Where to start? There are so many!
One of the cornerstones of implementation science is the use of theory.
Unfortunately, the vast number of theories, models, and frameworks available in the implementation science toolkit can make it difficult to determine which is the most appropriate to address or frame a research question. There are dozens of theories, models, and frameworks used in implementation science that have been developed across a wide range of disciplines, and more are published each year.
Two reviews provide schemas to organize implementation science theories, models, and frameworks and narrow the range of choices:
Bridging research and practice: models for dissemination and implementation research (Tabak, Khoong, Chambers, & Brownson, 2013)
Tabak et al’s schema organizes 61 dissemination and implementation models based on three variables: 1) construct flexibility, 2) focus on dissemination and/or implementation activities, and 3) socio-ecological framework level.
The authors argue that classification of a model based on these three variables will assist in selecting a model to inform D&I science study design and execution. For more information, check out this archived NCI webinar with presenters Dr. Rachel Tabak and Dr. Ted Skolarus:
💻 Applying Models and Frameworks to D&I Research: An Overview & Analysis.
✪ Making sense of implementation theories, models, and frameworks (Nilsen, 2015)
Per Nilsen's schema sorts implementation science theories, models, and frameworks into five categories:
1) process models, 2) determinants frameworks, 3) classic theories, 4) implementation theories, and 5) evaluation frameworks.
Adapted from: Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(1):1-13.
Below, we borrow from Nilsen’s schema to organize overviews of a selection of implementation science theories, models, and frameworks. In each overview, you will find links to additional resources.
Open Access articles will be marked with ✪
Please note some journals will require subscriptions to access a linked article.
What are you using implementation science to accomplish?
Process Models
In 2013, Chambers, Glasgow, and Stange published ✪ The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change in the Open Access (✪) journal Implementation Science. The Dynamic Sustainability Framework arose from the need to better understand how the sustainability of health interventions can be improved.
Examples of Use
- ✪ Results-based aid with lasting effects: Sustainability in the Salud Mesoamérica Initiative (Globalization and Health, 2018)
- ✪ Study Protocol: A Clinical Trial for Improving Mental Health Screening for Aboriginal and Torres Strait Islander Pregnant Women and Mothers of Young Children Using the Kimberley Mum's Mood Scale (BMC Public Health, 2019)
- ✪ Sustainability of Public Health Interventions: Where Are the Gaps? (Health Research Policy and Systems, 2019)
Recognizing that implementation science frameworks were largely developed using research from business and medical contexts, Aarons, Hurlburt, and Horwitz created the four-phase implementation model EPIS (Exploration, Adoption/Preparation, Implementation, Sustainment) in 2010 to address implementation in public service sector contexts. The framework development article, Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors, is available open access (✪) from Administration and Policy in Mental Health and Mental Health Services Research.
In 2018 the authors refined the EPIS model into the cyclical EPIS Wheel, allowing for closer alignment with rapid-cycle testing. A model for rigorously applying the Exploration, Preparation, Implementation, Sustainment (EPIS) framework in the design and measurement of a large scale collaborative multi-site study is available Open Access (✪) from Health & Justice.
Learn More
- ✪ Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Implementation Science, 2019)
- A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration (Administration and Policy in Mental Health and Mental Health Services Research, 2016)
- Advancing Implementation Research and Practice in Behavioral Health Systems (Administration and Policy in Mental Health and Mental Health Services Research, 2016)
- ✪ A model for rigorously applying the Exploration, Preparation, Implementation, Sustainment (EPIS) framework in the design and measurement of a large scale collaborative multi-site study (Health and Justice, 2018)
- Characterizing Shared and Unique Implementation Influences in Two Community Services Systems for Autism: Applying the EPIS Framework to Two Large-Scale Autism Intervention Community Effectiveness Trials (Administration and Policy in Mental Health and Mental Health Services Research, 2019)
- ✪ Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Implementation Science, 2019)
- 💻 WEBINAR: Use of theory in implementation research: The EPIS framework: A phased and multilevel approach to implementation
The need to adapt to local context is a consistent theme in the adoption of evidence based practices, and in 2012 researchers published the Dynamic Adaption Process to address this need. Finding that adaptation was often ad hoc rather than intentional and planned, the DAP helps identify core components and adaptable characteristics of an evidence based practice and supports implementation with training. The framework development article, Dynamic adaptation process to implement an evidence-based child maltreatment intervention, was published in the open access journal, Implementation Science.
