A Review of Implementation Science Theories, Models and Frameworks through an Equity Lens

January 10, 2022
Correy Watkins & Rebekah Hornak

Have you ever felt like you have tunnel vision? Is your work so focused that sometimes you wonder what other perspectives you could miss? The team at the National Implementation Research Network often utilizes the Active Implementation Frameworks (AIFs; Fixsen & Blase, 2020) to drive our support, research, and publications. However, as a growing team with new members, we wanted to reinvigorate our review of implementation research and diversify our understanding of the various implementation science theories, models, and frameworks. We also recognize that to profoundly move forward with equity in implementation we need to examine the multitude of concepts, tools, resources, and research that makes up implementation science.  

Often, practitioners will use the terms theory, model, and framework interchangeably.  To ensure our understanding as a group, we grounded our learning with the following definitions from the Handbook on Implementation Science (Nilsen & Birken, 2020): 

Theory: A set of analytical principles or statements designed to structure our observation, understanding and explanation of the world. 

Model: Involves a deliberate simplification of a phenomenon or a specific aspect of a  phenomenon 

Framework: Denotes a structure overview, outline, system, or plan consisting of various descriptive categories. 

In addition, to narrow our focus for the discussion the following theories, models and frameworks were reviewed by the team: 

As the team reviewed the various theories, models, and frameworks we took the time to examine each through a lens of Equitable Implementation. We posed the following learning questions: What key takeaways or wonderings do you on the theories, models, and frameworks? How can the theories, models and frameworks be utilized to ensure equity in implementation? 

Exploration, Preparation, Implementation, Sustainment Framework 

One nugget that the team took away from the review of EPIS was the importance placed on involving experts of all levels in the implementation process.  The value placed on people’s lived experience is a excellent segue into equity for the framework. The EPIS Framework’s inner and outer context also allows for more explicit guidance on equity in implementation. For example, the outer context requires special attention paid to priorities of funders in relation to how it impacts implementation. 

The Consolidated Framework for Implementation Research 

When reviewing CFIR, the most profound aspect of the framework was the attention dedicated to stakeholders and understanding context as part of implementation. So much so, that the framework has identifying external change agents as its own construct. The framework also addresses implementation barriers directly which the team appreciated. Regarding equity, our wonderings surround biases and definitions. For example, how is stakeholder defined within the framework? How can biases be limited when selecting constructs? As a result of this review, we as a team really want to dig into the tools and templates provided by the framework and examine both definitions and constructs. 

Promoting Action on Research Implementation in Health Services  

One of the most fascinating features of PARIHS is the way the various characteristics segue from exploration into the additional stages of installation and initial implementation.  After reviewing the materials for PARIHS, the team appreciated the approach of starting with engaging stakeholders, moving into developing systems and then testing the innovation selected.  Specifically, it was noted that PARIHS focuses on collecting information and perspectives on practitioner expertise, community decision making and contextual knowledge.   

Normalization Process Theory 

After an initial review, the team left with more questions than they did answers! While we appreciated the focus on behaviors and the work that people do within implementation, we found ourselves wanting more. For example, the constructs focused on individualization and internalization, but we felt it could be flushed out more. How was equity considered when developing the constructs? Do the questions on the NoMAD survey address equity or are the questions biased? Before utilizing the tool, a further review will need to be completed. 

The Behaviour Change Wheel Approach 

Finally, the Behaviour Change Wheel Approach left the team wanting more information and time to dig deeper.  After a quick glance, we thought that the approach could be used to improve equity in implementation through both the policy strategies and the behavior components.  The Behaviour Wheel Approach is complex in that it contains many layers. Each layer, intervention, component and strategy lend itself to opportunities to improve equity in implementation, but will require significant unpacking and understanding of all of the moving parts. 

Solving complex problems and disrupting or transforming systems are arduous tasks. We at the National Implementation Research Network take pride in supporting implementation and system change or disruption. A major challenge right now is equity in implementation. It is our belief that no matter what theory, model, or framework that you choose to use in your implementation journey that equity is a major component. We must include the voices and views of all stakeholders to have effective implementation that leads to positive outcomes. Addressing equity in implementation and supporting effective implementation practice require us to expand our experiences to understand the different perspectives within Implementation Science. 

 

References

Allen, M., Wilhelm, A., Ortega, L. E., Pergament, S., Bates, N., & Cunningham, B. (2021). Applying a race(ism)-conscious adaptation of the CFIR framework to understand implementation of a school-based equity-oriented intervention. Ethnicity & Disease, 31(Suppl), 375–388. https://doi.org/10.18865/ed.31.s1.375 

Aarons, G.A., Hurlburt, M., Horwitz, S.M. (2011) Advancing a conceptual model of evidence-based  practice implementation in public service sectors. Administration and Policy in Mental Health 38,  4-23.  10.1007/s10488-010-0327-7 

Damschroder, L., Aron D., Keith, R., Kirsh, S., Alexander, J. (2009) Fostering implementation of health  services research findings into practice: a consolidated framework for advancing  implementation science. Implementation Science 4, 50.  https://doi.org/10.1186/1748-5908-4-50 

Kitson, A., Harvey, G., McCormack, B. (1998) Enabling the implementation of evidence-based practice: a  conceptual framework. Quality in Health Care 7, 149-159. 10.1136/qshc.7.3.149 

May, C.R., Johnson M., Finch, T. (2021b) Implementation, context, and complexity. Implementation  Science 11, 141. https://doi.org/10.1186/s13012-016-0506-3 

Metz, A., Woo, B., & Loper, A. (2021). Equitable Implementation at Work [web log]. Retrieved 2021, from https://ssir.org/articles/entry/equitable_implementation_at_work. 

Michie, S. Atkins, L., West, R. (2014) The Behaviour Change Wheel: A Guide to Designing Interventions,  1st edn. London: Silverback Publishing. 

Nilsen, P., & Birken, S. A. (Eds.). (2020). Handbook on implementation science. Edward Elgar.