Implementation Science

Implementation is defined in the literature as a “specified set of activities designed to put into practice an activity or program of known dimensions.” (106). Implementation is distinct from adoption, defined as “a decision to make full use of an innovation as the best course of action available” (107). Adoption occurs prior to implementation and signifies an intention to implement. The transition between adoption and implementation, particularly in organizations, can be lengthy and complex (108).

There are multiple challenges associated with implementation and numerous examples of programs that were supported by positive results from efficacy trials, adopted and introduced with great enthusiasm, only to fail when programmers attempted to implement them in real world conditions (109).

Although implementation processes can be observed and studied, researchers often face

challenges in measuring determinants of implementation effectiveness (110). The implementation process is complex with a variety of multi-level factors that impact on success, especially in the context of the “messy…under-resourced public health settings around the world.” (111). The gap in understanding about how to move from positive research results (i.e., efficacy trials) to effective practice (i.e., implementation and scale-up) has led some public health researchers to propose a shift in focus away from efficacy trials and towards practice-based implementation research, where the focus would be to identify factors that lead to successful and sustainable scale up of programs and innovations that have high public health impact (111). This area of implementation research has been referred to generally as implementation science, defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and

effectiveness of health services” (112).

Interest in the field of implementation science among healthcare practitioners and public health professionals has grown in the past decade. In 2006, Implementation Science, an open access, peer- reviewed online journal, began publication of articles that specifically focus on increasing knowledge about methods for implementation research and the translation of research into practice. In 2013, the

journal achieved an Impact Factor of 3.47 and ranked 8th _{among 217 journals on health policy worldwide.} One of the reasons for creating a new journal was to provide a “flagship home” for implementation research since previously this research was published across a wide range of journals making it difficult to access (112). Even now, numerous articles continue to be published in several specialty areas that seek to understand the reasons for implementation success and failure and identify factors that influence

implementation effectiveness (12,13,108,110,113-117).

In the past decade, a number of systematic literature reviews were published on implementation research in the health field. Four of these reviews addressed key areas in implementation: best practices in scale-up and sustainability of innovations in health service delivery and organizations; implementation processes and the multi-level influences on implementation effectiveness; the impact of implementation on program outcomes; and the core components needed for effective community-based interventions (106,109,118,119). Although these reviews addressed different questions and different types of programs, all four systematic reviews identified eleven common factors that influence implementation: funding, skill proficiency, work climate, shared decision making, coordination with other agencies, formulation of tasks, leadership, program champion, management support, training and technical assistance (109).

Based on these reviews and other published studies, a number of implementation frameworks, models and theories have been developed and used to guide implementation research (120). One review found that many of these theories had overlapping constructs and each missed some important elements (121). Another review synthesized information from 25 implementation frameworks to construct the Quality Implementation Framework, a “conceptual overview of the critical steps that comprise the process of quality implementation” (122). The most recent systematic review assessed the

comprehensiveness of 49 existing implementation frameworks to determine the types of frameworks in use, the similarities and variations in frameworks across innovations and whether the frameworks addressed all the concepts that could affect implementation of an innovation (123). The review showed that many of the frameworks were innovation-specific and lacked core concepts related to

select an appropriate framework or a combination of frameworks to guide research or project implementation (123).

In an attempt to bring order to the plethora of theories, models and frameworks that have emerged in the implementation science literature, one recent paper proposed a taxonomy with five categories of theoretical approaches to achieve three broad aims (Figure 2) (124).

This structure provides a useful way for implementation researchers to assess gaps in the implementation science literature. In the case of low-income countries, for example, there have been numerous studies that use evaluation frameworks to evaluate implementation of interventions (125). There is, however a significant gap in the literature related to the use of implementation theories in low- income countries to identify and explain what influences implementation outcomes. This study seeks to fill this gap by conducting research using implementation theory to identify organizational determinants of implementation effectiveness in a low-income country context.

CHAPTER 3: METHODOLOGY