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Background Understanding the mechanisms of implementation strategies (i.e., the processes by which strategies produce desired effects) is important for research to understand why a strategy did or did not achieve its intended effect, and it is important for practice to ensure strategies are designed and selected to directly target determinants or barriers. This study is a systematic review to characterize how mechanisms are conceptualized and measured, how they are studied and evaluated, and how much evidence exists for specific mechanisms. Methods We systematically searched PubMed and CINAHL Plus for implementation studies published between January 1990 and August 2018 that included the terms “mechanism,” “mediator,” or “moderator.” Two authors independently reviewed title and abstracts and then full texts for fit with our inclusion criteria of empirical studies of implementation in health care contexts. Authors extracted data regarding general study information, methods, results, and study design and mechanisms-specific information. Authors used the Mixed Methods Appraisal Tool to assess study quality. Results Search strategies produced 2277 articles, of which 183 were included for full text review. From these we included for data extraction 39 articles plus an additional seven articles were hand-entered from only other review of implementation mechanisms (total = 46 included articles). Most included studies employed quantitative methods (73.9%), while 10.9% were qualitative and 15.2% were mixed methods. Nine unique versions of models testing mechanisms emerged. Fifty-three percent of the studies met half or fewer of the quality indicators. The majority of studies (84.8%) only met three or fewer of the seven criteria stipulated for establishing mechanisms. Conclusions Researchers have undertaken a multitude of approaches to pursue mechanistic implementation research, but our review revealed substantive conceptual, methodological, and measurement issues that must be addressed in order to advance this critical research agenda. To move the field forward, there is need for greater precision to achieve conceptual clarity, attempts to generate testable hypotheses about how and why variables are related, and use of concrete behavioral indicators of proximal outcomes in the case of quantitative research and more directed inquiry in the case of qualitative research.

Background Implementation science is at a sufficiently advanced stage that it is appropriate for the field to reflect on progress thus far in achieving its vision, with a goal of charting a path forward. In this debate, we offer such reflections and report on potential threats that might stymie progress, as well as opportunities to enhance the success and impact of the field, from the perspective of a group of US-based researchers. Main body Ten mid-career extramurally funded US-based researchers completed a “pre-mortem” or a group brainstorming exercise that leverages prospective hindsight to imagine that an event has already occurred and to generate an explanation for it — to reduce the likelihood of a poor outcome. We came to consensus on six key themes related to threats and opportunities for the field: (1) insufficient impact, (2) too much emphasis on being a “legitimate science,” (3) re-creation of the evidence-to-practice gap, (4) difficulty balancing accessibility and field coherence, (5) inability to align timelines and priorities with partners, and (6) overly complex implementation strategies and approaches. Conclusion We submit this debate piece to generate further discussion with other implementation partners as our field continues to develop and evolve. We hope the key opportunities identified will enhance the future of implementation research in the USA and spark discussion across international groups. We will continue to learn with humility about how best to implement with the goal of achieving equitable population health impact at scale.

Background A substantial literature has established the role of the inner organizational setting on the implementation of evidence-based practices in community contexts, but very little of this research has been extended to the education sector, one of the most common settings for the delivery of mental and behavioral health services to children and adolescents. The current study examined the factor structure, psychometric properties, and interrelations of an adapted set of pragmatic organizational instruments measuring key aspects of the organizational implementation context in schools: (1) strategic implementation leadership, (2) strategic implementation climate, and (3) implementation citizenship behavior. Method The Implementation Leadership Scale (ILS), Implementation Climate Scale (ICS), and Implementation Citizenship Behavior Scale (ICBS) were adapted by a research team that included the original scale authors and experts in the implementation of evidence-based practices in schools. These instruments were then administered to a geographically representative sample ( n  = 196) of school-based mental/behavioral health consultants to assess the reliability and structural validity via a series of confirmatory factor analyses. Results Overall, the original factor structures for the ILS, ICS, and ICBS were confirmed in the current sample. The one exception was poor functioning of the Rewards subscale of the ICS, which was removed in the final ICS model. Correlations among the revised measures, evaluated as part of an overarching model of the organizational implementation context, indicated both unique and shared variance. Conclusions The current analyses suggest strong applicability of the revised instruments to implementation of evidence-based mental and behavioral practices in the education sector. The one poorly functioning subscale (Rewards on the ICS) was attributed to typical educational policies that do not allow for individual financial incentives to personnel. Potential directions for future expansion, revision, and application of the instruments in schools are discussed.

