Implementation Science At A Glance

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U.S. Department of Health & Human Services National Institutes of HealthImplementationScienceat a GlanceA Guide for Cancer Control Practitioners

ForewordSince the National Cancer Institute (NCI) Implementation Science Team was formed within theDivision of Cancer Control and Population Sciences some fifteen years ago, we have seen theimportance of improving the resources needed to support implementation of evidence-basedcancer control interventions. While the team also focuses on efforts to advance the scienceof implementation, and considers the need to integrate implementation science within thebroader field of cancer control and population sciences, we know that unless we support theadoption, implementation, and sustainment of research-tested interventions in communityand clinical settings, we will not move very far in reducing the burden of cancer. To that end,we recognize that the advances in our understanding of implementation processes in recentyears will have greater benefit if communicated in a way that supports and informs theimportant work of cancer control practitioners.This resource, Implementation Science at a Glance, is intended to help practitioners and policymakers gain familiarity with the building blocks of implementation science. Developed byour team and informed by our ongoing collaborations with practitioners and policy makers,Implementation Science at a Glance introduces core implementation science concepts, tools,and resources, packaged in a way that maps to the various stages that practitioners mayfind themselves in as they seek to use evidence-based interventions to meet the needs ofpatients, families, and communities. This resource also includes several case examples ofhow cancer control organizations have gone through the process of exploring evidencebased interventions, preparing for their integration into varied practice settings, activelyimplementing them, and evaluating their impact over time.While we know that the volume of implementation science topics can fill many books, wehope that this resource provides an initial set of valuable and digestible information, alongwith suggested resources for those interested in learning more. In addition, we hope thatthis resource can continue to be refined over time, and that you share your experiences inapplying this to the betterment of your communities and key constituents. Thank you for allyour efforts to address cancer control needs, and thanks in advance for your guidance as weimprove the impact of our research.David A. Chambers, DPhilDeputy Director for Implementation ScienceDivision of Cancer Control and Population SciencesNational Cancer InstituteiImplementation Science at a Glance

AcknowledgmentsThe National Cancer Institute would like to thank the many cancer control practitioners,implementation scientists, and program partners whose thoughtful comments and robustcontributions were integral to the creation of this resource.We particularly thank Amy Allen, Stephenie Kennedy-Rea, and Mary Ellen Conn; Ann-HilaryHeston; Kathryn Braun; and Suzanne Miller Halegoua and Erin Tagai for their contributions tothe case studies.We are grateful to the NCI Implementation Science Team, particularly Margaret Farrell, WynneNorton, and Prajakta Adsul, who provided hours of review and consultation and guidedthis resource to its completion. We note with gratitude the work of Dalena Nguyen, whoseattention to detail and commitment to excellence greatly enhanced the resource’s content andquality, as well.Implementation Science at a Glanceii

Implementation Science at a Glance

Contents1ForewordAcknowledgmentsIntroduction112Who Is This Guide For?How Do I Use This Guide?What Is Implementation Science and Why Is It Important?iii4568101111161718192124AssessEngaging Stakeholders and PartnersConfirming Evidence for an InterventionChoosing an InterventionPrepareMaintaining FidelityAdapting an InterventionImplementDiffusion of InnovationsConsolidated Framework for Implementation ResearchInteractive Systems Framework for Dissemination and ImplementationImplementation StrategiesEvaluate32What to EvaluateHow to EvaluateSustainabilityScaling UpDe-Implementing33Case Studies33353739West Virginia Program to Increase Colorectal Cancer ScreeningKakui Ahi (Light the Way): Patient NavigationTailored Communication for Cervical Cancer RiskLIVESTRONG at the YMCA41Implementation Resources for PractitionersGlossary of TermsReferences252729304345Implementation Science at a Glance

