Table 4 Recommendations to advance evidence and implementation science
From: Revisiting concepts of evidence in implementation science
Domain | Recommendation | Rationale | Potential solutions | Actorsa |
|---|---|---|---|---|
Evidence base | 1. Use an evidence typology rather than an evidence hierarchy | The choice and strength of study design is dependent on the research questions and setting, particularly the context for the study | • Identify and implement alternatives and modifications (e.g., natural experiments; interrupted time series, adaptive designs, systems modeling, mixed methods, participatory modeling, multi-level pragmatic trials, policy implementation) to the efficacy RCT • Match the research question with the study design, balanced with considerations of rigor and pragmatism | • Funders • Researchers • Policy makersb |
2. Increase focus on practice-based and community-defined evidence | Much of the existing evidence base is developed by university researchers in high-resource settings | • Strike a better balance between explicit (research) knowledge and tacit (lived experience) knowledge • Conduct practice-based research, particularly for low-resource settings and settings that face numerous structural and social impediments to health and well-being • Engage multi-level stakeholders and practice-based partners in substantive and meaningful ways in the context of and beyond research and research grants, including identifying stakeholder prioritized issues and outcomes | • Funders • Researchers • Practitioners | |
3. Speed the pace of evidence development | The research enterprise (review processes, conducting research, publishing and disseminating research) moves slowly, often much more slowly than practice and policy | • Conduct rapid reviews/living syntheses (so-called living meta-analyses) • Use rapid methods, designs, analyses • Bring together practitioners, researchers, community members, and policy makers to identify promising innovations in need of evaluation (including realist evaluation) • Reorient funding mechanisms to be more adaptive and flexible, and to support rapid-cycle evaluation (e.g., quick addition of measures to existing studies) | • Funders • Researchers • Practitioners • Policy makers | |
4. Address potential biases in implementation | Biases are often present in small scale studies that are not taken into account in larger studies or studies do not account for context | • Reconfigure small scale studies to account for generalizability biases (bias in intervention intensity, implementation support, delivery agent, target audience, duration, setting, measurement, resources required, directional conclusion, outcome) • Specify which communities, organizations, staff, and individuals are included and which are excluded and why at multiple levels and stages of a study, and their characteristics | • Researchers • Practitioners | |
Context | 5. Document ways in which context drives implementation | When context is taken into account in research, study findings are more applicable to different populations, settings, and time periods | • Employ new theories, models, and frameworks (e.g., Normalization Process Theory) to understand context, including ones outside the field of implementation science that address social and community context in depth • Use mixed-methods and user-centered design approaches to study context, particularly at organizational, community, policy, and society levels • Define and apply contextual variables that lead to effective replication and may facilitate sustainability and scale-up • Investigate mechanisms of implementation strategies to enable greater generalization into different contexts | • Researchers • Practitioners |
6. Further develop pragmatic methods and measures to assess and address context | Pragmatic methods show promise by engaging multiple stakeholders, heterogeneous settings, and real-world conditions | • Make use of pragmatic measures (e.g., those that are user-friendly, sensitive to change, low cost, important to practitioners) • Apply pragmatic tools such as PRECIS-2 PS • Make use of guidelines to develop and evaluate complex interventions (e.g., the MRC guidance) | • Researchers • Practitioners | |
7. Apply lessons from LMICs and other low-resource settings | There are particular challenges and opportunities for development of new evidence in LMICs | • Document and seek to replicate conditions under which innovations emerge and thrive • Apply principles of transportability research across different countries and diverse settings that have a range of capacity, resources, and infrastructure • Apply findings from task shifting research | • Funders • Researchers • Practitioners | |
8. Further develop the science of adaptation | The process of modifying and refining EBIs and implementation strategies has not been well documented and understood | • Apply tools such as FRAME, FRAME IS, and other emerging coding systems to address and study key considerations in adaptation (e.g., when and how adaptations occur, whether planned or unplanned, their impact) • Use adaptation process models to guide cultural and contextual adaptations to address fit and dynamic context, while also remaining true to the original function • Better link implementation with the field of cultural adaptation to enhance the reach and equity of EBIs • Investigate ways of guiding adaptations that center on equity and investigate contexts in which EBIs may be adapted successfully versus when new EBIs may need to be developed to address specific health issues, historical experiences of populations, or sociocultural contexts | • Funders • Researchers • Practitioners | |
