Implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it
The field of implementation research is growing, but it is not well understood despite the need for better research to inform decisions about health policies, programmes, and practices. This article focuses on the context and factors affecting implementation, the key audiences for the research, implementation outcome variables that describe various aspects of how implementation occurs, and the study of implementation strategies that support the delivery of health services, programmes, and policies. We provide a framework for using the research question as the basis for selecting among the wide range of qualitative, quantitative, and mixed methods that can be applied in implementation research, along with brief descriptions of methods specifically suitable for implementation research. Expanding the use of well designed implementation research should contribute to more effective public health and clinical policies and programmes.
Implementation research attempts to solve a wide range of implementation problems; it has its origins in several disciplines and research traditions (supplementary table A). Although progress has been made in conceptualising implementation research over the past decade,1 considerable confusion persists about its terminology and scope.2 3 4 The word “implement” comes from the Latin “implere,” meaning to fulfil or to carry into effect.5 This provides a basis for a broad definition of implementation research that can be used across research traditions and has meaning for practitioners, policy makers, and the interested public: “Implementation research is the scientific inquiry into questions concerning implementation—the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions).”
Implementation research can consider any aspect of implementation, including the factors affecting implementation, the processes of implementation, and the results of implementation, including how to introduce potential solutions into a health system or how to promote their large scale use and sustainability. The intent is to understand what, why, and how interventions work in “real world” settings and to test approaches to improve them.
Implementation research seeks to understand and work within real world conditions, rather than trying to control for these conditions or to remove their influence as causal effects. This implies working with populations that will be affected by an intervention, rather than selecting beneficiaries who may not represent the target population of an intervention (such as studying healthy volunteers or excluding patients who have comorbidities).
Context plays a central role in implementation research. Context can include the social, cultural, economic, political, legal, and physical environment, as well as the institutional setting, comprising various stakeholders and their interactions, and the demographic and epidemiological conditions. The structure of the health systems (for example, the roles played by governments, non-governmental organisations, other private providers, and citizens) is particularly important for implementation research on health.
Implementation research is especially concerned with the users of the research and not purely the production of knowledge. These users may include managers and teams using quality improvement strategies, executive decision makers seeking advice for specific decisions, policy makers who need to be informed about particular programmes, practitioners who need to be convinced to use interventions that are based on evidence, people who are influenced to change their behaviour to have a healthier life, or communities who are conducting the research and taking action through the research to improve their conditions (supplementary table A). One important implication is that often these actors should be intimately involved in the identification, design, and conduct phases of research and not just be targets for dissemination of study results.
Implementation outcome variables describe the intentional actions to deliver services.6 These implementation outcome variables—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, coverage, and sustainability—can all serve as indicators of the success of implementation (table 1 ⇓ ). Implementation research uses these variables to assess how well implementation has occurred or to provide insights about how this contributes to one’s health status or other important health outcomes.
Implementation outcome variables