The science of deimplementation—reducing harmful or ineffective practices—has focused almost exclusively on clinical prescribing, with no studies conducted in community or educational settings. Early care and education (ECE) settings offer a strategic venue for shaping eating behaviors, with children consuming up to 500 meals annually in these environments. However, ECE educators routinely use feeding practices that undermine self-regulation, including pressuring children to eat, rushing mealtimes, and offering food as reward. These practices contribute to food aversions, diminished self-regulation, and obesity risk. We will conduct a Hybrid Type 3 cluster-randomized trial evaluating a co-designed deimplementation strategy package (WISE Words) across 88 ECE sites in Arkansas and Louisiana. Sites will be randomized 1:1 to WISE Words or usual practice, with usual practice sites receiving the intervention after two years (waitlist design). WISE Words includes six strategies: dynamic training using improvisation methods, peer learning collaboratives with goal setting, external facilitation, audit and feedback, environmental reminders, and tailored educational materials. The primary outcome is de-adoption of inappropriate feeding practices measured via direct mealtime observation (Table Talk). Secondary outcomes include adoption of evidence-based practices, acceptability, appropriateness, and sustainability at 12- and 24-months post-intervention. Child outcomes include Body Mass Index, skin carotenoid levels (Veggie Meter) willingness to try new foods (observed) and food neophobia (teacher and caregiver report). An explanatory sequential mixed methods design will test mechanisms of change derived from the Implementation Trust Building Theory of Change examining whether trust mediates strategy effects on outcomes. This trial extends deimplementation science into community settings by targeting culturally embedded behavioral practices rather than clinical prescribing behaviors. Results will inform approaches to shifting entrenched practices in ECE and similar settings while testing trust as a deimplementation mechanism. Sustainability assessments will address a notable gap, as few studies have examined whether deimplementation effects persist. NCT07101321, July 20, 2025.
Practice facilitation is an effective multicomponent strategy that focuses on building primary care practice capacity for continuous quality improvement. Despite its growing use, few frameworks empirically specify how practice facilitation strategies are operationalized in resource-constrained settings such as small, independent primary care practices (SIPs). This study aimed to further expand our understanding of core practice facilitation processes and strategies used to facilitate the adoption of evidence-based interventions in SIPs. We conducted a qualitative analysis of practice facilitator (PF) field notes from a stepped-wedge randomized controlled trial evaluating the impact of practice facilitation on adoption of team-based care (TBC) for hypertension management in 74 SIPs across New York City. Facilitators conducted 16 structured site visits per practice over a 12-month intervention period and documented implementation activities after each visit using a standardized digital platform. We analyzed 528 visit transcripts using a hybrid deductive–inductive approach. Deductive coding focused on established practice facilitation strategy domains; inductive coding identified novel processes and strategies that emerged from the data. Coding was conducted iteratively with regular team calibration and member checking with the PF team. We identified an iterative process in which PFs observe/listen, diagnose, engage, and problem solve throughout the implementation period – a dynamic approach not described in previous frameworks. This process enhanced PFs’ understanding of each practice’s context and guided their selection and application of a core set of practice facilitation strategies. These included previously documented strategies such as training, coaching, educating, and facilitating, as well as a novel strategy we identified: modeling, in which PFs demonstrated specific tasks or workflows in real-time alongside staff, building confidence and reinforcing learning. This study refines and extends current facilitation frameworks to further define core processes and strategies that drive practice transformation in SIPs. The framework provides practical guidance for implementation efforts targeting small practice settings. ClinicalTrials.gov; NCT05413252; 2022-06-09.
