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Chapter 2 : What are we talking about?

D&I Definitions and Frameworks

“In many ways, [dissemination and implementation] is a very new science, and so when something is a new science, there are many undiscovered “corners of the room,” in a sense. I think that fundamentally, we've still got work to do in defining the terminology of dissemination and implementation research.”
— Ross Brownson, Ph.D.
Professor of Epidemiology | Co-Director, Prevention Research Center in St. Louis
George Warren Brown School of Social Work
Department of Surgery and Siteman Cancer Center,
Washington University School of Medicine Washington University in St. Louis

Learning Objectives:

To define common terminology

&
To demonstrate the use of common frameworks

Dissemination and Implementation

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Dissemination

The targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread (“scale up”) and sustain knowledge and the associated evidence-based interventions.

Implementation

The use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings.

Dissemination and implementation research

Intends to bridge the gap between public health, clinical research, and everyday practice by building a knowledge base about how health information, interventions, and new clinical practices and policies are transmitted and translated for public health and health care service use in specific settings.
 as defined by the National Institute of Health.

Dissemination

The targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread (“scale up”) and sustain knowledge and the associated evidence-based interventions.

Implementation

The use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings....

Dissemination and implementation research.

Intends to bridge the gap between public health, clinical research, and everyday practice by building a knowledge base about how health information, interventions, and new clinical practices and policies are transmitted and translated for public health and health care service use in specific settings.

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Dissemination and Implementation Research in Health: Translating Science into Practice

To help propel this crucial field forward, this book aims to address a number of key issues, including: how to evaluate the evidence base on effective interventions; which strategies will produce the greatest impact; how to design an appropriate study; and how to track a set of essential outcomes.

The D&I Continuum

Table from the National Cancer Institute
Discovery/Development
Delivery
Discovery/Development

Diffusion

1. Research diffusion

The passive process by which a growing body of information about an intervention, product, or technology is initially absorbed and acted upon by a small body of highly motivated recipients (Lomas, 1993).

 

2. Diffusion research

Centers on the conditions which increase or decrease the likelihood that a new idea, product, or practice will be adopted by members of a given culture (Rogers, 1995).

Dissemination

1. Research dissemination

Active process through which the information needs (pull) of target groups working in specific contexts (capacity) are accessed, and information is "tailored" to increase awareness of, acceptance of, and use of the lessons learned from science (Kerner, 2007).

 

2. Dissemination research

The study of processes and variables that determine and/or influence the adoption of knowledge, interventions or practice by various stakeholders (Lomas, 1997).

Delivery

Implementation

1. Research implementation

The utilization of strategies or approaches to introduce or modify evidence-based interventions within specific settings. This involves the identification of and assistance in overcoming barriers to, the application of new knowledge obtained from a disseminated message or program (Lomas, 1993).

 

2. Diffusion implementation

Research that supports the movement of evidence-based interventions and approaches from the experimental, controlled environment into the actual delivery contexts where the programs, tools, and guidelines will be utilized, promoted, and integrated into the existing operational culture (Rubenstein & Pugh, 2006).

Kerner, J Translating Research into Policy and Practice: Who’s Influencing Whom? Presentation at the Annual National Health Policy Conference. Washington, DC. 2007.

Lomas, J Diffusion, dissemination, and implementation: who should do what? Annals of New York Academy of Sciences 1993, 703, 226-235; discussion 235-227.

Lomas, J Improving Research and Uptake in the Health Sector: Beyond the Sound of One Hand Clapping. Centre for Health Economics and Policy Analysis. Policy Commentary 1997, C97-1.

Rogers, E. Diffusion of Innovations (Fourth ed.). 1995. New York: The Free Press.

Rubenstein, L. V., & Pugh, J. Strategies for promoting organizational and practice change by advancing implementation research. Journal of General Internal Medicine 2006, 21 Suppl 2, S58-64.

Key Terms for D&I

  • Evidence-based intervention
  • Adoption
  • Sustainability
  • Reinvention/adaptation
  • Dissemination strategy

Evidence-based intervention. n.

The objects of D&I activities are interventions with proven efficacy and effectiveness (i.e., evidence-based). Interventions within D&I research should be defined broadly and may include programs, practices, processes, policies, and guidelines. More comprehensive definitions of evidence-based interventions are available elsewhere. In D&I research, we often encounter with complex interventions (e.g., interventions using community-wide education) where the description of core intervention components and their relationships involve multiple settings, audiences, and approaches.