Background Innovative approaches are needed to maximize fit between the characteristics of evidence-based practices (EBPs), implementation strategies that support EBP use, and contexts in which EBPs are implemented. Standard approaches to implementation offer few ways to address such issues of fit. We characterized the potential for collaboration with experts from a relevant complementary approach, user-centered design (UCD), to increase successful implementation. Method Using purposive and snowball sampling, we recruited 56 experts in implementation ( n = 34) or UCD ( n = 22). Participants had 5+ years of professional experience ( M = 10.31), worked across many settings (e.g., healthcare, education, human services), and were mostly female (59%) and white (73%). Each participant completed a web-based concept mapping structured conceptualization task. They sorted strategies from established compilations for implementation (36 strategies) and UCD (30 strategies) into distinct clusters, then rated the importance and feasibility of each strategy. Results We used multidimensional scaling techniques to examine patterns in the sorting of strategies. Based on conceptual clarity and fit with established implementation frameworks, we selected a final set of 10 clusters (i.e., groups of strategies), with five implementation-only clusters, two UCD-only clusters, and three trans-discipline clusters. The highest-priority activities (i.e., above-average importance and feasibility) were the trans-discipline clusters plus facilitate change and monitor change. Implementation and UCD experts sorted strategies into similar clusters, but each gave higher importance and feasibility ratings to strategies/clusters from their own discipline. Conclusions In this concept mapping study, experts in implementation and UCD had perspectives that both converged (e.g., trans-discipline clusters, which were all rated as high-priority) and diverged (e.g., in importance/feasibility ratings). The results provide a shared understanding of the alignment between implementation science and UCD, which can increase the impact and sustainability of EBP implementation efforts. Implications for improved collaboration among implementation and UCD experts are discussed.

Background Children with autism receive most of their intervention services in public schools, but implementation of evidence-based practices (EBPs) for autism varies. Studies suggest that individual (attitudes) and organizational characteristics (implementation leadership and climate) may influence providers’ use of EBPs, but research is relatively limited in this area. This study examined individual and organizational factors associated with implementation of three EBPs—discrete trial training, pivotal response training, and visual schedules—for children with autism in special education classrooms in public elementary schools. Methods Participants included 67 autism support teachers and 85 other classroom staff from 52 public elementary schools in the northeastern United States. Participants reported their attitudes toward EBPs (e.g., intuitive appeal, willingness if required, openness, and divergence), implementation leadership and climate of their school, and the frequency with which they deliver each of three EBPs. Linear regression was used to estimate the association of attitudes about EBPs with organizational characteristics and intensity of EBP use. Demographic covariates with a bivariate association with EBP use significant at p  < .20 were entered into the adjusted models. Results There were significant findings for only one EBP, discrete trial training. Teachers who reported higher perceived divergence (perceived difference of usual practice with academically developed or research-based practices) between EBPs and current practices used less discrete trial training ( f 2  = .18), and teachers who reported higher appeal (willingness to adopt EBPs given their intuitive appeal ) of EBPs used more discrete trial training ( f 2  = .22). No organizational factors were significantly associated with implementation with any of the three EBPs. Conclusions Attitudes toward EBPs may affect teachers’ decisions to use EBPs; however, implementation leadership and climate did not predict EBP use. Future implementation efforts ought to consider the type of EBP and its fit within the context in terms of the EBP’s similarities to and differences from existing practices and programs in the setting. Implementation strategies that target individual attitudes about EBPs may be warranted in public schools.