The treatment of depression is essential for improving both psychiatric and medical outcomes for youth with HIV (YWH). Previous studies have shown that the combination of a medication algorithm and CBT tailored for YWH (COMB) is efficacious for decreasing depressive symptoms and improving quality of life, but sustainability of effects remains difficult. Most recently, a cluster-randomized RCT found at Week 24 statistically significant improvement in the site-level mean number of depressive symptoms, the proportion of YWH with a treatment response, and the proportion in remission at COMB sites compared to treatment as usual (TAU) sites (6.7 vs. 10.6, 62
Nurse-initiated care improves timely treatment access, but adoption varies. The Ministry of Health introduced 73 Emergency Care Assessment and Treatment (ECAT) protocols for public emergency departments (EDs) to standardise nurse-initiated care. A behaviour change strategy was used to implement ECAT in 29 EDs as part of a trial, using implementation strategies like education, clinical champions, videos, and audit and feedback. The aim of this study was to evaluate the implementation of the ECAT protocol and the strategies used for reach, effectiveness, adoption, quality, and maintenance (REAIM). This multi-method implementation evaluation used the RE-AIM framework. Methods comprised: i) emergency nurse surveys (Intervention and Control groups); ii) scoring by site implementation nurses of fidelity, adaptation and effectiveness of implementation strategies out of 5; iii) audits determining appropriateness of ECAT protocol use at 6–12 weeks and iv) implementation tracking logs during all study periods. Descriptive statistics were used for quantitative data, and content analysis for qualitative data (surveys/logs). Data from surveys (n = 787), audits (1375 audits, 509 nurses), fidelity scores (n = 11), and implementation tracking logs (>600 entries) were used to evaluate implementation of ECAT protocols in the 29 EDs. Emergency nurses reported high use of ECAT protocols in their daily practice (median (IQR) 9.0 (8.0, 10.0), and audits demonstrated 92.9
Qualitative methods are now central to implementation science, but they are used to do different kinds of work that are not always clearly distinguished. Some studies are designed to develop contextual or conceptual understanding, while others are expected to inform near-term decisions about rollout, adaptation, or implementation strategies. When these differences remain implicit, qualitative studies may be designed and evaluated against expectations they were never intended to meet, particularly around the role of theory, openness to unanticipated findings, and what counts as rigor. In this debate paper, we argue for a more explicit way of thinking about qualitative inquiry in implementation science. Rather than treating qualitative methods as a single approach, we suggest they are being configured in different ways in response to study purpose, time and resource constraints, the state of knowledge about the phenomenon or context, and stakeholder expectations. To make these differences visible, we propose a positioning framework that locates qualitative inquiry along a continuum of three orientations: Generative, Pragmatic, and Action-oriented. Generative inquiry prioritizes contextual depth and conceptual development; Action-oriented inquiry is organized to produce timely, decision-relevant findings; Pragmatic inquiry occupies the space between these poles. We then introduce a positioning guide and an accompanying table to show how these orientations shape key aspects of qualitative design, including question formulation, the role of theory, sampling, data collection, analysis, and reporting. The contribution of this paper is a framework for describing what qualitative studies in implementation science are trying to produce and how they should be assessed. Qualitative rigor cannot be reduced to a single standard when studies are making different kinds of claims. Making methodological positioning more explicit may help reduce mismatched expectations in study design and peer review, and support more consistent judgments about the contribution of qualitative work in implementation science.
Dissemination science lacks shared language for specifying what dissemination strategies are designed to achieve. Without clearly defined outcomes, researchers cannot design studies that explain why dissemination strategies succeed or fail, compare findings, or build cumulative evidence about how dissemination works. We drew on dissemination scholarship, communication and behavior theory, innovation diffusion, public policy, and organizational readiness frameworks, and two decades of applied experience within a national HIV research network, to identify and iteratively refine a set of dissemination outcomes. We propose a taxonomy of eight dissemination outcomes: Exposure, Comprehension, Credibility, Salience, Perceived Fit, Leadership Endorsement, Action Readiness, and Decision to Implement. We distinguish these from dissemination mechanisms and from implementation outcomes, locating the boundary between dissemination and implementation at the decision to implement. We illustrate the taxonomy using three studies from the Adolescent Medicine Trials Network for HIV Interventions and offer it not as a prescriptive framework but as a conceptual starting point. We hope this shared language supports clearer study design and helps build cumulative evidence about how dissemination works.
