The black box of implementation science

Researchers aim to shed light on methods that could help disseminate evidence-based practices

Since the evidence-based practice movement began in the 1990s, there has been a sharp increase in the number of studies that aim to systematize knowledge about useful interventions for health problems. However, while the volume of research highlighting new, more beneficial and cost-effective forms of healthcare continues to rise, in practice it is still common see patients receiving the same care as they did decades ago.

It is therefore pertinent to ask what is being lost in the process of translating research into practice, and why so little seems to really have changed. This is the very question that implementation science seeks to answer.

Implementation science is defined as the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence to improve the quality and effectiveness of health services and care (Eccles & Mittmann, 2006).

Although the field’s foundations date back to the 1960s, laid in part by E. M. Rogers’s Diffusion of Innovation Theory (1962), it is the limitations exposed by evidence-based practice that have given implementation science real impetus. During this unique period of time, researchers from all over the world came to the realization that despite the systematic communication of their findings and repeated corroboration of evidence, the practical adoption of research results was still incipient.

Faced with the persistent gap between academia and clinical practice, it is important to anticipate weaknesses in the osmosis-like transition of evidence. Even in scenarios where the evidence is strong enough to influence health policies and programs, it is clear that the goodwill of decision-makers is not enough to shape the implementation of end services.

Who has never heard the maxim “on paper, SUS [Brazil’s public health system] is wonderful”?

The failure to enact public policies capable of significantly affecting health indicators, in particular, has led to questions about how an intervention (or program) can fail to generate results despite having been proven effective, incorporated into guidelines for clinical practice, and allocated a sufficient budget.

Implementation science views this question from the perspective that an intervention can only produce the expected results if it is effectively implemented. What this means is that in addition to the concept of intervention or program effectiveness, implementation science adopts the concept of implementation effectiveness, which is the field’s object of study, while also recognizing that both are interdependent when it comes to achieving results.

In Brazil especially, where the most prominent academic output on health planning in the 1980s and 1990s was quickly replaced by the assessment approach in the 2000s, implementation science is attempting to decipher the “black box” that the process of implementing public health policies has become.

The objective is to shed light on the factors that affect implementation, identifying and communicating them systematically, not just for descriptive purposes, but actually working with them, modulating the context in which interventions occur so that they can be effectively implemented.

Recognizing that the implementation of health interventions can be affected by elements of different magnitude—such as the characteristics of the intervention itself, the situation in which it is to be adopted, the people involved in its execution, and the process itself—implementation science seeks to enable researchers and policy-makers to identify barriers and facilitators for each of these aspects.

This instrumentalization process is based on more than 60 implementation theories, structures, and models from the scientific literature, allowing for the characterization of barriers and facilitators in a common language, fostering the systematization of knowledge and accumulation of theoretical wisdom on ways of dealing with them.

From this perspective, the two central components of this type of study can be summarized as:

(1) The identification of barriers and facilitators for the incorporation of the health interventions, policies, or programs at different levels;

(2) The identification and development of strategies for overcoming barriers and taking advantage of facilitators to incorporate health interventions, policies, or programs.

The fundamental premise of implementation science is that only by identifying and working with barriers and facilitators can we reach the primary outcomes of interest in the process of translating health planning into results, known as implementation outcomes.

Implementation outcomes can be practically described as the elements required to ensure effective implementation, which according to Proctor et al. (2011) include acceptability, suitability, feasibility, and fidelity.

To some it might seem that beyond the issue of implementation outcomes, this is what we have always done—and in a way it is. In the context of scarce resources, a wide range of artifices must be used to put new interventions into practice.

However, it must also be recognized that these artifices are often not covered in intervention reports. Published scientific articles are generally more concerned with describing what was implemented and the results obtained. Even in the best cases, when news is released about the strategies employed in the implementation process, such as the training offered, for example, there is not enough information to ensure its replication. Proper training is commonly seen as one of the most deliberate and planned implementation strategies adopted in health interventions.

Perhaps suffering from the same naivety as the evidence-based practice movement, many cling to the belief that once people are aware of what needs to be done, they will suddenly and magically change their entire approach, which most have firmly established over many years in a particular service or institution.

We need to remember, however, that multifactorial processes require multifactorial solutions.

The scope of implementation science covers more than 70 documented implementation strategies across nine different categories: use of evaluative and iterative strategies; offering interactive assistance; adaptation and adjustment to the context; developing relationships between stakeholders; stakeholder training and qualification; support for healthcare professionals; user engagement; use of financial strategies; and infrastructure change.

Thus, in addition to providing tools, implementation science also offers a diverse range of implementation strategies organized around a common taxonomy and form of reporting in studies and communications.

In short, one of the main benefits of implementation science is the establishment of a common language that can guide researchers in their Tower of Babel that crosses the implementation of health interventions, policies, and programs.

When put like that, it may seem simple, but this benefit could be the key to not only decoding the modulation needs of the present landscape, but also more effectively communicating the elements that lead initiatives to success or failure. This opens up the possibility of replacing the “black box” of implementation with a theoretical and practical wisdom capable of guiding initiatives that close the gap between research and practice.

Carlos Alberto dos Santos Treichel is a nurse with a PhD in Public Health in Policies, Planning, and Management from the University of Campinas (UNICAMP). He is a professor at the Department of Maternity, Children, and Psychiatric Nursing at the School of Nursing of the University of São Paulo (USP).

Find out more:

Eccles, M.P.; Mittman, B.S. Welcome to Implementation Science. Implementation Sci 1, 1 (2006). https://doi.org/10.1186/1748-5908-1-1

Proctor, E., Silmere, H., Raghavan, R. et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health 38, 65–76 (2011). https://doi.org/10.1007/s10488-010-0319-7

Rogers EM. Diffusion of Innovations (1^st ed.), Free Press, NYC. 1962.

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