16.1.1 Determinants Frameworks

Determinants frameworks identify the range of factors, operating at different levels within the healthcare system, that may influence the adoption and implementation of evidence‐based interventions, as well as the effectiveness of these interventions in practice (Damschroder, 2020). The factors represent a set of characteristics, inherent in the context of implementation, that enable (i.e. facilitators) or hinder (i.e. barriers) the use of evidence‐based interventions in practice. The factors manifest at the levels of:

• Clients: Clients are the recipients or end users of the evidence‐based interventions. Multiple client characteristics affect their uptake, engagement and enactment of evidence‐based health interventions as detailed in Chapters 5, 9, 12, and 13. Of relevance are practical problems associated with access to the evidence‐based interventions in practice (e.g. transportation, time at which the intervention is offered); clients’ experience of the health problem and general health condition (e.g. level of severity at which the problem is experienced, presence of comorbid conditions); clients’ motivation to seek treatment; and clients’ beliefs about the health problem and its treatment that may shape their acceptability of the evidence‐based interventions (Harvey & Gumport, 2015; Nilsen & Bernhardsson, 2019; Pfadenhaver et al., 2017).
  

  Clients seen in practice may experience the health problem and present with sociodemographic and health characteristics in a way that differs, to various extent, from those reported for clients who participated in research studies that demonstrated the effectiveness of the interventions. The differences in the experience of the health problem and characteristics between the two cohorts of clients raise concerns about the applicability of the evidence, generated in research, to practice (as mentioned in Chapter 14). The limited relevance of evidence to practice can potentially influence the adoption of the evidence‐based intervention in practice.

  
  

  Clients seen in practice may be aware of the evidence‐based intervention and its benefits. Therefore, they demand or seek it, which motivates the implementation initiatives aimed to make the evidence‐based intervention available and accessible in the local practice. Alternatively, clients may perceive an evidence‐based intervention as unacceptable, and consequently decline its uptake when offered in the local practice setting.

  
  
• Health professionals: Health professionals are the users of evidence‐based interventions. Personal attributes and professional qualifications, mentioned in Chapters 5, 8, 9, and 13, affect the adoption and delivery of evidence‐based interventions in practice. Health professionals vary in their underlying philosophy of care and attitudes toward change in practice, which shape their perceptions of evidence‐based interventions. In general, health professionals value a client‐centered approach to care, characterized by flexibility and individualization of treatment. In health professionals’ opinion, these features are not afforded in evidence‐based interventions, limiting their acceptability and adoption of the interventions. In addition, health professionals may not have the theoretical knowledge underlying the evidence‐based interventions and the competence or sense of self‐efficacy to deliver the evidence‐based interventions, which reduce their enthusiasm for adopting the interventions (Harvey & Gumport, 2015; Lau et al., 2016).
  
• Evidence‐based interventions: The features of the evidence‐based interventions and the evidence supporting their effectiveness, influence their adoption, implementation, and effectiveness in practice. The specific features of interventions of concern include their complexity, applicability, and relevance to the local practice context; clarity and practicality of its protocol; customization; and cost (Lau et al., 2016). Evidence‐based interventions that are complex, involving multiple components that are delivered by interprofessional team members, following a standardized or fixed protocol that contains limited practical guidance, are difficult and expensive to carry out. Furthermore, the supportive evidence of many health interventions indicates that, although the interventions had statistically significant effects, the observed effects are often of a small size and not maintained over time. The effects are estimated and thus applicable to clients who experience the health problem, but do not have comorbid conditions, limiting the relevance of the evidence‐based intervention to all subgroups of clients seen in practice (Hartveit et al., 2019; Harvey & Gumport, 2015). Evidence‐based interventions that are complex, costly, and provide benefits comparable to those achieved with usual care may not be adopted.
  
• Context: The context in which the evidence‐based intervention is implemented is influential. The contextual factors operate at different levels, including the local practice setting (e.g. clinic, hospital, community center), the organization or the community, and the healthcare system or society at large. The factors may directly or interactively affect the adoption, implementation, and effectiveness of evidence‐based interventions as discussed in Chapters 5, 9, and 13. Contextual factors that are commonly identified include: communication and collaboration among health professionals; peer relationships or pressure; availability of human and material resources, in an adequate amount required to implement an intervention; culture prevalent in the practice setting, organization, community, or society (e.g. presence of commonly held values and beliefs); readiness for change, that is, decision‐makers and health professionals’ collective confidence to implement change and commitment to pursue a course of action leading to successful change (Teal et al., 2012); and practice setting or organization climate, that is, the perception shared among health professionals of the extent to which implementation of the evidence‐based intervention is supported and expected (DiMartino et al., 2018; Harvey & Gumport, 2015; Lau et al., 2016; Nilsen & Bernhardsson, 2019; Pfadenhaver et al., 2017).
  