We define guideline implementability as the characteristics of the guideline that reflect the extent to which it is likely to be adopted in clinical practice. Improving the intrinsic quality (e.g., context, format, language etc.) of clinical practice guidelines (CPGs) may be a cost-effective and broadly applicable approach. This study was aimed to develop the clinical practice guidelines implementability assessment tool (CPG-IAT) and test its psychometric properties. The study used the 2022 CPGs recorded in the STAR guideline repository as the evaluation sample. The evaluation team consisted of 60 members with clinical, guideline development, or prior rating experience, responsible for assessing the included guidelines. Guideline evaluation data were randomly assigned to be utilized for an exploratory factor analysis (n = 131) or for a confirmatory factor analysis (n = 130). Reliability and validity analyses were then conducted with the full sample. The exploratory factor analysis resulted in a 16-item tool with four dimensions representing Methodological Rigor and Transparency, Recommendation Clarity and Interpretability, clinical relevance and actionability. Confirmatory factor analysis supported a priori factor structure. The tool demonstrated excellent internal consistency reliability, convergent validity, construct reliability, split-half reliability, test-retest reliability, inter-rater reliability and pragmatic. The CPG-IAT provides a psychometrically validated instrument for assessing the intrinsic implementability of CPGs both during and after the guideline development process. The CPG-IAT contributes a systematically developed and empirically validated measure of guideline implementability, with potential to inform future research and practice aimed at enhancing the translation of evidence-based guidelines into clinical practice. China Clinical Trails Registry (ChiCTR2400086931); registered July 15, 2024. https://www.chictr.org.cn/.
In this editorial we reflect on recent contributions that have focused on how researchers should involve qualitative research in implementation science. Implementation science as a discipline has firmly entered the zeitgeist and is now attracting a wealth of qualitative inquiry. We welcome qualitative manuscript submissions which focus on profound and reflexive explorations of topics relevant to the journal and call for a greater methodological diversity of qualitative methods and analytic reportage. Novel theoretical and methodological developments are considered. Finally, as we usher in a new era of guiding principles for qualitative research in the field, we set out our new expectations for reporting qualitative research and explain why it will no longer be necessary to include a ‘checklist’ for qualitative submissions to the journal.
The Implementation Research Logic Model (IRLM) was developed to enhance the rigor, transparency, and reproducibility of implementation research by integrating key elements of implementation research and practice—contextual factors/determinants, implementation strategies, mechanisms, and implementation and health outcomes—into a unified framework. Since its publication in 2020, the IRLM has been widely applied to plan, evaluate, and communicate implementation research. This paper synthesizes diverse IRLM use cases to advance its application and accelerate discovery in implementation science. We conducted a citation analysis and systematic scoping review to assess the uptake, application, and adaptation of the IRLM. A forward citation search identified 331 citing articles, and a scoping review identified 124 additional studies using other logic models. Articles were coded for IRLM use, phase of application, construct linking, data sources, community engagement, and framework integration. Descriptive statistics and thematic/pattern analysis were used to summarize findings. Of the 331 citing articles, 118 included a completed IRLM. Most were used during the planning phase (68
Abstract Background Pulmonary rehabilitation programs (PRPs) are a core component of care for people with chronic obstructive pulmonary disease (COPD), yet referral is low. The aims of this study were to; (i) engage with people with COPD receiving care at a tertiary hospital and HCPs involved in the management of people with COPD, to co-design and implement strategies that sought to improve referrals to PRPs; (ii) evaluate the effect of implementing co-designed strategies on the rate of referral to PRPs across three tertiary hospitals; and (iii) understand the sustainability of co-designed strategies by estimating relative costs and number of potentially prevented hospitalisations to achieve cost neutrality. Methods This uncontrolled quasi-experimental study was informed by the behaviour change wheel and co-design framework. It included three distinct periods: (i) pre-implementation, (ii) co-design and implementation, and (iii) post-implementation. During pre- and post-implementation, people with COPD were sequentially recruited from three tertiary hospitals. Medical records were tracked to determine PRP referral. During the co-design and implementation period, four people with COPD and six HCPs developed and implemented strategies addressing known barriers to PRP referral. Referral rates in pre- and post-implementation periods were compared using segmented Poisson regression. Sustainability was estimated by modelling the number of hospitalisations that would need to be avoided annually to offset implementation costs. Program uptake, completion, and clinical outcomes were not assessed. Results Co-designed strategies included PRP promotional products; off-loading parking expenses; deploying ‘case finders’ across the three tertiary hospitals whose primary role was to find people with COPD appropriate for a PRP and support them to engage; and visual prompts for HCPs to refer. Data were available on 590 people with COPD (age 69 ± 11 years, FEV 1 49 ± 20% predicted, 56% males). Between pre- and post-implementation periods, the mean referral rate to PRP increased from 25% to 52%, respectively (incident rate ratio 2.1, 95% confidence interval 1.1 to 3.9). Co-designed strategies would be cost neutral if they prevented 14 major or 30 minor COPD-related hospitalisations annually. Conclusions Co-designed strategies that addressed known barriers to people with COPD being referred to a PRP produced a two-fold increase in rate of referrals. Given the evidence that PRPs reduce healthcare utilisation, long-term funding of these strategies may indicate cost neutrality.