Adoption. n.

Adoption is the decision of an organization or community to commit to and initiate an evidence-based intervention.

Sustainability. n.

Sustainability describes the extent to which an evidence-based intervention can deliver its intended benefits over an extended period of time after external support from the donor agency is terminated. Most often sustainability is measured through the continued use of intervention components; however, Scheirer and Dearing suggest that measures for sustainability should also include considerations of maintained community- or organizational-level partnerships, maintenance of organizational or community practices, procedures, and policies that were initiated during the implementation of the intervention, sustained organizational or community attention to the issue that the intervention is designed to address, and efforts for program diffusion and replication in other sites. Three operational indicators of sustainability are: (1) maintenance of a program's initial health benefits, (2) institutionalization of the program in a setting or community, and (3) capacity building in the recipient setting or community.

Reinvention/adaptation. n.

For the success of D&I, interventions often need to be reinvented or adapted to fit the local context (i.e., needs and realities). Reinvention or adaptation is defined as the degree to which an evidence-based intervention is changed or modified by a user during adoption and implementation to suit the needs of the setting or to improve the fit to local conditions. The need for adaptation and understanding of context has been called Type 3 evidence (i.e., the information needed to adapt and implement an evidence-based intervention in a particular setting or population). Ideally, adaptation will lead to at least equal intervention effects as is shown in the original efficacy or effectiveness trial. To reconcile the tension between fidelity and adaptation, the core components (or essential features) of an intervention (i.e., those responsible for its efficacy/effectiveness) must be identified and preserved during the adaptation process.

Dissemination strategy. n.

Dissemination strategies describe mechanisms and approaches that are used to communicate and spread information about interventions to targeted users. Dissemination strategies are concerned with the packaging of the information about the intervention and the communication channels that are used to reach potential adopters and target audiences. Passive dissemination strategies include mass mailings, publication of information including practice guidelines, and untargeted presentations to heterogeneous groups. Active dissemination strategies include hands on technical assistance, replication guides, point-of-decision prompts for use, and mass media campaigns. It is consistently stated in the literature that dissemination strategies are necessary but not sufficient to ensure wide-spread use of an intervention.

For additional terms see Rabin, B.A. and Brownson, R.C. (2012). Developing the terminology for dissemination and implementation research in health. In Brownson, R.C., Colditz, G.A., & Proctor, E.K. (Eds.), Dissemination and Implementation Research in Health: Translating Science to Practice. New York: Oxford University Press or 
visit this site.

Models & Frameworks Overview

Why is it important to use models and frameworks?

Models and frameworks can guide the planning, development and evaluation of D&I studies. Tabak and colleagues (see p. 11 for reference) list the following reasons why models and frameworks should be used in D&I. They can:

  • Enhance effectiveness of interventions by helping to focus interventions on the essential processes of behavioral change, which can be quite complex.
  • Enhance interpretability of study findings.
  • Ensure that essential implementation strategies are included.

How do I use models and frameworks?

The clear integration of the selected D&I model or framework into all aspects of the study is critical. A guide to applying models and frameworks to D&I projects is provided by the VA QUERI Enhancing Implementation and further discussed by the VA Implementation Guide.

Ideally, your theory or framework will guide the formulation of your research question, development of your intervention, the evaluation of the intervention, and the interpretation of your findings. For an exercise to do this, you can use Table 1 Try-It activity at the end of this module.

How can we categorize frameworks and theories? 

A recent review identified 61 D&I models and frameworks and categorized them along three criteria:

Construct Flexibility (CF): Models were scored on a scale of 1 to 5, where 1 was Broad and 5 was Operational: 

  • Broad was defined as containing more loosely defined constructs, thereby allowing greater flexibility to apply the model to a wide array of activities and contexts.
  • Operational was defined as providing detailed, step-by-step actions clearly defined for a particular activity and context.
Dissemination and Implementation

Models were scored on a continuum of the following five categories: focus on dissemination only (D only), dissemination more than implementation (D < I), both activities equally (D = I), implementation more than dissemination (D < I), and implementation only (I only).

  • Dissemination was defined as actively spreading evidence-based programs to specified audiences via determined channels through planned strategies.
  • Implementation was defined as the process of using or integrating evidence-based programs within a setting.

Models were classified as focusing on a specific level or as cutting across several levels of the socio-ecological framework (outline shown below). Researchers also noted whether models addressed policy.

