Theory / Theorizing Archives - Implementation Science at UW

✪ Mental health policy implementation in low- and middle-income countries: a realist review protocol

Abstract:

Introduction

Formulating and implementing mental health policy is foundational to public mental health. The implementation of mental health policy varies in low- and middle-income countries (LMICs), with some countries having better implementation outcomes than others. Low implementation poses challenges relating to addressing the high burden and wide treatment gaps of mental health conditions. While different implementation strategies are applied to implement mental health policy in different contexts, there is little knowledge of what category of strategies are being used and how and why their implementation produces varied outcomes. To this end, we propose to conduct a realist synthesis to explain how, why, for whom, and under what health system conditions certain policy implementation strategies work or not in LMICs.

Methods and analysis

This paper will detail the protocol on conducting a realist review of the literature on mental health policy implementation in LMICs. Realist reviews/syntheses are theory-driven reviews designed to formulate and test (confirm, refute, or refine) initial programme theories to explain how, why, for whom and under what contexts a programme, intervention or policy works as intended or not. Theory is built by exploring and abstracting context-mechanism-outcome (CMO) configurations in the data. These CMO configurations are identified through retroductive theorizing, a mechanism-centred approach to theory development. We will adopt these steps to guide the process of realist synthesis: i) identify the research question, clarifying the scope of the review and formulating the initial programme theory (ii) conducting background searches in PubMed, PsycINFO, Africa-Wide Information, African Index Medicus (AIM), CINAHL and Scopus databases, and grey literature (iii) appraising the quality of studies and data extraction and (iv) synthesising data.

Registration

The review is part of a realist evaluation exploring mental health policy implementation in LMICs and is registered under PROSPERO (registration number: CRD42024580312). Findings will inform the development of initial mental health policy implementation programme theories explaining why and how mental health policy implementation in LMICs works.

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✪ Mechanism-Based Middle-Range Theories: Using Realist Syntheses to Reconcile Specificity to Context and Generalizability

Abstract:

Realist synthesis is a recognized methodological approach to evidence synthesis to inform evidence-based health policy and practice. The implicit assumption behind research synthesis is that the evidence it generates should be generalizable––drawing broad inferences from specific observations. While this understanding is generally shared among social scientists, tensions exist between having generalizable evidence and how this evidence can be useful in specific contexts. This paper considers the role of mechanism-based middle-range theories obtained from realist synthesis in bridging specificity to context and generalizability. Retroductive theorizing in realist synthesis helps to identify ideas about mechanisms related to the phenomenon embedded in the social and organizational contexts that could, in principle, have a much broader application. Also, because mechanism-based middle-range theories are linked to contextual features, they capture contextual nuances to enhance evidence implementation. We conclude that middle-range mechanisms provide an opportunity to achieve generalizability and contextualization in implementation science.

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✪ Balancing realist review outputs with the needs of policymakers and practitioners

Abstract:

A realist review is a theory-driven approach to synthesizing evidence based on the realist philosophy of science. Realist reviews are conducted to provide the policy and practice community with a rich, detailed and practical understanding of complex social interventions that will likely be of much more use to them when planning and implementing programmes. Robust realist reviews must balance philosophical engagement, methodological rigour and relevance to practice. Nevertheless, they have been criticized for being more philosophically inclined and less methodologically robust, with findings that have little implication for practice. Using the philosophy/epistemology➔ methodology➔ theory➔ practice concept flow, we report how we balanced philosophical principles and practical insights in a recently conducted realist review on participatory practices that impact the benefits of non-communicable disease research and interventions in low- and middle-income countries. If realist reviews are not comprehensible enough for these practitioners, their utility and relevance may suffer from being limited to a specialist cohort of academics. We propose that realist review findings and outputs must be framed and communicated to meaningfully engage practitioners without undertaking translational efforts.

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✪ Reimagining policy implementation science in a global context: a theoretical discussion

Abstract:

Introduction

Policy implementation science (IS) is defined here as generating knowledge and deploying implementation strategies to effectively adopt and integrate evidence-based interventions (EBIs) into policy designs and improve policy implementation and effectiveness (1–3). Most existing policy IS scholarly works originate from the Global North (United States, Canada, and Western Europe) and describe or evaluate strategies to increase the uptake of EBIs (4). The existing Global North-generated frameworks focus less on the critical resources needed to formulate and implement a policy in diverse settings. Current approaches to policy IS lack sufficient contextual nuance to be applicable to...[read more].

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✪ Changing hearts and minds: theorizing how, when, and under what conditions three social influence implementation strategies work

Abstract:

Background

Opinion leadership, educational outreach visiting, and innovation championing are commonly used strategies to address barriers to implementing innovations and evidence-based practices in healthcare settings. Despite voluminous research, ambiguities persist in how these strategies work and under what conditions they work well, work poorly, or work at all. The current paper develops middle-range theories to address this gap.

