N003, U-97. 1996, Rockville, MD, U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research

  6. 6.

    Avorn J, Soumerai S, Everitt D, Ross-Degnan D, Beers M, Sherman D: A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. New England Journal of Medicine. 1992, 327: 168-173.

  7. 7.

    Banks N, Palmer R, Kane N, Braun O, Feldstein M, Harrington A: Implementation and evaluation of a computerized reminder system in ambulatory care. Proc Ann Symp Comput Applic Med Care. 1988, 12: 753-757.

  8. 8.

    Boissel J, Collet J, Alborini A, Cordel J, Filsnoel J, Gillet J: Education program for general practitioners on breast and cervical cancer screening: a randomized trial. PRE.SA.GF Collaborative Group. Revue d Epidemiologie et de Sante Publique. 1995, 43: 541-547.

  9. 9.

    Caggiula A, Watson J, Kuller L, Olson M, Milas N, Berry M: Cholesterol-lowering intervention program. Effect of the step I diet in community office practices. Archives of Internal Medicine. 1996, 156: 1205-1213. 10.1001/archinte.156.11.1205.

  10. 10.

    Calkins E, Katz L, Karuza J, Wagner A: The small group consensus process for changing physician practices: influenza vaccination. HMO Practice. 1995, 9: 107-110.

  11. 11.

    Callahan C, Hendrie H, Dittus R, Brater D, Hui S, Tierney W: Improving treatment of late life depression in primary care: a randomized clinical trial. Journal of the American Geriatrics Society. 1994, 42: 839-846.

  12. 12.

    Carney P, Dietrich A, Keller A, Landgraf J, O'Connor G: Tools, teamwork, and tenacity: an office system for cancer prevention. Journal of Family Practice. 1992, 35: 388-394.

  13. 13.

    Cohen S, Weinberger M, Hui S, Tierney W, McDonald C: The impact of reading on physicians' nonadherence to recommended standards of medical care. Social Science & Medicine. 1985, 21: 909-914.

  14. 14.

    Costanza M, Zapka J, Harris D, Hosmer D, Barth R, Gaw V: Impact of a physician intervention program to increase breast cancer screening. Cancer Epidemiology, Biomarkers & Prevention. 1992, 1: 581-589.

  15. 15.

    de Burgh S, Mant A, Mattick R, Donnelly N, Hall W, Bridges-Webb C: A controlled trial of educational visiting to improve benzodiazepine prescribing in general practice. Australian Journal of Public Health. 1995, 19: 142-148.

  16. 16.

    Dempsey C: Nursing home-acquired pneumonia: outcomes from a clinical process improvement program. Pharmacotherapy. 1995, 15: 33S-38S.

  17. 17.

    Diwan V, Wahlstrom R, Tomson G, Beermann B, Sterky G, Eriksson B: Effects of 'group detailing' on the prescribing of lipid-lowering drugs: a randomized controlled trial in Swedish primary care. Journal of Clinical Epidemiology. 1995, 48: 705-711. 10.1016/0895-4356(94)00221-B.

  18. 18.

    Elliott T, Murray D, Oken M, Johnson K, Braun B, Elliott B: Improving cancer pain management in communities: main results from a randomized controlled trial. Journal of Pain & Symptom Management. 1997, 13: 191-203.

  19. 19.

    Evans A, Rogers L, Peden JGJ, Seelig C, Layne R, Levine M: Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group. American Journal of Preventive Medicine. 1996, 12: 259-265.

  20. 20.

    Evans D, Mellins R, Lobach K, Ramos-Bonoan C, Pinkett-Heller M, Wiesemann S: Improving care for minority children with asthma: professional education in public health clinics. Pediatrics. 1997, 99: 157-164. 10.1542/peds.99.2.157.

  21. 21.

    Feder G, Griffiths C, Highton C, Eldridge S, Spence M, Southgate L: Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London. BMJ. 1995, 311: 1473-1478.

  22. 22.

    Fender G, Prentice A, Gorst T, Nixon R, Duffy S, Day N: Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia education study. BMJ. 1999, 318: 1246-1250.

  23. 23.

    Fletcher S, Harris R, Gonzalez J, Degnan D, Lannin D, Strecher V: Increasing mammography utilization: a controlled study. Journal of the National Cancer Institute. 1993, 85: 112-120. 10.1093/jnci/85.2.112.

  24. 24.