  • System level, such as the hospital system or government level
  • Community level, such as the local government or neighborhood level
  • Organization level, such as the hospital, service organization, or factory level
  • Individual level, or focusing on the personal characteristics of individuals
Figure from:Tabak RG, Khoong EC, Chambers DA, Brownson, RC. Models in dissemination and implementation research: useful tools in public health services and systems research. Frontiers in PHSSR. 2013; 2(1):8.

For more details on the 61 models and frameworks see:

Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med 2012;43(3):337-350.

Eccles MP, Mittman BS. Welcome to implementation science. Implement Sci 2006;1(1):1.

Tabak RG, Khoong EC, Chambers DA, Brownson, RC. Models in dissemination and implementation research: useful tools in public health services and systems research.Frontiers in PHSSR. 2013;2(1):8.

Centers for Disease and Prevention (CDC) Prevention Research Centers http://www.cdc.gov/prc/stories-prevention-research/stories/dissemination-and-implementation.htm

6 Key D&I Models and Frameworks

FRAMEWORK

1

FRAMEWORK

1

Canadian Institutes for Health Research (CIHR) Model of Knowledge Translation

A global KT model, based on a research cycle, that could be used as a conceptual guide for the overall KT process.

Canadian Institutes of Health Research (2005). About knowledge translation. Retrieved September 10, 2013, from http://www.cihr-irsc.gc.ca/e/39033.html

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Practice applying these definitions to your research issue with this handy PDF download.
Try-It Activity : D&I Framework ConstructsTry-It Activity : D&I Framework Constructs

6 Key D&I Models and Frameworks

FRAMEWORK

2

FRAMEWORK

2

Consolidated Framework for Implementation Research (CFIR) (Damschroder)

The Consolidated Framework For Implementation Research (CFIR) offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50.

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6 Key D&I Models and Frameworks

FRAMEWORK

3

FRAMEWORK

3

Interactive Systems Framework (Wandersman et al)

The Interactive Systems Framework for Dissemination and Implementation (ISF) was created to help bridge research and practice by specifying the systems and processes required to support dissemination and implementation of evidence-based programs, processes, practices, and policies. The ISF identifies three key systems necessary for this process which include the Prevention Synthesis and Translation System, the Prevention Support System, and the Prevention Delivery System.

Wandersman A, Duffy J, Flaspohler P, Noonan R, Lubell K, et al. Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation. American Journal of Community Psychology 2008, 41(3–4), 171-181.

Flaspohler P, Lesesne CA, Puddy RW, Smith E, Wandersman A. Advances in bridging research and practice: introduction to the second special issue on the interactive system framework for dissemination and implementation American Journal of Community Psychology 2012, 50(3-4), 271-281.

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6 Key D&I Models and Frameworks

FRAMEWORK

4

FRAMEWORK

4

A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. (Feldstein and Glasgow)

A comprehensive model for translating research into practice was developed using concepts from the areas of quality improvement, chronic care, the diffusion of innovations, and measures of the population-based effectiveness of translation. PRISM--the Practical, Robust Implementation and Sustainability Model--evaluates how the health care program or intervention interacts with the recipients to influence program adoption, implementation, maintenance, reach, and effectiveness.

Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008 Apr;34(4):228-43.

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6 Key D&I Models and Frameworks

FRAMEWORK

5

FRAMEWORK

5

Precede-Proceed Model (Green & Kreuter)

The goals of the Precede-Proceed Model are to explain health-related behaviors and environments, and to design and evaluate the interventions needed to influence both the behaviors and the living conditions that influence them and their consequences. This model has been applied, tested, studied, extended, and verified in over 960 published studies and thousands of unpublished projects in community, school, clinical, and workplace settings over the last decade.

Green, LW, and Kreuter, MW, Health Program Planning: An Educational and Ecological Approach, 4th edition (New York: McGraw-Hill) 2001.

http://www.lgreen.net/precede.htm

Aboumatar, H, Ristaino, P, Davis, RO, Thompson, CB, Maragakis, L, Cosgrove, S, Rosenstein, B, and Perl, TM. Infection Prevention Promotion Program Based on the PRECEDE Model: Improving Hand Hygiene Behaviors among Healthcare Personnel. Infect Control Hosp Epidemiol 2012, 33(2):144-151.

