Cathy L. Melvin, PhD. MPH, Associate Professor, Department of Public Health Sciences
Co-Director, SCTR Community Engagement Program
Team Lead, Dissemination and Implementation Science, Hollings Cancer Center
Medical University of South Carolina

Review Need and Rationale for Dissemination and
Implementation (D & I) Research

Understand Definitions

Explore Models for D & I Research and Practice

Review Two D & I Models

Illustrate application for an important public health issue
◦ D&I
◦ D & I Research
◦ Expected Outcomes of D & I
◦ Consolidated Framework for Advancing Implementation (CFIR)
◦ Interactive Systems Framework (ISF) and its companion Quality
Improvement Tool (QIT)

Reason 1:
Vast resources are invested in the development of
interventions to prevent and treat disease; however,
only a fraction of research products is translated to
practice and policy in order to affect population
health.
Original research
18%
Negative
results
variable
Dickersin, 1987
Submission
46%
Koren, 1989
Negative
results
0.5 year
Kumar, 1992
0.6 year
Kumar, 1992
Acceptance
Publication
35%
Lack of
numbers
Balas, 1995
0.3 year
Poyer, 1982
Expert
opinion
Bibliographic databases
50%
Poynard, 1985
Inconsistent
indexing
17:14
6. 0 - 13.0 years Antman, 1992
Reviews, guidelines, textbook
9.3 years
Implementation
It takes 17 years to turn 14 per cent of original research
E.A. Balas, 2000
to the benefit of patient care1


Reason 2
Dissemination and implementation (D&I)
science seeks to understand how to
systematically facilitate deployment and
utilization of evidence-based approaches to
improve the quality and effectiveness of
health promotion, health services, and health
care.2

Classic diffusion of innovation is defined as the passive process
by which a program or product is absorbed into more
widespread use2

Often the “default” approach to increasing widespread use

Dependent on a number of factors
◦ Characteristics of the innovation itself
◦ Properties of the communication channel through which the intervention is
disseminated
◦ Time from no use of the intervention to full adoption across the population
and the different activities that occur across time
◦ Characteristics of the social system in which the innovation is being
disseminated




Definition: the active approach of spreading evidence-based
interventions to the target audience(s) via determined
channels using planned strategies2
Intention: to spread information and the associated evidencebased interventions to all appropriate audiences via credible,
trusted communication channels
Outcomes: increased awareness of evidence, increased
adoption and/or likelihood of adoption
Dissemination Research: addresses how information about
health promotion and care interventions is created, packaged,
transmitted, and interpreted among a variety of important
stakeholder groups.3




Definition: the process of putting to use or integrating
evidence-based interventions within a setting2
Intention: to investigate and address major bottlenecks (e.g.
social, behavioral, economic, management) that impede
effective implementation, test new approaches to improve
health programming, as well as determine a causal
relationship between the intervention and its impact3
Outcomes: use and/or integration of evidence in practice
settings and communities
Implementation Research: study of methods to promote the
integration of research findings and evidence into healthcare
policy and practice. It seeks to understand the behavior of
healthcare professionals and other stakeholders as a key
variable in the sustainable uptake, adoption, and
implementation of evidence-based interventions3


Recent review identified 61 models (e.g. theories and
frameworks) describing either dissemination and/or
implementation models to guide research3
Of the 61 identified models:
◦ 11 were Dissemination only (I)
◦ 16 were combined but mostly Dissemination (D>I)
◦ 17 were equally Dissemination and Implementation
(D=I)
◦ 5 were combined but mostly Implementation (I>D)
◦ 12 were Implementation only (I)

Prevention Synthesis and Translation System (PSTS)
◦ Entities that
 synthesize evidence about effective prevention innovations and
 translate evidence into accessible, user friendly formats
adaptable to local circumstances and settings

Prevention Support System (PSS)
◦ Entities that support change in prevention practice via
 innovation-specific capacity building and
 general capacity building

Prevention Delivery System (PDS)
◦ Entities that carry out activities necessary to implement
prevention interventions at the organizational, community,
state, or national level


Practical translation of the implementation science
literature
Six components
◦ Develop an implementation team
◦ Foster supportive organizational/communitywide climate and
conditions
◦ Develop an implementation plan
◦ Receive training and technical assistance
◦ Practitioner-developer collaboration in implementation
◦ Evaluate the effectiveness of the intervention7
Consolidated Framework for
Implementation Research (CFIR)5
Source: 5
Five CFIR Domains
“An overarching typology to promote
implementation theory development”
Combines 19 conceptual models in 5 Domains:
Intervention characteristics
 Outer setting
 Inner setting
 Characteristics of the individuals involved
 Process of implementation

Uses of CFIR



Formative stage: capacity and needs assessment to
identify barriers and facilitators to implementation
Implementation stage: to track key implementation
processes
Outcome and impact stage: to explore what factors
influenced implementation and how implementation
influenced intervention performance
At macro level: to organize and synthesize findings
across studies using common language and
definitions
The Problem

Despite availability and
extensive marketing of the
HPV vaccines—a cost effective
and proven solution,
vaccination rates remain low
in the US: 33% for all 3 doses
in 2012

Vaccination rates for 2 other
vaccines given at the same
time to adolescents are much
higher
Missed Opportunities



Lack of awareness &
information
Concerns about

◦ safety,
◦ duration of efficacy, and
◦ impact on sexual debut

Cost of vaccine and other
barriers, especially for
uninsured individuals

Parents
Hesitancy/self-efficacy to
discuss and promote the
vaccine
Pediatric providers poorly
motivated by distal
disease consequences
Reluctance to frame HPV
as routine and as a
cancer prevention
measure
Providers