Methods

Conceptual articles, systematic reviews, and empirical studies informed the development of causal pathway diagrams (CPDs). CPDs are visualization tools for depicting and theorizing about the causal process through which strategies operate, including the mechanisms they activate, the barriers they address, and the proximal and distal outcomes they produce. CPDs also clarify the contextual conditions (i.e., preconditions and moderators) that influence whether, and to what extent, the strategy's causal process unfolds successfully. Expert panels of implementation scientists and health professionals rated the plausibility of these preliminary CPDs and offered comments and suggestions on them.

Findings

Theoretically, opinion leadership addresses potential adopters' uncertainty about likely consequences of innovation use (determinant) by promoting positive attitude formation about the innovation (mechanism), which results in an adoption decision (proximal outcome), which leads to innovation use (intermediate outcome). As this causal process repeats, penetration, or spread of innovation use, occurs (distal outcome). Educational outreach visiting addresses knowledge barriers, attitudinal barriers, and behavioral barriers (determinants) by promoting critical thinking and reflection about evidence and practice (mechanism), which results in behavioral intention (proximal outcome), behavior change (intermediate outcome), and fidelity, or guideline adherence (distal outcome). Innovation championing addresses organizational inertia, indifference, and resistance (determinants) by promoting buy-in to the vision, fostering a positive implementation climate, and increasing collective efficacy (mechanisms), which leads to participation in implementation activities (proximal outcome), initial use of the innovation with increasing skill (intermediate outcome) and, ultimately, greater penetration and fidelity (distal outcomes). Experts found the preliminary CPDs plausible or highly plausible and suggested additional mechanisms, moderators, and preconditions, which were used to amend the initial CPD.

Discussion

The middle-range theories depicted in the CPDs furnish testable propositions for implementation research and offer guidance for selecting, designing, and evaluating these social influence implementation strategies in both research studies and practice settings.

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✪ Getting cozy with causality: Advances to the causal pathway diagramming method to enhance implementation precision

Abstract:

Background

Implementation strategies are theorized to work well when carefully matched to implementation determinants and when factors—preconditions, moderators, etc.—that influence strategy effectiveness are prospectively identified and addressed. Existing methods for strategy selection are either imprecise or require significant technical expertise and resources, undermining their utility. This article outlines refinements to causal pathway diagrams (CPDs), a method for articulating the causal process through which implementation strategies work and offers illustrations of their use.

Method

CPDs are a visualization tool to represent an implementation strategy, its mechanism(s) (i.e., the processes through which a strategy is thought to operate), determinants it is intended to address, factors that may impede or facilitate its effectiveness, and the series of outcomes that should be expected if the strategy is operating as intended. We offer principles for constructing CPDs and describe their key functions.

Results

Applications of the CPD method by study teams from two National Institute of Health-funded Implementation Science Centers and a research grant are presented. These include the use of CPDs to (a) match implementation strategies to determinants, (b) understand the conditions under which an implementation strategy works, and (c) develop causal theories of implementation strategies.

Conclusions

CPDs offer a novel method for implementers to select, understand, and improve the effectiveness of implementation strategies. They make explicit theoretical assumptions about strategy operation while supporting practical planning. Early applications have led to method refinements and guidance for the field.

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✪ Theorizing is for everybody: Advancing the process of theorizing in implementation science

Abstract:

There has been a call to shift from treating theories as static products to engaging in a process of theorizing that develops, modifies, and advances implementation theory through the accumulation of knowledge. Stimulating theoretical advances is necessary to improve our understanding of the causal processes that influence implementation and to enhance the value of existing theory.

We argue that a primary reason that existing theory has lacked iteration and evolution is that the process for theorizing is obscure and daunting. We present recommendations for advancing the process of theorizing in implementation science to draw more people in the process of developing and advancing theory.

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Authors:

✪ Open Access

Read the full text in the open access journal PLOS One

Abstract:

Introduction

Methods and analysis

Registration

Authors:

✪ Open Access

Read the full text in the open access journal Qualitative Health Research

Abstract:

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✪ Open Access

Read the full text in the open access journal Health Policy and Planning

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✪ Open Access

Read the full text in the open access journal Frontiers in Health Services

Abstract:

Introduction

Authors:

✪ Open Access

Read the full text in the open access journal Frontiers in Health Services

Abstract:

Background

Methods

Findings

Discussion

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Research and Practice

Abstract:

Background

Method

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Frontiers in Health Services

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Authors:

✪ Open Access

Read the full text open access in the journal Preventive Medicine