Sustaining evidence-based HIV prevention interventions remains a challenge, particularly among at-risk youth in Africa. The 4 Youth by Youth (4YBY) sustainment study is a hybrid type 2 cluster randomized controlled trial that evaluates the sustainability and cost-effectiveness of a crowdsourced approach to sustaining a package of evidence-based HIV prevention services. The study will be conducted across 40 community sites, supported by 18 community-based organizations (CBOs) providing HIV prevention services in Nigeria. Given their longstanding engagement with young people, CBOs serve as key partners in assessing long-term sustainability strategies for the 4YBY intervention, which has proven effective in increasing HIV prevention service uptake among youth. This protocol describes a cluster randomized controlled trial that will be conducted across 40 sites, all randomized into two arms. Half of the sites (20) will be assigned to receive the standard 4YBY intervention (4YBY-S), while the other 20 sites will receive the standard 4YBY intervention plus an enhanced sustainability strategy (4YBY-S + 4YBY-E). While the 4YBY-S group will continue implementing core intervention activities, the 4YBY-E group will receive additional sustainability-focused support. The Enhanced Sustainability Strategy in the 4YBY-E arm consists of four key components. First, “People” involves identifying and training sustainability teams within CBOs to champion intervention longevity. Second, “Learning”, where bi-weekly collaborative sessions will be established to foster knowledge-sharing and problem-solving among stakeholders. Third, “Adaptation Monitoring” will focus on continuously tracking and modifying intervention strategies to better align with local needs. Finally, “Nurturing Coaches” includes dedicated coaches who will provide technical assistance, conduct audits, and offer feedback to strengthen sustainability efforts. Evaluation will be guided by Youth Participatory Action Research (YPAR), the PEN-3 Cultural Model, Proctor’s Implementation Outcomes Framework, and the Consolidated Framework for Implementation Research (CFIR). The study hypothesizes that sites receiving the enhanced sustainability strategy (4YBY-S + 4YBY-E) will exhibit greater sustainability of core intervention components, defined as the continued delivery, adaptation, and integration of the intervention within community-based organizations—compared to sites receiving only the standard 4YBY intervention (4YBY-S). Additionally, the 4YBY-S + 4YBY-E arm is expected to achieve a higher uptake of HIV prevention services at 24 months, reflecting both the intervention’s effectiveness and its long-term viability within community settings. This protocol represents one of the first cluster randomized controlled trials evaluating intervention sustainment strategies for a youth-led, evidence-based HIV prevention program in Africa. Findings will advance implementation science by establishing a threshold for sustainable strategies and identifying the key factors that support the long-term integration and continuation of HIV prevention services for at-risk youth. The results critically impact scaling up community-led interventions and shaping policy frameworks to strengthen the global HIV response. The protocol was registered with clinicaltrials.gov under registration NCT07072481.