Background Despite consistent recognition of their influence, empirical study of how outer setting factors (e.g., policies, financing, stakeholder relationships) influence public systems’ investment in and adoption of evidence-based treatment (EBT) is limited. This study examined associations among unmodifiable (e.g., demographic, economic, political, structural factors) and modifiable (e.g., allocation of resources, social processes, policies, and regulations) outer setting factors and adoption of behavioral health EBT by US states. Methods Multilevel models examined relationships between state characteristics, an array of funding and policy variables, and state adoption of behavioral health EBTs for adults and children across years 2002–2012, using data from the National Association for State Mental Health Program Directors Research Institute and other sources. Results Several unmodifiable state factors, including per capita income, controlling political party, and Medicaid expansion, predicted level of state fiscal investments in EBT. By contrast, modifiable factors, such as interagency collaboration and investment in research centers, were more predictive of state policies supportive of EBT. Interestingly, level of adult EBT adoption was associated with state fiscal supports for EBT, while child EBT adoption was predicted more by supportive policies. State per capita debt and direct state operation of services (versus contracting for services) predicted both child and adult EBT adoption. Conclusions State-level EBT adoption and associated implementation support is associated with an interpretable array of policy, financing, and oversight factors. Such information expands our knowledge base of the role of the outer setting in implementation and may provide insight into how best to focus efforts to promote EBT for behavioral health disorders.

Background Innovative approaches are needed to maximise the uptake and sustainment of evidence-based practices in a variety of health service contexts. This protocol describes a study that will seek to characterise the potential of one such approach, user-centred design (UCD), which is an emerging field that seeks to ground the design of an innovation in information about the people who will ultimately use that innovation. The use of UCD to enhance strategies for implementation of health services, although promising, requires a multidisciplinary perspective based on a firm understanding of how experts from each discipline perceives the interrelatedness and suitability of these strategies. Method This online study will use a combination of purposive and snowball sampling to recruit a sample of implementation experts ( n  = 30) and UCD experts ( n  = 30). These participants will each complete a concept mapping task, which is a mixed-method conceptualisation technique that will allow for identification of distinct clusters of implementation and/or UCD strategies. The research team has selected a set of implementation strategies and UCD strategies that each participant will sort and rate on dimensions of importance and feasibility. Data analyses will focus on describing the sample, identifying related clusters of strategies, and examining the convergences, divergences, and potential for collaboration between implementation science and UCD. Discussion By leading to a better understanding of the overlap between implementation science and UCD, grounded within established theoretical frameworks, this study holds promise for improving the impact and sustainability of evidence-based health services in community settings.

Background There is a fundamental gap in understanding the causal mechanisms by which strategies for implementing evidence-based practices address local barriers to effective, appropriate service delivery. Until this gap is addressed, scientific knowledge and practical guidance about which implementation strategies to use in which contexts will remain elusive. This research project aims to identify plausible strategy-mechanism linkages, develop causal models for mechanism evaluation, produce measures needed to evaluate such linkages, and make these models, methods, and measures available in a user-friendly website. The specific aims are as follows: (1) build a database of strategy-mechanism linkages and associated causal pathway diagrams, (2) develop psychometrically strong, pragmatic measures of mechanisms, and (3) develop and disseminate a website of implementation mechanisms knowledge for use by diverse stakeholders. Methods For the first aim, a combination of qualitative inquiry, expert panel methods, and causal pathway diagramming will be used to identify and confirm plausible strategy-mechanism linkages and articulate moderators, preconditions, and proximal and distal outcomes associated with those linkages. For the second aim, rapid-cycle measure development and testing methods will be employed to create reliable, valid, pragmatic measures of six mechanisms of common strategies for which no high-quality measures exist. For the third aim, we will develop a user-friendly website and searchable database that incorporates user-centered design, disseminating the final product using social marketing principles. Discussion Once strategy-mechanism linkages are identified using this multi-method approach, implementation scientists can use the searchable database to develop tailored implementation strategies and generate more robust evidence about which strategies work best in which contexts. Moreover, practitioners will be better able to select implementation strategies to address their specific implementation problems. New horizons in implementation strategy development, optimization, evaluation, and deployment are expected to be more attainable as a result of this research, which will lead to enhanced implementation of evidence-based interventions for cancer control, and ultimately improvements in patient outcomes.