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6 Key D&I Models and Frameworks

FRAMEWORK

6

FRAMEWORK

6

Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) (Glasgow et al)

The RE-AIM framework is designed to enhance the quality, speed, and public health impact of efforts to translate research into practice in five steps:

  • Reach your intended target population
  • Efficacy or effectiveness
  • Adoption by target staff, settings, or institutions
  • Implementation consistency, costs and adaptations made during delivery
  • Maintenance of intervention effects in individuals and settings over time

Glasgow RE, Vogt TM, Boles SM. 1999. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health 1999; 89(9):1922-1927

www.re-aim.org

Allicock M, Johnson LS, Leone L, Carr C, Walsh J, Ni A, Resnicow K, Pignone M, Campbell M. Promoting fruit and vegetable consumption among members of black churches, Michigan and north Carolina, 2008-2010. Prev Chronic Dis. 2013 Mar;10:E33.

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Practice applying these definitions to your research issue with this handy PDF download.
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Resources

Implementation Science: Methods, Models, and Opportunities to Integrate Evidence, Policy, and Practice​

Russell Glasgow, PhD
Slides Video

Identify key characteristics of implementation science and how it is different from traditional health research; describe an example of how implementation science has been applied to population-based cancer screening; describe resources for funding, measures and other tools for implementation science available from NCI & NIH​.

​Diffusion of Innovations: Implications for Practice​

Jim Dearing, PhD
Slides Video

An introduction to the diffusion of innovation paradigm and the implementation science perspectives about fidelity, adaption and sustainability

​The Field of Healthcare Marketing: Implications for Dissemination and Implementation Practice​​

Elaine Morrato, DrPH, MPH
Slides Video

An overview of the changing healthcare marketplace and insights on strategic communication in today's media world.

Key Takeaways : Section 1

Click To Reveal Flipcard Answer

Dissemination

The targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread (“scale up”) and sustain knowledge and the associated evidence-based interventions.

Implementation

The use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings.

Dissemination and implementation research

Intends to bridge the gap between public health, clinical research, and everyday practice by building a knowledge base about how health information, interventions, and new clinical practices and policies are transmitted and translated for public health and health care service use in specific settings.

Key Takeaways : Section 2

Diffusion-Dissemination-Implementation Continuum

Click To Reveal Flipcard Answer
Discovery/Development
Delivery

Diffusion

A passive process by which info is absorbed and acted on.

Dissemination

An active process through which information addresses needs, and is tailored to increase awareness/acceptance.

Implementation

The utilization of strategies to introduce/modify EBI’s within specific settings. Barriers identified and overcome, knowledge applied.

Key Takeaways : Section 3

More Key Terms

Click To Reveal Flipcard Answer

Evidence-Based Intervention (EBI)

Those programs, practices, processes, policies, and guidelines with proven efficacy and effectiveness.

Adoption

The decision of an organization or community to commit to and initiate Evidence-Based Interventions.

Sustainability

Extent to which an intervention can deliver intended benefits over time (without external support).

Reinvention / Adaptation

The degree to which Evidence-Based Interventions are changed or modified to suit the needs of the setting or improve to fit the conditions, which may change over time.

Dissemination Strategy

Mechanisms and approaches used to communicate and spread information about Evidence-Based Interventions. A necessary but not sufficient characteristic ensuring widespread use.

Key Takeaways : Section 4

Models and Frameworks

Click To Reveal Flipcard Answer

Why are models and framework useful in guiding, planning and developing a D&I study?

  • Enhance effectiveness of the intervention

  • Enhance Interpretability and understanding how and why a result comes about

  • Ensure inclusion of essential D&I strategies

What are 3 domains used to categorize D&I Frameworks?

  1. Construct Flexibility: Broad vs. Operational

  2. Activity Focus: Dissemination vs. Implementation

  3. Socio-Ecological Framework level: System, Community, Organization or Individual

The Diffusion of Innovations Theory is a model for designing dissemination, what are its key elements?

  • Attributes of the Innovation

  • Communication Channels

  • Time and the Adoption Process

  • Social System

Checklist To Get Started

  • Which models and frameworks could best guide my D&I efforts?

  • Are there resources available to me to help me decide on best model or framework?

  • Is there preferred model or framework identified in the literature for my research interest?

  • What do funders in my area of research think about different models and frameworks?

  • Did I integrate the selected model or framework in all aspects of my D&I work (i.e., planning and development of intervention, evaluation, etc.)?

  • How can the selected model or framework help explain the process and outcome of my D&I efforts?

Read Chapter 3