• Strategies: Strategies used to facilitate the implementation of evidence‐based interventions can influence their adoption and delivery. In addition to the specific strategies used to disseminate an intervention (see Section 16.1.2), the material or instrumental (e.g. increasing availability and access to resources), social (e.g. strong leadership making necessary changes in policies and practice guidelines), and financial support influence the success of the implementation initiatives (DiMartino et al., 2018; Lau et al., 2016; Nilsen, 2015; Pfadenhaver et al., 2017).

16.1.2 Process Frameworks

Process frameworks specify the phases or stages and steps to plan and execute the implementation initiatives (Damschroder, 2020; Nilsen, 2015). The process aims to facilitate change in practice (i.e. adoption and use of evidence‐based interventions) at the individual (i.e. health professionals) and the collective (i.e. healthcare team members, support staff, decision‐makers) levels (Hartveit et al., 2019). Despite some variability in its description, the implementation process comprises two main stages: pre‐implementation and implementation (Moullin et al., 2015). Recent emphasis on the importance of accounting for the features of the local context in which the evidence‐based intervention is implemented, contributed to the embracement of a collaborative process. In a collaborative process, stakeholder groups encompassing clients, health professionals, and decision‐makers are engaged in preparing for and monitoring the implementation of evidence‐based interventions (Aarons et al., 2017; Glandon et al., 2017; Pfadenhaver et al., 2017; Wandersman et al., 2016). The steps of this collaborative approach are reviewed next, and practice guidance for carrying them out is presented in Section 16.2.

16.1.3 Evaluation Frameworks

Evaluation frameworks delineate the outcomes expected of the implementation initiatives. The outcomes form the basis for designing research studies to evaluate the success of the implementation initiatives (Damschroder, 2020; Nilsen, 2015). Generally, two sets of outcomes are specified.

The first set entails outcomes expected as a result of the implementation strategies aimed to promote the adoption of the evidence‐based intervention in practice. These outcomes manifest as changes in health professionals’ perceptions (e.g. acceptability) of the evidence‐based intervention, knowledge, and competence in providing the intervention, adoption (i.e. actual use of the intervention in practice), and appropriate delivery (i.e. with fidelity) of the intervention in daily practice. Changes in these outcomes take place and are assessed at the health professionals’ individual level and at the collective level. The collective level is often represented in the number or percentage of health professionals implementing the evidence‐based intervention within the local practice setting.

The second set of outcomes reflects the benefits, to clients, anticipated of the evidence‐based intervention. They include improvement in the clients’ experience of the health problem, general health, and well‐being. These outcomes are assessed at the individual client level and may be reported at the practice level as the percentage of clients exhibiting improvement (Fixsen et al., 2019a; Procter et al., 2011).

16.1.4 Selection of a Framework

Although implementation frameworks are categorized as focusing on determinants, processes, or outcomes, there is overlap in the categories; that is, some frameworks cover combinations of determinants, processes and outcomes. Selecting one particular framework may not provide a full or comprehensive understanding of the complexity of implementation, thereby limiting the careful planning, conduct and evaluation of the implementation initiatives (Nilsen, 2015). Therefore, it is advisable to develop, in collaboration with stakeholder groups, a logic model that specifies the determinants, processes and outcomes of relevance to the local practice context of implementation. As suggested by Smith et al. (2020), the implementation logic model identifies:

1. Determinants of implementation: These include the facilitators and barriers to implementation operating in the local practice setting.
   
2. Implementation strategies: These are the activities selected to address the locally experienced determinants, and applied to facilitate the adoption of the evidence‐based intervention.
   
3. Mechanisms of action: These reflect the series of events or processes responsible for the success of the implementation strategies in enhancing adoption of the evidence‐based intervention in practice. The processes represent changes in the determinants or in immediate outcomes induced by the strategies; examples are increased health professionals’ knowledge and competence in delivering the evidence‐based intervention.
   
4. Outcomes: The outcomes usually operationalize the ultimate outcomes of the implementation strategies. These are illustrated with the adoption of the evidence‐based intervention in practice.

The implementation logic model focuses on the implementation strategies. It should be supplemented with the logic model of the evidence‐based intervention to comprehensively evaluate the success of the implementation initiatives in improving clients’ experiences. The intervention’s logic model operationalizes the theory underlying the intervention as described in Chapter 5. The logic model guides the specification of client outcomes (i.e. second set of outcomes as mentioned in Section 16.1.3) to be assessed in the implementation evaluation initiatives. The logic model also informs the design and conduct of the process and outcome evaluation of the evidence‐based intervention, which are embedded within the implementation evaluation project, forming a hybrid or dual evaluation of the implementation strategies and of the evidence‐based intervention.