Despite ongoing efforts, achieving consistent success in implementing evidence-based practices remains challenging due to diverse, context-specific implementation needs. This analysis examined the time required to implement practices currently represented in the Universal Stages of Implementation Completion® (SIC) data repository under research-led conditions (supported by researchers) versus real-world conditions (supported by purveyors or other technical support providers). The SIC measures the implementation process across three well-established phases of implementation: Pre-implementation (Phase 1), Implementation (Phase 2), and Sustainment (Phase 3). Implementation outcomes were compared between research-led and real-world implementation conditions, representing 547 and 818 sites, respectively, across 43 program practices (i.e., interventions) in the Universal SIC repository. Descriptive analyses were conducted using data aggregated at the practice level to contrast implementation conditions. Intraclass Correlation Coefficients (ICC) from multilevel models (MLM) were calculated to compare outcome variation within and between practices. MLMs examined whether implementation condition was associated with SIC scores (proportion, duration, and Final Stage reached) and key implementation process outcomes (i.e., achieving practice Start-Up and Competency in practice delivery). In aggregated descriptive analyses, research-led sites demonstrated slightly higher rates of practice Start-Up (48
BackgroundThe potential for implementation science (IS) to address health inequities is limited by insufficient attention to power. Although the field emphasizes context, it remains unclear how best to examine and intervene on power relations related to the implementation of evidence-based interventions (EBIs). This scoping review aimed to determine: 1) To what extent do research projects studying EBI implementation explicitly examine power? 2) In these studies, how is power conceptualized, defined, operationalized, and understood? 3) What opportunities exist to examine and intervene upon power through IS research?MethodsFollowing established procedures, we undertook a six-step process: 1) articulating research question and purpose; 2) identifying relevant studies; 3) selecting studies; 4) extracting data; 5) summarizing data; and 6) reporting results. We characterized studies' attention to power using Fung's power framework, which attends to everyday, policy, structural, and ethical power. Based on publications available as of February 2022, we included English-language EBI implementation studies from clinical, community, and public health settings that explicitly attended to power. Data extraction included study context, IS frameworks used, definitions and measures of power, and characterizations of how power influenced implementation processes and outcomes.ResultsOf 3,531 articles screened, 28 papers explicitly discussed power in relation to EBI implementation and 11 presented a formal definition of power. Most studies explored everyday and structural power, with far less attention to policy power and almost none to ethical power. Conceptualizations and operationalizations of power varied widely, and few studies reported grounding in IS frameworks. Explicit strategies to intervene upon power were limited. Most studies focused on short-term integration goals, with limited discussion of how power dynamics shape what counts as evidence, whose interests are served, or opportunities for systems transformation.ConclusionsResearchers have the opportunity to explicitly integrate power theories and frameworks into conceptual models for IS studies to reshape IS efforts and build this evidence base. This will allow the field to move towards critical, systems-focused perspectives that examine how power shapes and can be used to reshape the evidence base, implementation systems, implementation strategies, and implementation, health, and system outcomes.
About one-third of the computed tomography (CT) scans ordered yearly to evaluate for pulmonary embolism (PE) in emergency departments (ED) in the U.S. are avoidable. Clinical guidelines recommend the use of validated PE prediction rules which reduce CT scan ordering without an increase in missed PEs, but there is low provider adoption. Clinical decision support (CDS) that incorporates these rules along with nudges (subtle, non-coercive influences on decision-making) may improve provider adoption. In our pilot trial of a PE risk CDS tool with a nudge at order entry, adoption was significantly higher (39.1
Process evaluation of implementation strategies is increasingly common, but a review by Bracci et al. showed that room for improvement exists. In this contribution, we complement their recommendations by ideas on the design of process evaluations. Process evaluations are meant to provide explanations for why implementation strategies were effective, or not effective. Therefore, they are best guided by theory or frameworks, but the frequent focus on intervention acceptability reflects a lack of imagination on moderators and mediators that influence outcomes. Intervention fidelity is relevant in all process evaluations. Meaningful synthesis of process evaluation studies requires a homogeneous outcome, such as uptake of practices.
BACKGROUND:Over the past two decades, implementation science has developed a strong conceptual foundation through the proliferation and widespread use of theories, models, and frameworks (TMFs). These have provided coherence, shared vocabulary, and methodological discipline across a rapidly expanding field. However, this success has also produced an unintended consequence: increasing reliance on deductive modes of inquiry, in which a limited set of established TMFs are repeatedly applied as analytic templates across diverse empirical contexts. This tendency toward early deductivism risks constraining theoretical development, reducing sensitivity to heterogeneity, complexity, and temporality inherent in implementation, and reinforcing methodological circularity. TOWARD AN INDUCTIVE RENEWAL OF IMPLEMENTATION SCIENCE:In this conceptual paper, we argue for an inductive renewal of implementation science that rebalances deduction with stronger inductive and abductive forms of reasoning. Rather than abandoning established TMFs, we propose reframing them as evolving heuristics - resources for structuring inquiry that remain open to refinement, extension, and selective reconfiguration through empirical engagement. We clarify the complementary roles of induction, abduction, and deduction in theory development, emphasizing abductive iteration as a mechanism for translating empirical discovery into cumulative conceptual advancement. We outline strategies for advancing this agenda across three interdependent levels. At the study level, this involves treating TMFs as provisional heuristics, re-embracing qualitative discovery, and using abductive reasoning to refine theory through engagement with unexpected findings. At the field level, shared infrastructures for synthesis and longitudinal learning are needed to support cumulative, context-sensitive theorizing and to account for the temporal dynamics of implementation. Institutionally, journals and funders must recalibrate incentives to value theory development, adaptation, and transparency alongside theory application. Drawing on examples from research on knowledge brokering and implementation scale-up, we show how theoretically informative contributions emerge when empirical surprises, temporal dynamics, and analytic tensions are used to interrogate and refine existing TMFs rather than being absorbed into pre-specified categories. CONCLUSION:A mature implementation science must move beyond asking which TMF best fits a study, toward examining how empirical phenomena challenge, extend, and reshape theory. Sustaining this balance is essential for theoretical coherence and continued conceptual innovation.