    Flynn B, Gavin P, Worden J, Ashikaga T, Gautam S, Carpenter J: Community education programs to promote mammography participation in rural New York State. Preventive Medicine. 1997, 26: 102-108. 10.1006/pmed.1997.0110.

  25. 25.

    Gemson D, Ashford A, Dickey L, Raymore S, Roberts J, Ehrlich M: Putting prevention into practice. Impact of a multifaceted physician education program on preventive services in the inner city. Archives of Internal Medicine. 1995, 155: 2210-2216. 10.1001/archinte.155.20.2210.

  26. 26.

    Goldberg H, Wagner E, Fihn S, Martin D, Horowitz C, Christensen D: Putting prevention into practice. Impact of a multifaceted physician education program on preventive services in the inner city. Joint Commission Journal on Quality Improvement. 1998, 24: 130-142.

  27. 27.

    Gortmaker S, Bickford A, Mathewson H, Dumbaugh K, Tirrell P: A successful experiment to reduce unnecessary laboratory use in a community hospital. Medical Care. 1988, 26: 631-642. 10.1097/00005650-198806000-00011.

  28. 28.

    Gorton T, Cranford C, Golden W, Walls R, Pawelak J: Primary care physicians' response to dissemination of practice guidelines. Archives of Family Medicine. 1995, 4: 135-142. 10.1001/archfami.4.2.135.

  29. 29.

    Grady K, Lemkau J, Lee N, Caddell C: Enhancing mammography referral in primary care. Preventive Medicine. 1997, 26: 791-800. 10.1006/pmed.1997.0219.

  30. 30.

    Headrick L, Speroff T, Pelecanos H, Cebul R: Efforts to improve compliance bwith the National Cholesterol Education Program guidelines. Results of a randomized controlled trial. Archives of Internal Medicine. 1992, 152: 2490-2496. 10.1001/archinte.152.12.2490.

  31. 31.

    Herman C, Speroff T, Cebul R: Improving compliance with immunization in the older adult: results of a randomized cohort study. Journal of the American Geriatrics Society. 1994, 42: 1154-1159.

  32. 32.

    Hobbs F, Delaney B, Carson A, Kenkre J: A prospective controlled trial of computerized decision support for lipid management in primary care. Fam Pract. 1996, 13: 133-137. 10.1093/fampra/13.2.133.

  33. 33.

    Hulscher M, van Drenth B, Wouden van der J, Mokkink H, van Weel C, Grol R: Changing preventive practice: a controlled trial on the effects of outreach visits to organise prevention of cardiovascular disease. Quality in Health Care. 1997, 6: 19-24. 10.1136/qshc.6.1.19.

  34. 34.

    Keyserling T, Ammerman A, Davis C, Mok M, Garrett J, Simpson R: A randomized controlled trial of a physician-directed treatment program for low-income patients with high blood cholesterol: the Southeast Cholesterol Project. Archives of Family Medicine. 1997, 6: 135-145. 10.1001/archfami.6.2.135.

  35. 35.

    Leviton L, Goldenberg R, Baker C, Schwartz R, Freda M, Fish L: Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial. JAMA. 1999, 281: 46-52. 10.1001/jama.281.1.46.

  36. 36.

    Lin E, Katon W, Simon G, Von Korff M, Bush T, Rutter C: Achieving guidelines for the treatment of depression in primary care: is physician education enough?. Medical Care. 1997, 35: 831-842. 10.1097/00005650-199708000-00008.

  37. 37.

    Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D: Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. Annals of Internal Medicine. 1993, 119: 36-41.

  38. 38.

    Lobach D, Hammond W: Computerized decision support based on a clinical practice guideline improves compliance with care standards. American Journal of Medicine. 1997, 102: 89-98. 10.1016/S0002-9343(96)00382-8.

  39. 39.

    Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ: Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med. 1989, 321: 1306-1311.

  40. 40.

    Marton K, Tul V, Sox HCJ: Modifying test-ordering behavior in the outpatient medical clinic. A controlled trial of two educational interventions. Archives of Internal Medicine. 1985, 145: 816-821. 10.1001/archinte.145.5.816.

  41. 41.

    Mazzuca S, Vinicor F, Cohen S, Norton J, Fineberg N, Fineberg S: The Diabetes Education Study: a controlled trial of the effects of intensive instruction of internal medicine residents on the management of diabetes mellitus. Journal of General Internal Medicine. 1988, 3: 1-8. 10.1007/BF02595748.

  42. 42.