IntroductionImplementation Science at a Glance details how greater use of implementation sciencemethods, models, and approaches can improve cancer control practice.While many effective interventions can reduce cancer risk, incidence, and death, as well asenhance quality of life, they are of no benefit if they cannot be delivered to those in need.Implementation strategies are essential to improve public health. In the face of increasinglydynamic and resource-constrained conditions, implementation science plays a critical role indelivering cancer control practices.Implementation Science at a Glance provides a single, concise summary of key theories, methods,and considerations that support the adoption of evidence-based cancer control interventions.Who Is This Guide For?We wrote this guide for cancer control practitioners who seek an overview of implementationscience that is neither superficial nor overwhelming.Implementation science is a rapidly advancing field. Researchers from many disciplines arestudying and evaluating how evidence-based guidelines, interventions, and programs are putinto practice.How Do I Use This Guide?Implementation Science at a Glance offers a systematic approach to implement your evidencebased, public health program, regardless of where you are in your implementation process.We organized this guide into a four-stage framework: assess, prepare, implement, andevaluate. Each stage poses important questions for practical considerations.ADDITIONAL RESOURCESLook forend of this workbook., which links to a list of additional resources at theWhile this guide is organized into four distinct stages, these components blend and overlapin practice. We have also included four case studies to illustrate how implementation scienceplays out in real-world settings.1Implementation Science at a Glance

ASSESSPREPARE»» Evidence-Based Interventions»» Adaptations»» Stakeholder Engagement and»» FidelityEVALUATEIMPLEMENT»» Sustainability»» Theories»» Scale-Up»» Models»» De-Implementation»» Frameworks»» Return on Investment»» Implementation StrategiesPartnershipsWhat Is Implementation Science andWhy Is It Important?Implementation science is the study of methods to promote the adoption and integrationof evidence-based practices, interventions, and policies into routine health care and publichealth settings to improve the impact on population health.1Implementation science examines how evidence-based programs work in the real world. Byusing implementation science and implementation strategies, you can help bridge the dividebetween research and practice—and bring programs that work to communities in need.Applying implementation science may help you understand how to best use specific strategiesthat have been shown to work in your (or similar) settings.By applying implementation science frameworks and models, you may:»» Reduce program costs»» Improve health outcomes»» Decrease health disparities in your communityImplementation Science at a Glance2

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Engaging Stakeholders and PartnersPeople and place matter. Therefore, it isimportant to seek out stakeholder inputthroughout your process of preparation andimplementation. Consider partnering withresearchers to advance your goals. Creatingmeaningful partnerships will help you:»» Enhance the quality and practicalityStakeholders are people, communities,and organizations that could beaffected by a situation. While internalstakeholders participate throughcoordinating, funding, and supportingimplementation efforts, externalstakeholders contribute views andexperiences in addressing the issuesimportant to them as patients,participants, and members of thecommunity.2,3»» Disseminate your evaluation findingsAsk these questions to identify keystakeholders:»» Better understand your community andits strengths and weaknesses, assets,values, culture, traditions, leaders, andfeelings on change»» Increase the likelihood thatyour intervention will be adoptedand sustained»» Ensure that your intervention isrelevant to stakeholdersof your efforts»» Create relationships with academic centersthat can help sustain your programCreating and leveraging partnerships withresearchers and academic programs canempower communities and create socialchange. Successful research and communitycollaboration can be particularly effective in:»» Fostering a willingness to learn fromone another»» Building community members’involvement in research»» Benefiting all partners withresearch outcomes»» Increasing buy-in for your program5What You Can Do:Engage StakeholdersImplementation Science at a Glance»» Who will be affected by what we aredoing or proposing?»» Who are the relevant officials?»» What are the relevant organizations?»» Who has been involved in similarsituations in the past?»» Who or what is frequentlyassociated with relevant topic areas?Measuring and assessing outcomesimportant to stakeholders can havea significant impact on the adoption,implementation, and sustainment ofevidence-based practices.Remember that stakeholderengagement is necessary throughoutthe entire implementation process.These questions can help guide you asyou move through the assess, prepare,implement, and evaluate stages.Assess