Examples of Use
- ✪ A two-way street: bridging implementation science and cultural adaptations of mental health treatments (Implementation Science, 2013)
- ✪ “Scaling-out” evidence-based interventions to new populations or new health care delivery systems (Implementation Science, 2017)
- ✪ Implementing measurement based care in community mental health: a description of tailored and standardized methods (Implementation Science, 2018)
- ✪ "I Had to Somehow Still Be Flexible": Exploring Adaptations During Implementation of Brief Cognitive Behavioral Therapy in Primary Care (Implementation Science, 2018)
- An Implementation Science Approach to Antibiotic Stewardship in Emergency Departments and Urgent Care Centers (Academic Emergency Medicine, 2020)
In 2008, Feldstein and Glasgow developed the Practical, Robust Implementation and Sustainability Model (PRISM) to address the lack of consideration of non-research settings in efficacy and effectiveness trials. This model evaluates how the intervention interacts with recipients to influence program adoption, implementation, maintenance, reach, and effectiveness. The framework development article was published by The Joint Commission Journal on Quality and Patient Safety.
Examples of Use
- Using the Practical, Robust Implementation and Sustainability Model (PRISM) to Qualitatively Assess Multilevel Contextual Factors to Help Plan, Implement, Evaluate, and Disseminate Health Services Programs (Translational Behavioral Medicine, 2019)
- Stakeholder Perspectives on Implementing a Universal Lynch Syndrome Screening Program: A Qualitative Study of Early Barriers and Facilitators (Genetics Medicine, 2016)
- Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Five Veterans Health Administration (VHA) Hospitals (The Joint Commission Journal on Quality and Patient Safety, 2018)
In 2012 Meyers, Durlak, and Wandersman synthesized information from 25 implementation frameworks with a focus on identifying specific actions that improve the quality of implementation efforts. The result of this synthesis was the Quality Implementation Framework (QIF), published in the American Journal of Community Psychology. This framework is comprised of fourteen critical steps across four phases of implementation, and has been used widely in child and family services, behavioral health, and hospital settings.
Examples of Use
- ✪ Practical Implementation Science: Developing and Piloting the Quality Implementation Tool (American Journal of Community Psychology, 2012)
- Survivorship Care Planning in a Comprehensive Cancer Center Using an Implementation Framework (The Journal of Community and Supportive Oncology, 2016)
- ✪ The Application of an Implementation Science Framework to Comprehensive School Physical Activity Programs: Be a Champion! (Frontiers in Public Health, 2017)
- ✪ Developing and Evaluating a Lay Health Worker Delivered Implementation Intervention to Decrease Engagement Disparities in Behavioural Parent Training: A Mixed Methods Study Protocol (BMJ Open, 2019)
- Implementation Process and Quality of a Primary Health Care System Improvement Initiative in a Decentralized Context: A Retrospective Appraisal Using the Quality Implementation Framework (The International Journal of Health Planning and Management, 2019)
Determinant Frameworks
In 2005, the National Implementation Research Network (NIRN) published an Open Access (✪) monograph synthesizing transdisciplinary research on implementation evaluation. The resulting Active Implementation Frameworks (AIFs) include the following five elements: Usable Intervention Criteria, Stages of implementation, Implementation Drivers, Improvement Cycles, and Implementation Teams. A robust support and training website is maintained by NIRN, complete with activities and assessments to guide active implementation.
Learn More:
- Statewide Implementation of Evidence-Based Programs (Exceptional Children, 2013)
- Active Implementation Frameworks for Successful Service Delivery: Catawba County Child Wellbeing Project (Research on Social Work Practice, 2014)
- The Active Implementation Frameworks: A roadmap for advancing implementation of Comprehensive Medication Management in primary care (Research in Social and Administrative Pharmacy, 2017)
In 2009, Veterans Affairs researchers developed a menu of constructs found to be associated with effective implementation across 13 scientific disciplines. Their goal was to review the wide range of terminology and varying definitions used in implementation research, then construct an organizing framework that considered them all. The resulting Consolidated Framework for Implementation Research (CFIR) has been widely cited and has been found useful across a range of disciplines in diverse settings.