    McDonald C: Use of a computer to detect and respond to clinical events: its effect on clinician behavior. Annals of Internal Medicine. 1976, 84: 162-167.

  43. 43.

    McDonald C, Wilson G, McCabe G: Physician response to computer reminders. JAMA. 1980, 244: 1579-1581. 10.1001/jama.244.14.1579.

  44. 44.

    McDonald C, Hui S, Smith D, Tierney W, Cohen S, Weinberger M: Reminders to physicians from an introspective computer medical record. A two-year randomized trial. Annals of Internal Medicine. 1984, 100: 130-138.

  45. 45.

    Nalven L, Hofkosh D, Feldman H, Kelleher K: Teaching pediatric residents about early intervention and special education. Journal of Developmental & Behavioral Pediatrics. 1997, 18: 371-376.

  46. 46.

    Nattinger A, Panzer R, Janus J: Improving the utilization of screening mammography in primary care practices. Archives of Internal Medicine. 1989, 149: 2087-2092. 10.1001/archinte.149.9.2087.

  47. 47.

    Ockene J, Adams A, Pbert L, Luippold R, Hebert J, Quirk M: The Physician-Delivered Smoking Intervention Project: factors that determine how much the physician intervenes with smokers. Journal of General Internal Medicine. 1994, 9: 379-384. 10.1007/BF02629517.

  48. 48.

    Onion C: Changes inmedical practice following superficial and deep processing of evidence: a controlled experiment in clinical guideline implementation. PhD. 1997, University of Liverpool

  49. 49.

    Overhage J, Tierney W, Zhou X, McDonald C: A randomized trial of "corollary orders" to prevent errors of omission. Journal of the American Medical Informatics Association. 1997, 4: 364-375.

  50. 50.

    Palmer R, Louis T, Hsu L, Peterson H, Rothrock J, Strain R: A randomized controlled trial of quality assurance in sixteen ambulatory care practices. Medical Care. 1985, 23: 751-770. 10.1097/00005650-198506000-00001.

  51. 51.

    Putnam R, Curry L: Impact of patient care appraisal on physician behaviour in the office setting. CMAJ. 1985, 132: 1025-1029.

  52. 52.

    Raisch D, Bootman J, Larson L, McGhan W: Improving antiulcer agent prescribing in a health maintenance organization. American Journal of Hospital Pharmacy. 1990, 47: 1766-1773.

  53. 53.

    Restuccia J: The effect of concurrent feedback in reducing inappropriate hospital utilization. Medical Care. 1982, 20: 46-62. 10.1097/00005650-198201000-00004.

  54. 54.

    Rogers J, Haring O, Wortman P, Watson R, Goetz J: Medical information systems: assessing impact in the areas of hypertension, obesity and renal disease. Medical Care. 1982, 20: 63-74. 10.1097/00005650-198201000-00005.

  55. 55.

    Sommers L, Sholtz R, Shepherd R, Starkweather D: Physician involvement in quality assurance. Medical Care. 1984, 22: 1115-1138. 10.1097/00005650-198412000-00006.

  56. 56.

    Soumerai SB, Salem-Schatz S, Avorn J, Casteris CS, Ross-Degnan D, Popovsky MA: A controlled trial of educational outreach to improve blood transfusion practice. JAMA. 1993, 270: 961-966. 10.1001/jama.270.8.961.

  57. 57.

    Soumerai S, McLaughlin T, Gurwitz J, Guadagnoli E, Hauptman P, Borbas C: Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA. 1998, 279: 1358-1363. 10.1001/jama.279.17.1358.

  58. 58.

    Steffensen F, Sorensen H, Olesen F: Impact of local evidence-based clinical guidelines--a Danish intervention study. Fam Pract. 1997, 14: 209-215. 10.1093/fampra/14.3.209.

  59. 59.

    Studnicki J, Remmel R, Campbell R, Werner D: The impact of legislatively imposed practice guidelines on cesarean section rates: the Florida experience. American Journal of Medical Quality. 1997, 12: 62-68. 10.1177/0885713X9701200111.

  60. 60.

    Thamer M, Ray N, Henderson S, Rinehart C, Sherman C, Ferguson J: Influence of the NIH Consensus Conference on Helicobacter pylori on physician prescribing among a Medicaid population. Medical Care. 1998, 36: 646-660. 10.1097/00005650-199805000-00005.

  61. 61.