Focus on poorly performing
practices
Conduct audience research
with providers
Identify barriers/enablers
Develop tailored, evidencebased communication
strategies, materials and
products
Distribute through credible
channels
Repeat exposure
Dissemination Goal –
Adoption by Practices





Develop an implementation
team in each practice
Foster supportive
organizational/communitywide climate and conditions
Develop an implementation
plan
Receive tailored training
and technical assistance
Evaluate the effectiveness
of the intervention
◦ Increased series completion
◦ Decreased missed
opportunities
Implementation Goal –
HPV Vaccine Uptake & Reach
Conduct audience research with patients, providers and opinion leaders to
1.
1.
2.
3.
2.
3.
4.
Identify preferred communication channels considered credible by audience
members
Assess availability and use of existing educational materials and practice-based
tools such as those available from CDC and professional associations
Identify practice-based tools and materials currently in use in each setting and for
each audience
Customize and test prototypes of evidence-based products and
dissemination strategies with all stakeholders
Develop dissemination plan for poorly performing practices
Collaborate with experts, community and academic partners to problem
solve and examine factors affecting quality of dissemination
1.
Form Implementation Team representing all stakeholders in each
practice
2.
Foster supportive climate and conditions by
1.
2.
3.
4.
Using champions
Developing policies
Communicating perceived need and benefit
Establishing practices to counterbalance stakeholder resistance to change
3.
Develop practice-specific implementation plan
4.
Receive training and technical assistance for specific needs
5.
Evaluate the effectiveness of the implementation strategies
1.
2.
3.
4.
Fidelity
Dose and quality of training and technical assistance
Participation and participant responsiveness
Documentation of adaptations to original implementation plan

Development of tailored,
evidence-based
◦
◦
◦ Communication and Dissemination
Strategies
◦ Educational Materials and Products


◦
Effectiveness of Dissemination
Strategies
◦ Increased Awareness
◦ Intention to Adopt or Change
Practice
◦ Use of Materials and Products
◦ Removal of Barriers
◦ Adoption via Policy or Protocol
Relative Value of
Dissemination Strategies and
Channels
Dissemination Goal –
Adoption by Practices
Assessments of


Intervention Fidelity
Dose and Quality of
Training and Technical
Assistance
Participation and Participant
Responsiveness
Documentation of
Adaptations to Original
Implementation Plan

Increased series completion

Decrease missed
opportunities
Implementation Goal –
HPV Vaccine Uptake & Reach

Knowledge translation is a process:
• Involving a complex set of activities including a combination
of face-to-face interaction, reading, reflection, and discussion
• Promoting a dynamic, iterative, and collaborative process
• Between diverse stakeholders: researchers, decisionmakers and practitioners
• Resulting in mutual learning, synthesis of knowledge,
problem-solving, planning and application of new learning
based on quality research and the specific context leading to
practice change.

How to promote knowledge translation?
Create systematic opportunities for meaningful,
focused interaction or exchange8,9
1.
2.
3.
4.
5.
6.
Balas EA & Boren SA. (2000). Managing clinical knowledge for health care improvement. In: Bemmel J, McCray
AT, editors. Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer
Verlagsgesellschaft mbH; 2000:65-70.
Glasgow, Russell E., et al. "Disseminating effective cancer screening interventions." Cancer 101.S5 (2004):
1239-1250.
Tabak RG, Khoong EC, Chamber D and Brownson RC. (2012) Bridging Research and Practice: Models for
Dissemination and Implementation Research. Am J Prev Med 43(3):337-350. doi:
10.1016/j.amepre.2012.05.024.
[Internet] 4th Annual NIH Conference on the Science of Dissemination and Implementation: Policy and Practice
Damschroder LJ, Aron DC, Keith RE, et al. (2009) Fostering implementation of health services research findings
into practice: a consolidated framework for advancing implementation. Implementation Science, 4:50 doi:
10.1186/1748-5908-4-50
Wandersman A, Duffy J, Flaspohler P, et al. (2008) Bridging the gap between prevention research and practice:
the interactive systems framework for dissemination and implementation. Am j Community Pyschol 41:171181.
7.
Meyers DC, Katz J, Chien V, et al. (2012) Practical implementation science: developing and piloting the quality
implementation tool. Am J Community Psychol 50:481-496, doi 10.1007/s10464-012-9521-y
8.
Canadian Institutes of Health Research (CIHR) CIHR. (2004). Knowledge translation strategy 2004–2009:
Innovation in action. Ottawa, ON: Canadian Institutes of Health Research. Retrieved from www.cihr.ca
9.
Lowe, M, Rappolt, S, Jaglal, S., & Macdonald, G. (2007). The role of reflection in implementing learning from
continuing education to practice. Journal of Continuing Education in Health Care Practice, 27, 143-148.

Trans-NIH Dissemination and Implementation Program
Announcement
◦ The targeted distribution of information and intervention materials
to a specific public health or clinical practice audience with the
intent of spreading knowledge and the associated evidence-based
interventions3

CDC Program Announcement
◦ The systematic study of how the targeted distribution of
information and intervention materials to a specific health audience
can be successfully executed so that increased knowledge about
the evidence-based public health interventions achieve greater use
and impact of the intervention4

The use of strategies to adopt and integrate
evidence-based public health interventions and
change practice patterns within specific settings.
(Trans-NIH Dissemination and Implementation Program Announcement)

The systematic study of how a specific set of
activities and designed strategies are used to
successfully integrate an evidence-based public
health intervention within specific settings (e.g.,
primary care clinic, community center, school).
(CDC Program Announcement)