Implementation Strategies and Targets in Health and Mental Health

Background and Purpose: Despite increasing acknowledgement of the importance of evidence-based practice, many consumers of health and mental health care receive substandard services while empirically supported treatments (ESTs) “languish on the shelves” (Institute of Medicine, 2006). Indeed, it may take 10-20 years before a promising treatment is implemented in routine care (Institute of Medicine, 2001). This highlights the importance of identifying, developing, and refining strategies to disseminate and implement ESTs (National Institute of Mental Health PAR-10-038, 2010). Implementation science is in its relative infancy, though progress has been made with regard to 1) the identification of strategies and 2) the development of conceptual models that highlight specific targets for change. This study attempts to bridge these two literatures by connecting discrete implementation strategies to implementation targets in an effort to advance the conceptual literature. Potential targets fall within the following domains: practitioner (awareness, skill, etc.); intervention characteristic (complexity, etc.); organization (culture, readiness for change, etc.); consumer (awareness of ESTs, etc.) community (unique cultural considerations, etc.), policy (funding and regulatory environment, etc.); and implementation outcomes (acceptability, sustainability, etc.). The objective of this study is to assess 1) whether there is a theoretical and pragmatic benefit in matching strategies to targets, and 2) whether the targets are adequately addressed by identified implementation strategies.

Method: A taxonomy of implementation strategies developed by the Cochrane Effective Practice and Organisation of Care Review Group (2002) was used as a starting point to organize a list of strategies, and was supplemented with other strategies from the implementation literature. For the current study, a research team paired implementation strategies with implementation targets and discussed theoretical and practical justifications for inclusion until consensus was reached. These pairings were subsequently scrutinized by a transdisciplinary implementation research workgroup with medical, behavioral, and applied social science expertise in order to obtain further consensus about the fit between each strategy and target.

Results: Consensus was reached on a total of over 50 implementation strategies and over 40 targets. Many of the strategies proved to be quite versatile and had the potential to address multiple implementation targets. However, it was very clear that multiple strategies would be required in order to address the wide range of implementation targets. There were also several targets that were not well addressed by the current list of implementation strategies. For instance, practitioner level targets such as perceived self-efficacy and emotional responses to implementation were not well addressed. Finally, there was a dearth of strategies that seemed to have the potential to impact consumer, community, and policy-level implementation targets.

Conclusions and Implications: Though further empirical work is needed to determine the effectiveness of individual and bundled implementation strategies, this study highlights the importance of conceptual models of implementation, and suggests that strategies can be selected based upon the extent to which they address the targets for change that are most relevant to specific stakeholders and organizational contexts. Consumer, community, and policy level targets are too frequently ignored despite their integral role in the ultimate success of implementation efforts.