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Virginie Fayad
Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers.
Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks).
However, the last decade of implementation science has seen wider recognition of the need to establish the theoretical bases of implementation and strategies to facilitate implementation. There is mounting interest in the use of theories, models and frameworks to gain insights into the mechanisms by which implementation is more likely to succeed. Implementation studies now apply theories borrowed from disciplines such as psychology, sociology and organizational theory as well as theories, models and frameworks that have emerged from within implementation science. There are now so many theoretical approaches that some researchers have complained about the difficulties of choosing the most appropriate [6-11].
This article seeks to further implementation science by providing a narrative review of the theories, models and frameworks applied in this research field. The aim is to describe and analyse how theories, models and frameworks have been applied in implementation science and propose a taxonomy that distinguishes between different approaches to advance clarity and achieve a common terminology. The ambition is to facilitate appropriate selection and application of relevant approaches in implementation studies and foster cross-disciplinary dialogue among implementation researchers. The importance of a clarifying taxonomy has evolved during the many discussions on theoretical approaches used within implementation science that the author has had over the past few years with fellow implementation researchers, as well as reflection on the utility of different approaches in various situations.
A model typically involves a deliberate simplification of a phenomenon or a specific aspect of a phenomenon. Models need not be completely accurate representations of reality to have value [31,37]. Models are closely related to theory and the difference between a theory and a model is not always clear. Models can be described as theories with a more narrowly defined scope of explanation; a model is descriptive, whereas a theory is explanatory as well as descriptive [29].
It was possible to identify three overarching aims of the use of theories, models and frameworks in implementation science: (1) describing and/or guiding the process of translating research into practice, (2) understanding and/or explaining what influences implementation outcomes and (3) evaluating implementation. Theoretical approaches which aim at understanding and/or explaining influences on implementation outcomes (i.e. the second aim) can be further broken down into determinant frameworks, classic theories and implementation theories based on descriptions of their origins, how they were developed, what knowledge sources they drew on, stated aims and applications in implementation science. Thus, five categories of theoretical approaches used in implementation science can be delineated (Table 1; Figure 1):
Process models are used to describe and/or guide the process of translating research into practice. Models by Huberman [40], Landry et al. [41], the CIHR (Canadian Institutes of Health Research) Knowledge Model of Knowledge Translation [42], Davis et al. [43], Majdzadeh et al. [44] and the K2A (Knowledge-to-Action) Framework [15] outline phases or stages of the research-to-practice process, from discovery and production of research-based knowledge to implementation and use of research in various settings.
Early research-to-practice (or knowledge-to-action) models tended to depict rational, linear processes in which research was simply transferred from producers to users. However, subsequent models have highlighted the importance of facilitation to support the process and placed more emphasis on the contexts in which research is implemented and used. Thus, the attention has shifted from a focus on production, diffusion and dissemination of research to various implementation aspects [21].
The how-to-implement models typically emphasize the importance of careful, deliberate planning, especially in the early stages of implementation endeavours. In many ways, they present an ideal view of implementation practice as a process that proceeds step-wise, in an orderly, linear fashion. Still, authors behind most models emphasize that the actual process is not necessarily sequential. Many of the action models mentioned here have been subjected to testing or evaluation, and some have been widely applied in empirical research, underscoring their usefulness [9,55].
Implementation researchers are also wont to apply theories from other fields such as psychology, sociology and organizational theory. These theories have been referred to as classic (or classic change) theories to distinguish them from research-to-practice models [45]. They might be considered passive in relation to action models because they describe change mechanisms and explain how change occurs without ambitions to actually bring about change.
Another theory used in implementation science, the Normalization Process Theory [120], began life as a model, constructed on the basis of empirical studies of the implementation of new technologies [121]. The model was subsequently expanded upon and developed into a theory as change mechanisms and interrelations between various constructs were delineated [122]. The theory identifies four determinants of embedding (i.e. normalizing) complex interventions in practice (coherence or sense making, cognitive participation or engagement, collective action and reflexive monitoring) and the relationships between these determinants [123].
Although evaluation frameworks may be considered in a category of their own, theories, models and frameworks from the other four categories can also be applied for evaluation purposes because they specify concepts and constructs that may be operationalized and measured. For instance, Theoretical Domains Framework (e.g. [127,128]), and Normalization Process Theory [129] and COM-B (e.g. [130,131]) have all been widely used as evaluation frameworks. Furthermore, many theories, models and frameworks have spawned instruments that serve evaluation purposes, e.g. tools linked to PARIHS [132,133], CFIR [134] and Theoretical Domains Framework [135]. Other examples include the EBP Implementation Scale to measure the extent to which EBP is implemented [136] and the BARRIERS Scale to identify barriers to research use [137], as well as instruments to operationalize theories such as Implementation Climate [138] and Organizational Readiness [139].
Implementation science has progressed towards increased use of theoretical approaches to address various implementation challenges. While this article is not intended as a complete catalogue of all individual approaches available in implementation science, it is obvious that the menu of potentially useable theories, models and frameworks is extensive. Researchers in the field have pragmatically looked into other fields and disciplines to find relevant approaches, thus emphasizing the interdisciplinary and multiprofessional nature of the field.
This article proposes a taxonomy of five categories of theories, models and frameworks used in implementation science. These categories are not always recognized as separate types of approaches in the literature. For instance, systematic reviews and overviews by Graham and Tetroe [25], Mitchell et al. [8], Flottorp et al. [26], Meyers et al. [27] and Tabak et al. [28] have not distinguished between process models, determinant frameworks or classic theories because they all deal with factors believed or found to have an impact on implementation processes and outcomes. However, what matters most is not how an individual approach is labelled; it is important to recognize that these theories, models and frameworks differ in terms of their assumptions, aims and other characteristics, which have implications for their use.
What man is and what he must do becomes clear as soon as God reveals himself. The Decalogue is based on these words: "I am the Lord your God, who brought you out of the land of Egypt, out of the house of bondage" (Ex 20:2-3). In the "ten words" of the Covenant with Israel, and in the whole Law, God makes himself known and acknowledged as the One who "alone is good"; the One who despite man's sin remains the "model" for moral action, in accordance with his command, "You shall be holy; for I the Lord your God am holy" (Lev 19:2); as the One who, faithful to his love for man, gives him his Law (cf. Ex 19:9-24 and 20:18-21) in order to restore man's original and peaceful harmony with the Creator and with all creation, and, what is more, to draw him into his divine love: "I will walk among you, and will be your God, and you shall be my people" (Lev 26:12).
Through the moral life, faith becomes "confession", not only before God but also before men: it becomes witness. "You are the light of the world", said Jesus; "a city set on a hill cannot be hid. Nor do men light a lamp and put it under a bushel, but on a stand, and it gives light to all in the house. Let your light so shine before men, that they may see your good works and give glory to your Father who is in heaven" (Mt 5:14-16). These works are above all those of charity (cf. Mt 25:31-46) and of the authentic freedom which is manifested and lived in the gift of self, even to the total gift of self, like that of Jesus, who on the Cross "loved the Church and gave himself up for her" (Eph 5:25). Christ's witness is the source, model and means for the witness of his disciples, who are called to walk on the same road: "If any man would come after me, let him deny himself and take up his cross daily and follow me" (Lk 9:23). Charity, in conformity with the radical demands of the Gospel, can lead the believer to the supreme witness of martyrdom. Once again this means imitating Jesus who died on the Cross: "Be imitators of God, as beloved children", Paul writes to the Christians of Ephesus, "and walk in love, as Christ loved us and gave himself up for us, a fragrant offering and sacrifice to God" (Eph 5:1-2).
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