Applying Multiple Frameworks and Theories in Implementation Research

Jeffrey Smith

Implementation Research Coordinator

Mental Health QUERI

“In theory there is no difference between theory and practice... in practice there is.”

Yogi Berra

Mental Health QUERI Approach to Implementation
        - Design interventions based on theory, lit review and results from formative evaluation  
        - Conduct formative evaluation

engage with stakeholders

identify determinants of current practice

assess barriers and facilitators to implementation

organizational-level

team / clinic-level

individual provider-level

patient-level

tailor intervention design and implementation to local context

there is a need, after a translation study, to have gained an understanding of the implementation efforts, potential causal events leading to change, and suggestive evidence re: the specific translation components and processes that appeared to most influence success. (adaptation of Altman)

Note:  this note is from the slide presentation by Cheryl Stetler to QUERI Translation Coordinators, February 2003

Mental Health QUERI Approach to Implementation (cont)
        - Use external facilitation techniques (PARiHS Framework)

engage with stakeholders to problem-solve and identify new strategies or tools for overcoming barriers when initial success is sub-optimal
        - Conduct summative (or impact) evaluation

there is a need, after a translation study, to have gained an understanding of the implementation efforts, potential causal events leading to change, and suggestive evidence re: the specific translation components and processes that appeared to most influence success. (adaptation of Altman)

Note:  this note is from the slide presentation by Cheryl Stetler to QUERI Translation Coordinators, February 2003

An Approach to Using Theory for Implementation Planning

Select framework / theory / model of planned behavior change

Assess fit with initial theory

Identify potential strategies for achieving change

Select interventionsthat fit with plannedstrategies (based on theory)

Identify interventiontools that fit bothstrategy and theory

Launch interventionusing identified toolsand strategies

Evaluate effectivenessof intervention,strategies, tools

Adapted from: Sales A, Smith JL, Curran G, Kochevar L. Models, strategies and tools: The role of theory in implementing evidence-based findings into health care practice.  Journal of General Internal Medicine 2006; 21:S43-49. 

Implementation Science  Frameworks and Theories (selected)
        - Organizational / System Level

Consolidated Framework for Implementation Research (VA Diabetes QUERI)

Promoting Action on Research Implementation in Health Services (PARiHS)

Stetler Organizational Framework for Institutionalizing EBPs

Greenhalgh Model for Diffusing Innovations in HCOs

Ottawa Model of Research Use

Simpson Transfer Model

Complexity Theory

Implementation Science Frameworks and Theories (cont.)
        - Interpersonal Level

Diffusion of Innovation (Rogers)

Social Influence Theory (Mittman)

Social Cognitive Theory... aka Social Learning Theory (Bandura)
        - Individual Level

Theory of Reasoned Action / Theory of Planned Behavior (Azjen & Fishbein)

Health Belief Model (Rosenstock)

Transtheoretical Model and Stages of Change (Prochaska & DiClemente)

Multiple theory approach 

Strengths
        -  useful in designing multifaceted interventions to influence   multi-level determinants of care (flexible)
        -  allows integration of theory, knowledge, methods from multiple   disciplines (multidisciplinary)

Limitations
        -  Can be unwieldy... need to provide rationale for applying multiple   theory approach, and rationale for selecting the specific frameworks / theories applied

Key Guidance on Evaluation
        -  combine with rigorous formative evaluation
        -  conduct summative (impact) evaluation to assess intervention effectiveness on key study outcomes
        -  confirm, refute or propose refinements to selected theory(ies)   based on study findings

Summary 
        -  Application of multiple frameworks/theories in   guiding intervention design and implementation can   be successful in implementing EBPs
        -  accommodates tailoring to setting when combined with formative evaluation
        -  example forthcoming (May 5 session)
        -  acknowledges there are generally multi-level determinants to complex, clinical QI issues
        -  organizational-level
        -  team-level
        -  interpersonal-level
        -  individual-level

QUESTIONS?

Contact:  

Jeff Smith 

VA Mental Health QUERI

E-mail: Jeffrey.Smith6@va.gov