Key QuestionsASSESSPREPAREIMPLEMENTEVALUATE»» Does your selected»» How will stakeholder»» Did you identify and»» How will you adjust yourevidence-basedintervention takestakeholders’ goals andneeds into account?engagement helpachieve programobjectives?»» Does your planinclude stakeholderengagement on keydecisions?»» Can your team engagestakeholders effectively,or will you need to hireexperts?communicate clear rolesfor all stakeholders?»» Did you includeresources forstakeholderengagement in yourimplementation plan?implementation plan inresponse to stakeholderfeedback?»» What outcomes aremost important to eachgroup of stakeholdersand each partner?»» Are you planning toinclude stakeholderengagement as youmonitor, review,and evaluate yourimplementation?Confirming Evidence for an InterventionCancer control practitioners make decisions based on various types of evidence: from moresubjective evidence—such as their direct experience with the populations they work with—tomore objective sources of evidence—including the results of well-designed research studies.In this resource, we use the terms “interventions,” “practices,” and “programs”interchangeably. We generally consider an intervention to be a combination of programcomponents, while a program often groups several interventions together.An evidence-based intervention is a health-focused intervention, practice, policy, or guidelinewith evidence demonstrating its ability to change a health-related behavior or outcome. 4Using evidence-based interventions can not only increase your effectiveness but also helpsave time and resources.The less robust the body of evidence supporting a program’s effectiveness, the moreimportant it is to evaluate the program and share your results.AssessImplementation Science at a Glance6

OBJECTIVESYSTEMATIC REVIEWSSummaries of a body of evidencemade up of multiple studies andrecommendationsWhat You Can Do:Make Sure the Intervention IsEvidence-BasedHow will you know if an interventionis evidence-based? A quick internetsearch may suggest a wide variety ofinterventions, which may or may notbe evidence-based. It is important toevaluate these potential sources.Evaluate existing information on theintervention, and consider:4»» Who created the information?RESEARCH STUDIES»» What types of interventions areIndividual studies that test aspecific intervention»» What methods were used to reviewhighlighted?the evidence?»» What criteria were applied to assessan intervention?PRACTITIONER REPORTSReports, briefs, or evaluations of astrategy in practice»» How current is the evidence?»» Are resources available to help youimplement the intervention?The following resources may provideevidence to support your intervention:EXPERT OPINION/PERSONAL EXPERIENCERecommendations made by crediblegroups or individuals that have notyet been tested»» United States Preventive ServicesTask Force»» NCI Research-Tested InterventionPrograms»» Healthy People Tools and Resources(Healthy People 2020)»» Pew-MacArthur Results FirstSUBJECTIVEInitiative»» The Guide to Community PreventiveServices (The Community Guide)Figure 1. A continuum of evidence to support interventions57Implementation Science at a GlanceAssess

Choosing an InterventionWhile it is important for interventions to be grounded in research and evidence, your programwill only be effective if it “fits” your community population and your resources.When choosing an evidence-based intervention to implement, consider the following:6» Does this intervention fit our community’s demographics, needs, values, and risk factors?» Different interventions will take different amounts of money, labor, and time.–– Does our organization have the capacity and resources this intervention requires?–– Do we have the expertise to implement this intervention?–– Can we engage partners or leverage other resources?» Does this intervention target our overall goal?After selecting your intervention, be wary about recommending adaptations without specificguidance, such as from the original developers. Adapting some aspects of an intervention canlead to a “voltage drop”: a change in expected outcome when an intervention moves from aresearch setting into a real-world context.The following sections can help guide you as you decide to implement an intervention as-is, ifit is a good fit, or to first adapt it to your local community.Populationcharacteristics, needs,values, and preferencesDECISIONMAKINGResources, includingpractitioner expertiseBest availableresearch evidenceFigure 2. Components to consider when selecting an intervention7ADDITIONAL RESOURCESAssessImplementation Science at a Glance8

