HEP4205 Tutorial Cases
Case 1 – Does the Puzzle Fit?
Learning Goals
1. What is dissemination and implementation? [1]
2. What are implementation determinants, which can be defined?
3. What is the Consolidated Implementation Framework (Damshröder)?
4. What is the Rogers Framework?
5. What is the Fleuren Framework?
6. What differences and similarities can be identified when comparing the way in
which Damshröder, Fleuren, and Rogers describe determinants of
implementation?
7. What are determinants that could function as potential barriers and facilitators
for implementation and dissemination, as explained by Damshröder, Fleuren
and Rogers,applied to the 10.000 steps project in Limburg?
1. What is dissemination and implementation?
Rabin, B.A. & Brownson R.C. (2018). Terminology for dissemination and implementation
research. In: Brownson, R.C., Colditz, G.A., & Proctor, E.K. (Eds) (2nd ed.). Dissemination
and implementation research in health: Translating science to practice. (pp. 19-46). Oxford:
Oxford University Press.
Evidence-Based Intervention
The subjects of D&I activities are interventions with proven efficacy and effectiveness (i.e.,
evidence-based). Interventions within D&I research are defined broadly and may include
programs, practices, processes, policies, and guidelines. More comprehensive definitions of
evidence-based interventions are available elsewhere. In D&I research, we often encounter
complex interventions (e.g., multilevel interventions using community-wide education) where
the description of core intervention components and their relationships involve multiple
settings, audiences, and approaches.
Diffusion
● passive, untargeted, unplanned, and uncontrolled spread of new interventions.
● part of the diffusion-dissemination-implementation continuum
● least focused and intense approach.
Dissemination
= an active approach of spreading evidence-based interventions to the target
audience via determined channels using planned strategies.
,Implementation
= process of putting to use or integrating evidence-based interventions within a
setting.
● Mis-implementation involves one or both of two processes: the discontinuation of
effective programs and the continuation of ineffective practices in the context of
public health.
○ Mis-implementation is a broader term while de-implementation focuses on the
discontinuation component of mis-implementation.
Reach
= the ability of a program to engage its ultimate target audience in terms of quantity
(number/percent of participant) and quality (representativeness of participants).
● reach of a program can greatly influence the level of public health impact the
program can achieve.
Dissemination Research
● systematic study of processes and factors that lead to widespread use of an
evidence-based intervention by the target population.
● focus: identify the best methods that enhance the uptake and utilization of the
intervention.
Implementation Research
● seeks to understand the processes and factors that are associated with successful
integration of evidence-based interventions within a particular setting (e.g., a worksite
or school)
● assesses whether the core components of the original intervention were faithfully
transported to the real-world setting (i.e., the degree of fidelity of the disseminated
and implemented intervention with the original study)
● is concerned with the adaptation of the implemented intervention to local context
● Another essential component of IR: enhancement of readiness through the creation
of effective climate and culture in an organization or community.
Diffusion of Innovations
● proposed by Rogers to explain the processes and factors influencing the spread and
adoption of new innovations through certain channels over time.
● Key components of the diffusion theory: (1) perceived attributes of the innovation; (2)
innovativeness of the adopter; (3) social system; (4) individual adoption process; and
(5) diffusion system.
RE-AIM Framework
● developed by Glasgow and colleagues
● provides a conceptual model to guide researchers and practitioners in the
development of adequate multistage (reach, adoption, implementation, maintenance)
and multilevel (individual, setting) indicators when evaluating D&I efforts.
,Consolidated Framework for Implementation Research
● developed by Damschroder and colleagues to provide “an overarching typology to
promote implementation theory development and verification about what works
where and why across multiple contexts.”
● is composed of five major domains (i.e., intervention characteristics, outer setting,
inner setting, characteristics of the individuals involved, and the process of
implementation) and each domain includes multiple constructs (e.g., evidence
strength and quality, patient needs and resources, culture, evaluate).
Strategies for D&I
Dissemination Strategy
Dissemination strategies describe mechanisms and approaches that are used to
communicate and spread information about interventions to targeted users. Dissemination
strategies are concerned with the packaging of the information about the intervention and
the communication channels that are used to reach potential adopters and target audience.
Passive dissemination strategies include mass mailings, publication of information including
practice guidelines, and untargeted presentations to heterogeneous groups. Active
dissemination strategies include hands-on technical assistance, replication guides, point-of-
decision prompts for use, and mass media campaigns. It is consistently stated in the
literature that dissemination strategies are necessary but not sufficient to ensure widespread
use of an intervention.
, Implementation Strategy
Implementation strategies refer to the systematic processes or methods, techniques,
activities, and resources that support the adoption, integration, and sustainment of
evidence-based interventions into usual settings. Fixsen and colleagues refer to
implementation strategies as core implementation components or implementation drivers
and list staff selection, preservice and in-service training, ongoing consultation and coaching,
staff and program evaluation, facilitative administrative support, and systems interventions
as components. Powell and colleagues differentiated discrete (i.e., individual implementation
actions such as reminders, educational meetings), multifaceted (i.e., combination of two or
more discrete strategies such as training with technical assistance), and blended (i.e.,
protocolized implementation strategies).
2. What are implementation determinants, which can be
defined?
→ Factors which can affect implementation
Different theories (Fleuren, Damschröder & Rogers) include different determinants but most
state same types of determinants:
● Characteristics innovation
● Characteristics people using it
● Characteristics organisation/inner setting
● Characteristics of outer setting
● Characteristics of process or strategies that are being implemented
● Barriers, hinders, obstacles, impediments, enablers, and facilitators.
Aim of the frameworks:
● identification of the determinants of practice
● designing implementation interventions appropriate to the determinants
● application and assessment of implementation interventions that are matched to the
identified determinants
3. What is the Consolidated Implementation Framework
(Damshröder)?
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering
implementation of health services research findings into practice: a consolidated framework
for advancing implementation science. Implement Sci 2009;4:50.
Foundational definitions
Implementation, by its very nature, is a social process that is intertwined with the context in
which it takes place.
For implementation research, 'context' is the set of circumstances or unique factors that
surround a particular implementation effort.