Health equity | 9. Place greater emphasis on social determinants and structural factors that shape health inequities and inequitable implementation | Much of the evidence base is narrowly developed on diseases and risk behaviors, neglecting root and structural causes; many EBIs have not been evaluated among populations and settings experiencing inequities | • Show the value and impact of interventions that address health equity, root causes, and social determinants • Include structural racism and other equity relevant structural factors (economic inequality, stigma) in measures, frameworks, and models in assessing context and barriers/facilitators to implementation, or in planning for implementation • Map the pathways and mechanism through which upstream interventions operate to impact more proximal downstream factors and ultimately health inequities • Identify interventions that consider social context, prioritize community priorities, and build off existing community strengths/assets | • Funders • Researchers • Practitioners |
10. Integrate equity-relevant methods and measures | Equity has been under-addressed in implementation science and should be a feature of all studies | • Develop and apply models and frameworks that place a central focus on equity in both determinants and outcomes • Determine how well existing implementation strategies apply to a range of diverse populations and settings facing social and health inequities • Explicitly measure and track health equity, health inequities, and their determinants (structural racism) and how they are reduced or exacerbated by EBIs/strategies • Consider and track differential indicators of implementation (e.g., reach, feasibility, acceptability, appropriateness, adoption, implementation, sustainability) across different social groups (e.g., by race, ethnicity, age, gender, sexual orientation) or settings (e.g., urban, rural) • Prioritize equity indicators and determinants based on community and stakeholder input. | • Funders • Researchers • Practitioners | |
Policy implementation | 11. Expand the scope of policy implementation research | Despite its potential impact, there are many gaps in policy implementation research | • Focus on structural interventions and community-defined interventions and policies and consider both health and social policies (that have health impacts) • Determine ways in which to build equity in all policies • Study how the meaning of evidence and processes are shaped via the interactions between policy implementation and practice change • Develop reliable and valid measures for policy implementation | • Funders • Researchers • Policy makers |
12. Apply concepts from other fields to policy implementation research | Other disciplines (e.g., political science, law, sociology) have a long history of policy research that is relevant to implementation scientists | • Apply theories from other fields to policy implementation in health • Use principles of team science to build new and vibrant transdisciplinary teams • Seek to understand the culture, norms, processes, and context of policy makers | • Researchers • Policy makers | |
13. Expand knowledge of the spread of policy-relevant information | For effective dissemination of policy information, tailoring of messages and channels is needed | • Compare different messaging strategies for policy makers (e.g., social good versus cost-savings, return on investments) • Expand knowledge of the role of social media in policy implementation research (e.g., disseminating research, understanding the socio-political environment) • Expand knowledge on how to combat mis- and dis-information in policy implementation | • Researchers • Policy makers | |
Audience differences | 14. Apply principles of audience segmentation and human-centered or user-centered design | Implementation research can be informed by audience segmentation principles, which were developed outside the health sector | • Select and describe characteristics of discrete audiences for dissemination and implementation • Engage community members/patients as a core audience with a commitment to return research evidence to those affected • Develop messages and channels of high salience to various stakeholders (e.g., visually appealing, brief summaries for policy makers) • Apply audience segmentation approaches from the marketing world | • Researchers • Practitioners |
15. Apply principles of framing and other communication strategies | Individuals interpret the same data in different ways depending on the mental model through which they perceive information | • Compare the effectiveness of gain versus loss framing to various audiences • Identify ways in which framing in policy advocacy can be applied to implementation science • Apply principles of narrative communication to framing to turn scientific evidence into meaningful narratives for specific audiences | • Funders • Researchers • Policy makers |