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Maintaining FidelityFidelity refers to the degree to which an evidence-based intervention is implementedwithout compromising the core components essential for the program’s effectiveness. 8,9Lack of fidelity to the original design or intent makes it difficult to know which version of theintervention was implemented and, therefore, what exactly caused the outcomes.Why is fidelity important?One of the most common reasons that practitioners do not get the results they anticipate isthat they have not properly implemented the practice or program. To avoid this problem, andto get better results, you must understand the importance of implementing the practice orprogram as intended.When interventions implemented with fidelity are compared to those not implemented withfidelity, the difference in effectiveness can be profound. Those implemented with fidelity willhave a greater impact on outcomes than those implemented without fidelity.10The core components of an intervention relate to its:11»» Content – the substance, service, information, or other material that the interventionprovides (e.g., screening tests)»» Delivery – how the intervention is implemented (e.g., setting, format, channels, providers)»» Method – how the intervention will affect participants’ behavior or environmentAdapting an InterventionEvidence-based interventions are not one size fits all. You may have to adapt them to better fitthe population or local conditions.12 Adaptations may involve the addition, deletion, expansion,reduction, or substitution of various intervention components. 8,12,13 Core components to adaptto may include the setting, target audience, delivery, or culture.14Adapting an intervention can help improve health equity. For example, organizations thatserve communities with limited economic resources, such as local health departmentsor safety-net health centers, may adapt some parts of the intervention to leverage theirresources while still working toward similar outcomes.Additionally, sharing information about your adaptations and results can contribute to agreater understanding of the full range of factors that impact implementation in high-needand under-resourced areas.There are many areas in which changes to the original intervention can take place. See Figure 3.11Implementation Science at a GlancePrepare

Before adapting an intervention, considerthe following:SERVICE SETTING»» Are adaptations necessary?TARGET AUDIENCE»» How important is it to your partners toadapt this intervention?MODE OF DELIVERY»» What adaptation would you make?CULTURE»» Do you have the resources to implementthe adapted intervention?CORE COMPONENTSFigure 3. Sources of intervention adaptation14What You Can Do: Balance Fidelity and AdaptationsMaking too many changes toan intervention can reduceits original effectiveness, orworse, introduce unintendedand harmful outcomes.Before making adaptationsto the intervention, youshould think about howthe change to the originalintervention can improvethe fit to your community,setting, or target population,and at the same time,maintain fidelity to the corecomponents of the originalintervention. Think ofpossible adaptations as youwould a green, yellow, orred traffic light: green lightchanges are usually OK tomake; yellow light changesshould be approachedwith caution; and red lightchanges should be avoidedwhen possible.12Prepare»» Usually minor»» Made to increase the reach, receptivity, andparticipation of the communityGREEN LIGHTCHANGES»» May include:–– Program names–– Updated and relevant statistics or health––informationTailored language, pictures, culturalindicators, scenarios, and other content»» Typically add or modify intervention componentsand contents, rather than deleting themYELLOW LIGHTCHANGES»» May include:–– Substituting activities–– Adding activities–– Changing session sequence–– Shifting or expanding the primary––––RED LIGHTCHANGESaudienceChanging the delivery formatChanging who delivers the program»» Changes to core components of the intervention»» May include:–– Changing a health behavior model or––––––––theoryChanging a health topic or behaviorDeleting core componentsCutting the program timelineCutting the program dosageImplementation Science at a Glance12

What You Can Do: Use a Systematic Approach to AdaptationsTry this five-step process when adapting an intervention.12 The more adaptations you make,the more you will need to re-evaluate the effectiveness of the intervention.1ASSESS THE ACCEPTABILITYand importance of adaptationand consider adaptation23MAKE ADAPTATIONSASSESS FITMAKE FINAL DECISIONSabout what and how to adapt45PRETEST AND PILOT TESTFigure 4. A systematic approach to adapt your intervention1213Implementation Science at a GlancePrepare