Artificial intelligence (AI), including machine learning, natural language processing, and large language models, may support implementation practice and research in tasks such as evidence synthesis, determinant assessment, strategy selection, monitoring, adaptation, and theory development. However, these applications of AI do not form a single, uniform category. They span a continuum from practice-facing applications that support local implementation work to research- and methods-facing applications that support evidence generation and synthesis. The guidance on how to classify, evaluate, and report these uses of AI remains limited. The AI Methods for Implementation Science (AIM-IS) program aims to develop, validate, and maintain a suite of products to guide the responsible use of AI across implementation practice, implementation research, and bridging use cases. AIM-IS is a multi-phase, multi-method methodological development program. The unit of analysis is the AI-for-implementation use case: a specific AI capability supporting a defined implementation practice or research task within a workflow, decision point, and governance context. Phase 1 is a living scoping review mapping published AI use cases in implementation science, including how they are evaluated and what risks they raise. Phase 2 is a qualitative interview study with implementation researchers, practitioners, AI experts, community members, and data infrastructure and governance experts to refine use cases and identify feasibility constraints, outcome priorities, and reporting needs. Phase 3 will integrate findings from Phases 1 and 2 to develop the draft AIM-IS products, including a framework, a taxonomy of use cases, guardrails for responsible use, a practical guide, outcome domains, and reporting items. Phase 4 will use an eDelphi process and consensus meeting to refine and finalize these products. Phase 5 will conduct usability testing to improve clarity and ease of use, resulting in the finalized AIM-IS products. AIM-IS is informed by implementation science, sociotechnical systems, equity, and responsible AI frameworks, and includes a living-update approach to support ongoing refinement. The AIM-IS program will deliver a suite of products, including a framework, toolkit and reporting standard, to support the specification, governance, evaluation, and reporting of AI in implementation science. Together, these products aim to strengthen transparency, comparability, accountability, and attention to equity in how AI is used by implementation practitioners and researchers over time. Open Science Framework, March 15, 2026: https://doi.org/10.17605/OSF.IO/BX35K
Maternal health service utilization remains low in Bangladesh, while maternal health outcomes are poor and adolescent pregnancy rates are high. In this context, targeted social and behavior change communication (SBCC) can be an effective approach. This targeted SBCC research was participatorily designed in collaboration with Bangladesh local partners and was funded as part of the 2023–27 KOICA Strategic Partnership Program (SPP)- Strengthening Maternal and Neonatal Health System in Rangpur, Bangladesh (No. 2023–0515). The study was informed by implementation and behavior change theories, engaging key family members in the intervention. A hybrid effectiveness-implementation type II cluster-randomized study was designed to measure key maternal health service utilization outcomes as well as implementation outcomes. A total of 750 participants classified into four targeted groups-1) adolescent pregnant women, 2) adult pregnant women, 3) husbands and 4) mothers-in-law, will be invited to participate in group-based interactive community courtyard sessions. These 5-month curriculum targeted SBCC sessions cover maternal and newborn health topics such as antenatal care (ANC), safe delivery, postnatal care (PNC), and neonatal care. The primary outcomes include four or more ANC visits, facility delivery, Postnatal Care (PNC) and neonatal care within 48 h after delivery. Secondary outcomes are perceptions on early marriage, maternal health-seeking behaviors, family support, decision making, and satisfaction with the information gained from the targeted SBCC sessions. To assess the effectiveness, baseline and endline surveys, along with endline focus group discussions (FGDs) will be conducted before and after the 5-month curriculum. Additionally, implementation outcomes such as adoption, penetration, acceptability, coverage, feasibility, fidelity, and sustainability will be measured. This study engages key decision-makers such as pregnant women, their husbands, and mothers-in-law, to enhance maternal health service utilization. As Bangladesh is a patriarchal society, men within households are often the primary decision-makers regarding marriage and reproductive matters. Moreover, the child marriage and adolescent pregnancy rates remain high, contributing to persistently elevated maternal and neonatal mortality. By applying implementation science frameworks and behavior change theories, this study aims to generate evidence to inform future scale-up efforts in similar contexts. The protocol was registered with ISRCTN registry under registration ISRCTN12515877.