For additional resources, please visit the CFIR Technical Assistance Website. The website has tools and templates for studying implementation of innovations using the CFIR framework, and these tools can help you learn more about issues pertaining to inner and outer contexts. You can read the original framework development article in the Open Access (✪) journal Implementation Science.
Learn More:
- ✪ Evaluating and Optimizing the Consolidated Framework for Implementation Research (CFIR) for use in Low- and Middle-Income Countries: A Systematic Review (Implementation Science, 2020)
- ✪ A systematic review of the use of the Consolidated Framework for Implementation Research (Implementation Science, 2017)
- Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: A rapid-cycle evaluation approach to improving implementation (Implementation Science, 2017)
- ✪ The Consolidated Framework for Implementation Research: Advancing implementation science through real-world applications, adaptations, and measurement (Implementation Science, 2015)
- 💻 WEBINAR: Use of theory in implementation research: Pragmatic application and scientific advancement of the Consolidated Framework for Implementation Research (CFIR) (Dr. Laura Damschroder, National Cancer Institute of NIH Fireside Chat Series)
In 2005, Dr. Susan Michie and colleagues published the Theoretical Domains Framework in BMJ Quality & Safety, the result of a consensus process to develop a theoretical framework for implementation research. The primary goals of the development team were to determine key theoretical constructs for studying evidence based practice implementation and for developing strategies for effective implementation, and for these constructs to be accessible and meaningful across disciplines.
Learn More
- ✪ Validation of the theoretical domains framework for use in behaviour change and implementation research (Implementation Science, 2012)
- ✪ Theoretical domains framework to assess barriers to change for planning health care quality interventions: a systematic literature review (Journal of Multidisciplinary Healthcare, 2016)
- ✪ Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): a systematic review (Implementation Science, 2017)
- ✪ Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses’ use of electronic medication management systems in two Australian hospitals (Implementation Science, 2017)
- ✪ A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems (Implementation Science, 2017)
Examples of Use
- ✪ Hospitals Implementing Changes in Law to Protect Children of Ill Parents: A Cross-Sectional Study (BMC Health Services Research, 2018)
- Addressing the Third Delay: Implementing a Novel Obstetric Triage System in Ghana (BMJ Global Health, 2018)
Using collective experience in research, practice development, and quality improvement efforts, Kitson, Harvey and McCormack proposed in 1998 that success in implementation is a result of the interactions between evidence, context, and facilitation. Their resulting Promoting Action on Research Implementation in Health Services (PARIHS) framework posits that successful implementation requires clear understanding of the evidence in use, the context involved, and the type of facilitation utilized to achieve change.
The original framework development article, Enabling the implementation of evidence based practice: a conceptual framework is available Open Access (✪) from BMJ Quality & Safety.
Learn More:
- Ingredients for change: revisiting a conceptual framework (BMJ Quality & Safety, 2002)
- Evaluating the successful implementation of evidence into practice using the PARIHS framework: theoretical and practical challenges (Implementation Science, 2008)
- ✪ A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework (Implementation Science, 2010)
- ✪ A Guide for applying a revised version of the PARIHS framework for implementation (Implementation Science, 2011)
- 💻 WEBINAR: Use of theory in implementation research; Pragmatic application and scientific advancement of the Promoting Action on Research Implementation in Health Services (PARiHS) framework
Classic Theories
In 2017 Dr. Sarah Birken and colleagues published their application of four organizational theories to published accounts of evidence-based program implementation. The objective was to determine whether these theories could help explain implementation success by shedding light on the impact of the external environment on the implementing organizations.
Their paper, ✪ Organizational theory for dissemination and implementation research, published in the journal Implementation Science utilized transaction cost economics theory, institutional theory, contingency theories, and resource dependency theory for this work.