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There are multiple theories, models, and frameworks frequently used in implementation sciencethat can guide you as you plan, implement, and evaluate your intervention. While theories,models, and frameworks are distinct concepts, this resource uses them interchangeably.Implementation science models provide guidance for understanding how to address the gapbetween identifying an intervention and ensuring its adoption (the research-to-practice gap)and later sustaining the intervention.By spending the time to understand these underlying processes, you will be better preparedto more rapidly move effective programs, practices, or policies into communities.Models can help you understand the logic of how your implementation effort creates animpact and offer clear constructs to measure that impact.Using models can also help you find problem areas at your setting and help guide theselection of implementation strategies. Some models include:» Diffusion of Innovations» Consolidated Framework for Implementation Research» Interactive Systems Framework for Dissemination and ImplementationDiffusion of InnovationsDiffusion of Innovations theory refers to the process by which an innovation is communicatedover time through members of a social network.15 Diffusion consists of four elements:» The innovation, idea, practice, or object that is intended to be spread» Communication or the exchange of messages» A social system, structure, or group of individuals that interact» A process of dissemination or diffusion that occurs over timeThis theory suggests that an innovation, like an evidence-based intervention, will besuccessful or adopted by individuals when the innovation is diffused or distributed throughcommunities.16 Tables 1 and 2 describe the theory further.16Table 1. Concepts of Diffusion of InnovationsConstructs17DefinitionInnovationAn idea, object, or practice that an individual, organization, or community believes is newCommunication channelsThe means of transmitting the new idea from one person to anotherSocial systemsA group of individuals who together adopt the innovationTimeHow long it takes to adopt the innovationImplementation Science at a GlanceImplement

Table 2. Key Attributes Affecting the Speed and Extent of an Innovation’s DiffusionConstructsDefinitionRelative advantageIs the innovation better than what it will replace?CompatibilityDoes the innovation fit with the intended audience?ComplexityIs the innovation easy to use?TestabilityCan you test the innovation before deciding to adopt?ObservabilityAre the results of the innovation observable and easily measurable?Consolidated Frameworkfor Implementation ResearchThe Consolidated Framework forImplementation Research (CFIR) can helpyou identify what aspects of your contextyou should assess during the planningprocess. CFIR has five domains:17Each CFIR domain provides a menu ofkey factors for you to choose from. Thefactors have been linked with the effectiveimplementation of interventions. Examplesinclude, but are not limited to:» Intervention characteristics» Intervention characteristics: relativeadvantage, complexity, cost» Characteristics of individuals involved» Characteristics of individuals involved:» Inner settingself-efficacy, knowledge/beliefs aboutintervention» Outer setting» Process» Inner setting: culture, readiness forimplementation» Outer setting: external policy and incentivesINNER SETTINGCHARACTERISTICS OF INDIVIDUALSONTIE N D)RV TETE APEIN ADBL Y(TA E RA P PHA DE R IPOUTER SETTINGCORECOMPONENTSINT(U E RNA VEDA N TADP T IONEDPE A P)R I TAPH B LER EYCORECOMPONENTS» Process: planning, championsPROCESSFigure 5. Consolidated Framework for Implementation Research17ImplementImplementation Science at a Glance18

Interactive Systems Framework forDissemination and ImplementationThe Interactive Systems Framework (ISF) for Dissemination and Implementation wasdeveloped to address the “how-to” gap between scientifically determining what works andmoving that knowledge into the field for the benefit of the public.18Figure 6 shows the ISF and how it connects three systems to work together for successfuldissemination and implementation. The term “system” is used broadly to describe a set ofactivities that accomplish one of the three identified functions that make dissemination andimplementation possible. These systems are:19» SYNTHESIS AND TRANSLATION SYSTEM – Here, scientific knowledge is distilled intounderstandable and actionable information. Research institutions, universities, and NCIare all institutional examples of this system.» SUPPORT SYSTEM – This system supports the work of the other two systems by buildingthe capacity to carry out prevention activities. Agencies like state health departments orstate cancer control coalitions are often in the role of prevention support for grantees orlocal programs.» DELIVERY SYSTEM – This is where innovations are implemented or where “the rubbermeets the road.” Community-based organizations often function in the role of theprevention delivery system.As depicted in Figure 6, these three systems work together and are embedded within anunderlying context that influences decision making and the adoption of interventions. Theseunderlying conditions include:» Legislation that supports funding for cancer prevention and control» The best available theory and research evidence» The community or organizational context in which interventions are implemented» Macro-level policy factors such as state or federal budget constraints or legislative changesThese underlying considerations are graphically displayed as the climate in which the threesystems exist, and all of these have an impact on successful dissemination and implementation.Each system within the ISF also builds upon or influences the functions of the other twosystems. These relationships and influences are represented by the arrows that connect thesystems to each other.The ISF can offer you a non-exhaustive list of practical considerations and strategies toaddress each of the three systems involved. These strategies will make up the implementationeffort, leading to the population health and implementation outcomes you seek to change.19,2019Implementation Science at a GlanceImplement