Abstract Background Homelessness is a national crisis in the United States, particularly in the veteran population. Due to multiple chronic conditions, homeless individuals have elevated risk for acute care service use. Engagement in primary and specialty care can mitigate this risk. Interventions grounded in evidence-based practices of peer support, patient-centered care, and whole health are effective for increasing service engagement. However, implementation of such interventions with high-acuity patients often requires multi-component strategies that are intensive and costly. This protocol paper describes a hybrid type 3 effectiveness-implementation trial of Employing Peer Outreach and Whole Health in Recovery (EMPOWER) with high-need, homeless-experienced veterans in permanent supportive housing and will evaluate the impact and cost of high-intensity (vs. low-intensity) implementation strategies on outcomes. Methods (Aim 1) At 7 sites in the Veterans Health Administration (VA), a mixed methods pre-implementation evaluation will identify determinants and their potential impact on uptake of EMPOWER and inform modifications to the intervention and implementation strategies as needed. (Aim 2) A staircase cluster randomized design will evaluate the rollout of the implementation strategies, beginning with Audit and Feedback (low-intensity) and then switching to Implementation Facilitation (high-intensity) after 6 months. Implementation Facilitation is hypothesized to have a greater impact on the reach, effectiveness, adoption, implementation (fidelity), and maintenance of EMPOWER. (Aim 3) A budget impact analysis will estimate the average cost of implementing EMPOWER at future sites and comparative costs for implementing the low- and high-intensity strategies. Discussion This project will provide information on the relative impacts and relative costs of strategies aimed at implementing a peer-led, patient-centered, whole health intervention for homeless-experienced veterans in permanent supportive housing. The findings will provide guidance to VA and other healthcare systems that serve the aging population of homeless-experienced veterans. Trial registration Clinicaltrials.gov (NCT07309224).
Abstract Background Monitoring systems are important for evaluating key outcome measures, identifying opportunities for improvement, and informing public health investment. While disease surveillance systems are highly developed and widely used, monitoring systems for the implementation of public health programs and policies in community settings are less established. To address this gap, this review aimed to: 1) describe the scope of the literature on implementation monitoring systems and their operational features; and 2) synthesise this literature to produce features and suggested actions for system design. Methods A systematic search of five databases and grey literature sources was conducted to identify systems, frameworks, or guidance for monitoring the implementation of public health programs or policies in community settings. Studies focused on clinical healthcare, or disease surveillance were excluded. Two authors independently screened titles, abstracts, and full texts for eligibility. Included documents were then categorised by ‘Case’ (one or more documents exploring the same monitoring system, framework, or topic). For Research Aim 1, characteristic data for each Case were extracted and narratively summarised. For Research Aim 2, Best Fit Framework Synthesis was employed using an a priori framework informed by disease surveillance models. Full text of included documents were coded, and the framework iteratively modified, to develop a new framework with key features and suggested actions relevant to implementation monitoring systems in community settings. Results Ninety-seven documents were identified, describing 75 distinct real-world implementation monitoring Cases. Aim 1: Most Cases were intended for use in high-income countries (64%) and focused on monitoring programs (81%) rather than policy. The most common topic areas related to nutrition (36%) and reproductive, HIV, and sexual health (28%). Primary responsibility for monitoring systems was most often held by national-level agencies (43%). Aim 2: Synthesis led to 13 key features of monitoring systems, with corresponding suggested actions across five broad Action Areas: 1) planning and preparation; 2) data collection activities; 3) system appraisal; 4) partner engagement, and 5) system revision. Conclusions Findings emphasise that monitoring systems require attention across multiple Action Areas, including planning and resourcing, data collection, partner engagement, and system improvements (through both proactive appraisals and real-time response). This manuscript offers a foundational framework to guide policymakers and practitioners in monitoring the implementation of community-based public health policy or programs.