In 2019, Dr. Jennifer Leeman and colleagues applied these same three organizational theories to case studies of the implementation of colorectal cancer screening interventions in Federally Qualified Health Centers, in ✪ Advancing the use of organization theory in implementation science (Preventive Medicine, 2019).
In 2005 the NIH published ✪ Theory at a Glance: A Guide For Health Promotion Practice 2.0, an overview of behavior change theories. Below are selected theories from the intrapersonal and interpersonal ecological levels most relevant to implementation science.
There are two intrapersonal behavioral theories most often used to interpret individual behavior variation:
The Health Belief Model: An initial theory of health behavior, the HBM arose from work in the 1950s by a group of social psychologists in the U.S. wishing to understand why health improvement services were not being used. The HBM posited that in the health behavior context, readiness to act arises from six factors: perceived susceptibility, perceived severity. perceived benefits, perceived barriers, a cue to action, and self-efficacy. To learn more about the Health Belief Model, please read "Historical Origins of the Health Belief Model" (Health Education Monographs).
The Theory of Planned Behavior: This theory, developed by Ajzen in the late 1980s and formalized in 1991, sees the primary driver of behavior as being behavioral intention. Through the lens of the TPB, behavioral intention is believed to be influenced by an individual's attitude, their perception of peers' subjective norms, and the individual's perceived behavioral control.
At the interpersonal behavior level, where individual behavior is influenced by a social environment, Social Cognitive Theory is the most widely used theory in health behavior research.
Social Cognitive Theory: Published by Bandera in the 1978 article, Self-efficacy: Toward a unifying theory of behavioral change, SCT consists of six main constructs: reciprocal determinism, behavioral capability, expectations, observational learning, reinforcements, and self-efficacy (which is seen as the most important personal factor in changing behavior).
Examples of use in implementation science:
The Health Belief Model
- ✪ Using technology for improving population health: comparing classroom vs. online training for peer community health advisors in African American churches (Implementation Science, 2015)
The Theory of Planned Behavior
- ✪ Assessing mental health clinicians’ intentions to adopt evidence-based treatments: reliability and validity testing of the evidence-based treatment intentions scale (Implementation Science, 2016)
Social Cognitive Theory
Diffusion of Innovation theory has its roots in the early twentieth century, but the modern theory is credited to Everett Rogers with his publication in 1962 of Diffusion of Innovations. This theory holds that adopters of an innovation can be split into five categories that distribute in a Bell curve over time: innovators (2.5%), early adopters (13.5%), early majority (34%), late majority (34%) and laggards (16%). Further, the theory states that any given adopter's desire and ability to adopt an innovation is individual, based on information about, exposure to, and experience of the innovation and adoption process.
Learn More:
- Diffusion of preventive innovations (Addictive Behaviors, 2002)
- ✪ Diffusion of Innovation Theory (Canadian Journal of Nursing Informatics, 2011)
Implementation Theories
In 2011, Weiner, Belden, Bergmire, and Johnston published ✪ The meaning and measurement of implementation climate in Implementation Science to address the lack of theory behind the impact of climate in innovation implementation. They argued that implementation climate is distinct from constructs such as organizational climate, culture, or context in both its strategic focus on implementation and because it is innovation-specific.
Learn More:
- ✪ Implementing community-based provider participation in research: an empirical study (Implementation Science, 2012)
- ✪ Context matters: measuring implementation climate among individuals and groups (Implementation Science, 2014)
- ✪ Determining the predictors of innovation implementation in healthcare: a quantitative analysis of implementation effectiveness (BMC Health Services Research, 2015)
In 2009, Bryan Weiner developed a theory of organizational readiness for change to address the lack of theoretical development or empirical study of the commonly used construct. In the Open Access (✪) development article, organizational readiness for change is conceptually defined and a theory of its determinants and outcomes is developed. The focus on the organizational level of analysis filled a theoretical gap necessary to address in order to refine approaches to improving healthcare delivery entailing collective behavior change and in 2014, Shea et al published a measure of organizational readiness for implementing change, based on Weiner's 2009 theory, available Open Access (✪) through Implementation Science.
