A rigorous, stepwise procedure for multi-stakeholder design of implementation actions
Authors: Markaryan Marine , Janssens Thomas , De Baets Liesbet , Torta Diana 
Published: January 2024

Implementation of evidence-based practice necessitates identification of barriers and facilitators as well as using effective implementation strategies tailored to these barriers and facilitators. Collaboration with stakeholders is an essential aspect of implementation, but there is limited guidance on how to combine input from stakeholders with other sources of information when designing implementation actions. In this study, we adapt and evaluate a novel stepwise procedure (based on Knapp et al, 2022) to combine multi-stakeholder input with best available evidence on matching barriers to implementation strategies.
In the context of an implementation project for physiotherapist led Cognitive Behavior therapy for Insomnia (CBT-I) in patients with Knee Osteoarthritis (OA), stakeholders (physiotherapists (PTs), patients with OA and comorbid insomnia, general practitioners (GPs), orthopedic surgeons (OS), rheumatologists, and psychologists with expertise in CBT-I) participate in a rigorous, iterative process of identifying and prioritizing barriers, followed by a selection of implementation strategies to address identified barriers. In this process, stakeholder discussion or survey input is alternated with feedback from the research team, who are providing a summary of stakeholder perspectives and provide input based on findings from the implementation science literature. The process integrates aspects of user-centered design (Dopp et al., 2018; Dopp et al., 2020), a modified version of Delphi approach (Hasson et al., 2000), a participatory approach (Jagosh et al., 2012), and the Expert Recommendations for Implementing Change (ERIC) protocol (Powell et al., 2015; Waltz et al., 2015).
Compared to Knapp et al. (2022) we have streamlined the development process into a six-step alternating procedure. Furthermore, we have broadened the categories of stakeholders participating in the stakeholder discussions, including patients and health care providers of different disciplines. In order to facilitate representation of patients and different disciplines of health care providers, we are conducting the first step stakeholder discussions in two parallel teams: (1) a team focusing on the determinants related to patient-PT interactions, the process of implementation, and the intervention itself; and (2) a team focusing on the determinants related to interactions between different health care providers, the referral patterns, and the structural aspects of healthcare. The first team consists of patients, psychologists, and physiotherapists. The second team involves various healthcare providers involved in the treatment of osteoarthritis, both first and second line. That is physiotherapists, GPs, orthopedic surgeons, and rheumatologists.
The study is currently ongoing, and we will be discussing preliminary outcomes related to the methodology and design process, including evaluations at each stage of the project. The project can serve as a template for structured, multidisciplinary stakeholder engagement in the design of implementation actions. This work is integrated into a clinical trial that was funded by the Applied Biomedical Research Program, Research Foundation Flanders (Fonds voor Wetenschappelijk Onderzoek Vlaanderen), Belgium (FWO-TBM project no. TBM2021 - T000521N - 54252, “Towards PREcision MEdicine for Osteoarthritis: Added value of cognitive behavioural therapy for insomnia (the PREMEO trial).