IntroductionMechanisms explain how implementation strategies work. Implementation research requires careful operationalisation and empirical study of the causal pathway(s) by which strategies effect change, and factors that may amplify or weaken their effects. Understanding mechanisms is critically important to replicate findings, learn from negative studies or adapt an implementation strategy developed in one setting to another. Without understanding implementation mechanisms, it is difficult to design strategies to produce expected effects across contexts, which may have disproportionate effects on settings in which priority populations receive care. This manuscript outlines the protocol for an Agency for Healthcare Research and Quality-funded initiative to: (1) establish priorities for an agenda to guide research on implementation mechanisms in health and public health, and (2) disseminate the agenda to research, policy and practice audiences.Methods and analysisA network of scientific experts will convene in ‘Deep Dive’ meetings across 3 years. A research agenda will be generated through analysis and synthesis of information from six sources: (1) systematic reviews, (2) network members’ approaches to studying mechanisms, (3) new proposals presented in implementation proposal feedback sessions, (4) working group sessions conducted in a leading implementation research training institute, (5) breakout sessions at the Society for Implementation Research Collaboration’s (SIRC) 2019 conference and (6) SIRC conference abstracts. Two members will extract mechanism-relevant text segments from each data source and a third member will generate statements as an input for concept mapping. Concept mapping will generate unique clusters of challenges, and the network will engage in a nominal group process to identify priorities for the research agenda.Ethics and disseminationThis initiative will yield an actionable research agenda to guide research to identify and test mechanisms of change for implementation strategies. The agenda will be disseminated via multiple channels to solicit feedback and promote rigorous research on implementation mechanisms.

Background Strategic implementation leadership is a critical determinant of successful implementation, hypothesized to create a more supportive implementation climate conducive to the adoption and use of evidence-based practices. Implementation leadership behaviors may vary significantly across contexts, necessitating studies that examine the validity of established measurement tools in novel health service delivery sectors. The education sector is the most common site for delivering mental health services to children and adolescents in the USA, but research focused on implementation leadership in schools is in the early phases, and there is a need for adaptation and expansion of instruments in order to tailor to the school context. The current study adapted and validated the School Implementation Leadership Scale (SILS) (based on the Implementation Leadership Scale) in a sample of elementary school personnel from six school districts who were implementing one of two well-established prevention programs for supporting children’s mental health. Methods Participants were 441 public school teachers from 52 elementary schools in the Midwest and West Coast of the USA. Participants completed a survey that contained: (1) an adapted and expanded version of the SILS with additional items generated for four existing subscales as well as three new subscales (communication, vision/mission, and availability), and (2) additional tools to evaluate convergent and divergent validity (i.e., measures of general/molar leadership and teaching attitudes). Data underwent (1) examination of item characteristic curves to reduce items and ensure a pragmatic instrument, (2) confirmatory factor analyses to establish structural validity, and (3) evaluation of convergent and divergent validity. Results Item reduction analyses resulted in seven subscales of three items each. Results indicated acceptable fit for a seven-factor structural model (CFI = .995, TLI = .99, RMSEA = .07, SRMR = 0.02). Second-order factor loadings were high (λ = .89 to .96), suggesting that the SILS subscales comprise a higher-order implementation leadership factor. All subscales demonstrated good inter-item reliability (α = .91–.96). Convergent and divergent validity results were generally as hypothesized, with moderate to high correlations between SILS subscales and general leadership, moderate correlations with teaching attitudes, and low correlations with school demographics. Conclusions Overall, results provided strong structural, convergent, and divergent validity evidence for the 21-item, 7-factor SILS instrument. Implications for the measurement of implementation leadership in schools are discussed, as well as strategies to support leaders to enhance their strategic behaviors related to the implementation of mental health prevention programs (e.g., adaptation of existing leadership-focused implementation strategies).