Learn More:
- Review: Conceptualization and Measurement of Organizational Readiness for Change (Medical Care Research and Review, 2008)
- ✪ Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study (Implementation Science, 2013)
- ✪ Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory (Implementation Science, 2018)
- ✪ Assessing the reliability and validity of the Danish version of Organizational Readiness for Implementing Change (ORIC) (Implementation Science, 2018)
In 2010, Elizabeth Murray and colleagues published ✪ Normalisation process theory: a framework for developing, evaluating and implementing complex interventions, comprised of four major components: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. The authors argued that using normalisation process theory could enable researchers to think through issues of implementation concurrently while designing a complex intervention and its evaluation. They additionally held that normalisation process theory could improve trial design by highlighting possible recruitment or data collection issues.
Learn More:
- ✪ Development of a theory of implementation and integration: Normalization Process Theory (Implementation Science, 2009)
- ✪ Implementation, context and complexity (Implementation Science, 2016)
- ✪ Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory (BMC Medical Informatics and Decision Making, 2017)
- ✪ Implementation of cardiovascular disease prevention in primary health care: enhancing understanding using normalisation process theory (BMC Family Practice, 2017)
- ✪ Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review (Implementation Science, 2018)
Evaluation Frameworks
In their 2011 publication, Proctor and colleagues proposed that implementation outcomes should be distinct from service outcomes or clinical outcomes. They identified eight discrete implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability) and proposed a taxonomy to define them.
The framework development article, ✪ Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda, is available through Administration and Policy in Mental Health and Mental Health Services Research.
In 2023, Dr. Proctor and several colleagues published Ten years of implementation outcomes research: a scoping review in the journal Implementation Science, a scoping review of 'the field’s progress in implementation outcomes research.'
Examples of Use
- Toward Evidence-Based Measures of Implementation: Examining the Relationship Between Implementation Outcomes and Client Outcomes (Journal of Substance Abuse Treatment, 2016)
- ✪ Toward criteria for pragmatic measurement in implementation research and practice: a stakeholder-driven approach using concept mapping (Implementation Science, 2017)
- ✪ German language questionnaires for assessing implementation constructs and outcomes of psychosocial and health-related interventions: a systematic review (Implementation Science, 2018)
- The Elusive Search for Success: Defining and Measuring Implementation Outcomes in a Real-World Hospital Trial (Frontiers In Public Health, 2019)
In 1999, authors Glasgow, Vogt, and Boles developed this framework because they felt tightly controlled efficacy studies weren’t very helpful in informing program scale-up or in understanding actual public health impact of an intervention. The RE-AIM framework has been refined over time to guide the design and evaluation of complex interventions in order to maximize real-life public health impact.
This framework helps researchers collect information needed to translate research to effective practice, and may also be used to guide implementation and potential scale-up activities. You can read the original framework development article in The American Journal of Public Health. Additional resources, support, and publications on the RE-AIM framework can be found at RE-AIM.org. The 2021 special issue of Frontiers in Public Health titled Use of the RE-AIM Framework: Translating Research to Practice with Novel Applications and Emerging Directions includes more than 20 articles on RE-AIM.
Learn More:
- What Does It Mean to “Employ” the RE-AIM Model? (Evaluation & the Health Professions, 2012)
- The RE-AIM Framework: A Systematic Review of Use Over Time (The American Journal of Public Health, 2013)
- ✪ Fidelity to and comparative results across behavioral interventions evaluated through the RE-AIM framework: a systematic review (Systematic Reviews, 2015)
- ✪ Qualitative approaches to use of the RE-AIM framework: rationale and methods (BMC Health Services Research, 2018)
- ✪ RE-AIM in Clinical, Community, and Corporate Settings: Perspectives, Strategies, and Recommendations to Enhance Public Health Impact (Frontiers in Public Health, 2018)
- ✪ RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review (Frontiers in Public Health, 2019)
- ✪ RE-AIM in the Real World: Use of the RE-AIM Framework for Program Planning and Evaluation in Clinical and Community Settings (Frontiers in Public Health, 2019)