    Turner R, Peden J, O'Brien K: Patient-carried card prompts vs computer-generated prompts to remind private practice physicians to perform health maintenance measures. Archives of Internal Medicine. 1994, 154: 1957-1960. 10.1001/archinte.154.17.1957.

  62. 62.

    Urban N, Taplin S, Taylor V, Peacock S, Anderson G, Conrad D: Community organization to promote breast cancer screening among women ages 50-75. Preventive Medicine. 1995, 24: 477-484. 10.1006/pmed.1995.1076.

  63. 63.

    Weijden Van der T, Grol R, Knottnerus J: Feasibility of a national cholesterol guideline in daily practice. A randomized controlled trial in 20 general practices. International Journal for Quality in Health Care. 1999, 11: 131-137. 10.1093/intqhc/11.2.131.

  64. 64.

    van Essen G, Kuyvenhoven M, de Melker R: Implementing the Dutch College of General Practitioner's guidelines for influenza vaccination: an intervention study. British Journal of General Practice. 1997, 47: 25-29.

  65. 65.

    Vinicor F, Cohen S, Mazzuca S, Moorman N, Wheeler M, Kuebler T: DIABEDS: a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes. Journal of Chronic Diseases. 1987, 40: 345-356. 10.1016/0021-9681(87)90050-6.

  66. 66.

    Vissers M, Hasman A, Linden van der C: Protocol processing system (ProtoVIEW) to support residents at the emergency ward. Computer Methods & Programs in Biomedicine. 1995, 48: 53-58.

  67. 67.

    Watson M: The development, implementation and evaluation of prescribing guidelines in general practice; PhD. 1998, Primary Health Care and Epidemiology, University of Bristol

  68. 68.

    Green LW, Kreuter MW: Health promotion planning: an educational and environmental approach. 1991, Mountain View, California: Mayfield Pub Co, 2

  69. 69.

    Rogers EM: Diffusion of innovations. 1995, New York: The Free Press, 4

  70. 70.

    McDonald CJ: Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med. 1976, 295: 1351-1355.

  71. 71.

    Soumerai SB, Avorn J: Principles of educational outreach ('academic detailing') to improve clinical decision making. JAMA. 1990, 263: 549-556. 10.1001/jama.263.4.549.

  72. 72.

    Carlsen B, Glenton C, Pope C: Thou shalt versus thou shalt not: a meta-synthesis of GPs' attitudes to clinical practice guidelines. Br J Gen Pract. 2007, 57: 971-978. 10.3399/096016407782604820.

  73. 73.

    Oxman AD, Fretheim A, Flottorp S: The OFF theory of research utilization. J Clin Epidemiol. 2005, 58: 113-116. 10.1016/j.jclinepi.2004.10.002.

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Acknowledgements

We thank Vanessa Daigle Lybanon and Martin Eccles for comments on the paper and Kristin Konnyu for help in preparing the manuscript. The study was funded as part of a Chief Scientist Office funded PhD Studentship for Philippa Davies. The Health Services Research Unit is funded through the Chief Scientist Office of the Scottish Government Health Directorates. JG holds a Canada Research Chair in Health Knowledge Transfer and Uptake.

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    Affiliations

    1. Health Services Research Unit, University of Aberdeen, UK

      • Philippa Davies
      •  & Anne E Walker

    2. Clinical Epidemiology Program, Ottawa Health Research Institute and Department of Medicine, University of Ottawa, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa, ON, K1Y 4E9, Canada

      • Jeremy M Grimshaw

    Authors

    1. Search for Philippa Davies in:

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    Corresponding author

    Correspondence to Jeremy M Grimshaw.

    Additional information

    Competing interests

    The authors declare that they have no competing interests.

    Authors' contributions

    PD, AW, JG conceived the study. PD and AW abstracted data from paper. PD wrote first draft of paper. AW and JG commented on drafts of paper. All authors read and approved the final manuscript.

    Philippa Davies, Anne E Walker and Jeremy M Grimshaw contributed equally to this work.

    Electronic supplementary material

    Additional file 1: Use of theories and constructs in studies. Details of the studies that used theories (and constructs), the theories and constructs used and level and stage of use. (DOC 222 KB)

    Additional file 2: Glossary of theories/frameworks used. Brief descriptions of the identified theories and frameworks. (DOC 158 KB)

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    Keywords

    • Implementation Strategy
    • Social Marketing
    • Implementation Research
    • Rigorous Evaluation
    • Interrupted Time Series

    Implementation Science

    ISSN: 1748-5908