Applying Multiple Frameworks and Theories in Implementation Research

1. Applying Multiple Frameworks and Theories in Implementation Research Jeffrey Smith Implementation Research Coordinator Mental Health QUERI

2. “In theory there is no difference between theory and practice… in practice there is.” Yogi Berra

3. Mental Health QUERI Approach to Implementation • Design interventions based on theory, lit review and results from formative evaluation • Conduct formative evaluation • engage with stakeholders • identify determinants of current practice • assess barriers and facilitators to implementation • organizational-level • team / clinic-level • individual provider-level • patient-level • tailor intervention design and implementation to local context

4. Mental Health QUERI Approach to Implementation (cont) • Use external facilitation techniques (PARiHS Framework) • engage with stakeholders to problem-solve and identify new strategies or tools for overcoming barriers when initial success is sub-optimal • Conduct summative (or impact) evaluation

5. An Approach to Using Theory for Implementation Planning Select framework / theory / model of planned behavior change Select interventionsthat fit with plannedstrategies (based on theory) Identify potential strategies for achieving change Assess fit with initial theory Evaluate effectivenessof intervention,strategies, tools Launch interventionusing identified toolsand strategies Identify interventiontools that fit bothstrategy and theory Adapted from: Sales A, Smith JL, Curran G, Kochevar L. Models, strategies and tools: The role of theory in implementing evidence-based findings into health care practice. Journal of General Internal Medicine 2006; 21:S43-49.

6. Implementation Science Frameworks and Theories (selected) • Organizational / System Level • Consolidated Framework for Implementation Research (VA Diabetes QUERI) • Promoting Action on Research Implementation in Health Services (PARiHS) • Stetler Organizational Framework for Institutionalizing EBPs • Greenhalgh Model for Diffusing Innovations in HCOs • Ottawa Model of Research Use • Simpson Transfer Model • Complexity Theory

7. Implementation Science Frameworks and Theories (cont.) • Interpersonal Level • Diffusion of Innovation (Rogers) • Social Influence Theory (Mittman) • Social Cognitive Theory… aka Social Learning Theory (Bandura) • Individual Level • Theory of Reasoned Action / Theory of Planned Behavior (Azjen & Fishbein) • Health Belief Model (Rosenstock) • Transtheoretical Model and Stages of Change (Prochaska & DiClemente)

8. Strengths • useful in designing multifaceted interventions to influence multi-level determinants of care (flexible) • allows integration of theory, knowledge, methods from multiple disciplines (multidisciplinary) • Limitations • Can be unwieldy… need to provide rationale for applying multiple theory approach, and rationale for selecting the specific frameworks / theories applied • Key Guidance on Evaluation • combine with rigorous formative evaluation • conduct summative (impact) evaluation to assess intervention effectiveness on key study outcomes • confirm, refute or propose refinements to selected theory(ies) based on study findings Multiple theory approach

9. Summary Application of multiple frameworks/theories in guiding intervention design and implementation can be successful in implementing EBPs accommodates tailoring to setting when combined with formative evaluation example forthcoming (May 5 session) acknowledges there are generally multi-level determinants to complex, clinical QI issues organizational-level team-level interpersonal-level individual-level

10. QUESTIONS? Contact: Jeff Smith VA Mental Health QUERI E-mail: Jeffrey.Smith6@va.gov