Contemporary Trends and Future Directions
Looking ahead, experts have identified a handful of areas needing further research and development. Proctor and colleagues have called for a focus on the later-stage challenges of scaling up and sustaining evidence-supported interventions (Proctor et al., 2015). They identify a need for “conceptual consistency and operational clarity for measuring sustainability, developing evidence about the value of sustaining interventions over time, identifying correlates of sustainability along with strategies for sustaining evidence-supported interventions, advancing the theoretical base and research designs for sustainability research, and advancing the workforce capacity, research culture, and funding mechanisms for this important work” (p. 12). Some of this work has begun, including a framework to characterize modifications to interventions (Wiltsey Stirman, Baumann, & Miller, 2019) and development of the Sustainment Measurement Systems Scale for measuring determinants and outcomes of efforts to sustain prevention programs and initiatives (Palinkas et al., 2020).
Despite a wealth of conceptual implementation guidance, more studies are needed to validate TMF-guided approaches, explain mechanisms of change, and measure outcomes. According to Lewis, Weiner, Stanick, and Fischer (2015), the poor quality and impracticality of existing measures for implementation factors and outcomes have hindered the study of implementation process and strategies that are needed for promoting widespread scale-up of evidence-based care. There is a need for strong and pragmatic measures that are relevant for KUs and feasible for use in practice, and work is needed to identify elements of feasibility or pragmatism from the implementer’s perspective. Notable among this new direction for implementation inquiry is the Society for Implementation Research Collaboration’s Instrument Review Project (Lewis et al., 2015).
Another emerging focal area is the unique features of implementing e-health innovations. As we continue to see growth in e-health technology, we will also need to contend with how best to implement these digital technologies within complex environments. We have a poor understanding of the impact that the process of implementation may have on outcomes of e health interventions (Abbott, Foster, Marin, & Dykes, 2014). Abbott et al. (2014) call for a hybrid approach combining complexity science and IS to inform successful implementation of e-health innovations, and this work is only just beginning to emerge. Implementation TMFs can inform the design and evaluation of e-health innovations to better understand contextual and setting factors, develop more responsive and pragmatic interventions, and report results that are relevant to KUs (Glasgow, Phillips, & Sanchez, 2014; Ross, Stevenson, Lau, & Murray, 2016). Implementation facilitators identified in a recent systematic review on the effectiveness and implementation of technology-based interventions to support health care included aligning studies with organizational incentives, ensuring senior peer endorsement, and integrating the innovation into the clinical workload. Barriers included organizational challenges, and innovation design, content, and technical issues (Keyworth, Armitage, & Tully, 2019).
In a recent article, Powell et al. (2019) outline five priorities for enhancing the impact of implementation strategies. The researchers call for work to enhance methods for designing and tailoring implementation strategies; specify and test mechanisms of change; conduct more effectiveness research on discrete, multi-faceted, and tailored implementation strategies; increase economic evaluations of implementation strategies; and improve the tracking and reporting of implementation strategies. With respect to the latter priority, recent advances are notable, including the publication of StaRI (Pinnock et al., 2017a) and new guidance by the journal Implementation Science for appropriate reporting standards to be submitted alongside manuscripts.
Finally, emerging work is improving understanding of the mediating factors that are associated with implementation success. To date, however, the science of implementation has failed to elaborate on how different implementation strategies work. Improvement in implementation outcomes requires precise, testable theories that describe the causal pathways through which implementation strategies function (Lewis et al., 2018; Lewis et al., 2020). It is the hope of the authors and the Center on KTDRR, which commissioned this report, that this monograph helps to ground such future work in an appreciation of the ties between implementation science and its role within knowledge translation.
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