FUNDINGDELIVERY SYSTEMMOTIVATIONINNOVATIONSPECIFIC CAPACITYSUPPORT SYSTEMGENERALCAPACITYMOTIVATIONINNOVATIONSPECIFIC SYNTHESIS & TRANSLATION SYSTEMSYNTHESISTRANSLATIONFigure 6. The Interactive Systems Framework for Dissemination and Implementation19ImplementImplementation Science at a Glance20

Implementation StrategiesImplementation strategies are the “how-to” components of interventions. 4,21 Think of these asways to implement evidence-based practices, programs, and policies.Implementation strategies are the essential components of implementation science but areoften not adequately described nor labeled properly. A commonly used definition pitchesthem as “specific methods or techniques used to enhance the adoption, implementation,and sustainability of a public health program or practice.”21 It is important to note that animplementation strategy focuses on improving implementation outcomes such as acceptability,adoption, appropriateness, feasibility, costs, fidelity, penetration, and sustainability.Recent progress has been made to identify and define strategies relevant to the health carecontext, which resulted in a list of seventy-three distinct strategies. 22 These strategies can begrouped into eleven categories as shown in Figure 7. This list provides a good starting point tounderstand the different types of strategies that have been used and tested previously, andalso facilitates the selection of strategies that might be relevant to your practice context.DEVELOP STAKEHOLDERINTERRELATIONSHIPSCONVENE TEAMSUTILIZE FINANCIAL STRATEGIESPRACTICE FACILITATIONENGAGE CONSUMERSPROVIDE INTERACTIVE ASSISTANCEUSE EVALUATION PLANAND INTERACTIVE STRATEGIESSUPPORT PRACTITIONERSCHANGE INFRASTRUCTUREADAPT AND TAILOR TO CONTEXTTRAIN AND EDUCATESTAKEHOLDERSExamples of “Train and EducateStakeholders” Strategies»»»»Conduct educational outreach visitsUse train-the-trainer strategiesCreate a learning collaborativeProvide ongoing consultationFigure 7. Implementation strategy categories and examples2321Implementation Science at a GlanceImplement

What You Can Do: Identify Implementation StrategiesTo maximize the potential of your implementation efforts, it is important that you select strategiesthat fit your local context.Discuss with stakeholders the factors that may influence how your intervention is implemented.Their perspectives can provide important insights about the community and other contexts.Generating a list of these contextual considerations can be an important step to determine whichimplementation strategies best fit the local context. Table 3 illustrates how, once you have this list,you may select strategies to address these determinants.It is rare to use a single strategy during implementation. Selecting multiple strategies to addressmultiple barriers to implementing the intervention may be necessary. You may also need to selectdifferent strategies in different phases of implementation.Methods such as concept mapping and intervention mapping may also help you select relevantimplementation strategies.24Table 3. Selecting Strategies Based on Influential FactorsIdentified FactorImplementation StrategyYOUR DETERMINANTYOUR STRATEGYLack of knowledgeInteractive education sessionsBeliefs or attitudesPeer influence or opinion leadersCommunity-based servicesProcess redesignADDITIONAL RESOURCESImplementImplementation Science at a Glance22

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What to EvaluateIs what we’redoing working?Why or why not?How do we show the valueof the work we do?Evaluation is the systematic collection of information about activities, characteristics, andresults of programs to assess the program and implementation outcomes. 25Depending on what you and your organization prioritize, you can choose specific outcomesyou want to target, define what success would look like, and then evaluate your success.Key OutcomesThere are many outcomes that you can evaluate to assess or determine whether yourimplementation efforts were successful.There are distinct categories of outcomes you can evaluate in implementation science:» Imp

Implementation Science at a Glance, is intended to help practitioners and policy makers gain familiarity with the building blocks of implementation science. Developed by our team and informed by our ongoing collaborations with practitioners and policy makers, Implementation Science at a Glance introduces core implementation science concepts, tools,

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