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Implementation Science: Pre-Implementation Stage

Original Editor - Stacy Schiurring based on the course by Lucio Naccarella

Top Contributors - Stacy Schiurring, Tarina van der Stockt, Jess Bell and Kim Jackson  

Introduction

"Pre-implementation work is an important element of the early phase of preparing the setting for the introduction of an intervention, and the factors contributing towards the creation of an optimal pre-implementation community context are under-acknowledged."[1]

Rehabilitation is a complex multi-disciplinary process involving multiple professionals, patients, families, and care-providers across multi-level healthcare systems.[2] Implementation science provides systematic methods to promote the uptake of evidence-based rehabilitation practices and optimise patient outcomes.[3] Adopting, implementing, or sustaining new rehabilitation interventions is challenging. Why do some professionals adopt interventions more easily than others? Why does an intervention work in some settings but not others? When implementing new interventions in lower-middle income countries, rehabilitation professionals face challenges at systems, healthcare provider, and patient levels. Rehabilitation services in LMICs remain limited despite greater disability burden, with low workforce capacity, inadequate infrastructure, and sparse services outside major urban areas. Implementation science provides a framework for understanding these challenges and facilitating implementation efforts.

This page explores how to plan implementation processes to adopt, adapt, spread, or sustain new interventions.

What is implementation science? Watch this short video for a summary of this field of study.

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Understanding implementation science is the first step. The next is assessing your organisation's readiness to apply it.

Building Implementation Science Capability

The need to build implementation science expertise is recognised as urgently required to bridge the gap between evidence and practice, particularly in resource-poor or low-middle income countries (LMICs).[5][6] [7]

All rehabilitation leaders and stakeholders and their organisations have differing implementation science capability. Thus, it is important to reflect upon the implementation science maturity of an organisation to establish a baseline, then set about identifying implementation science strengths, gaps, readiness and priorities.

Table 1 Rehabilitation Implementation Science (IS) Organisations Maturity Matrix - it draws your attention to five dimensions (culture, capacity, planning, conducting, and using) and asks you to rate these along a continuum, from beginning, developing, embedded and leading.

Dimensions Maturity Level
Beginning Developing Embedded Leading
Culture IS awareness is low and in response to rehabilitation intervention problems Widespread awareness of IS benefits IS perceived as integral to rehabilitation performance Demonstrated commitment to IS through rehabilitation organisation
Capacity IS skills limited

No formal IS approaches in place

Formal IS approaches in place   General IS skills widespread Rehabilitation organisation is recognised for IS expertise
Planning IS occurring for some interventions IS approaches are coordinated and IS plans in place IS planning integral to rehabilitation policy development IS plan in place for most rehabilitation interventions
Conducting IS occurs infrequently IS approaches are coordinated and IS plans in place IS occurs widespread IS occurs and conforms to recognised IS standards  
Using IS findings dissemination within rehabilitation organisation IS findings routinely inform rehabilitation intervention decisions IS findings widely dissemination & used to drive rehabilitation intervention performance IS findings used to optimise rehabilitation inclusive health systems

Challenges to Implementing Evidenced-Based Interventions in LMICs

Before planning implementation, it's essential to understand the specific challenges rehabilitation professionals face in lower-middle income countries. Persistent system-level barriers still exist including limited quantification of existing services, lack of government policy and funding, and inadequate rehabilitation infrastructure.[8][9]

Box 1: Challenges to Implementing Evidence-Based Rehabilitation Interventions in LMICs - These key implementation challenges are based on the work of Leonard and colleagues in 2020[10]

System-level challenges

  • Limited awareness & understanding of evidence-based rehabilitation interventions
  • Limited quantification of existing rehabilitation services, workforce & service utilisation
  • Lack of specific government policy, strategic planning, legislation, fand unding for rehabilitation services across the health system level (primary, secondary & acute)

Health Care Provider level challenges

  • Lack of mandate to provide evidence-based rehabilitation interventions
  • Limited rehab workforce and capacity (awareness, skills) to treat, competing priorities and heavy workloads
  • Lack of coordination between services
  • High re-imbursements for non-evidence-based rehabilitation interventions

Patient-level challenges

  • Logistics of rehabilitation services
  • Affordability of rehabilitation services
  • Knowledge & attitudes to interventions
  • Health problem or condition-specific factors [11]

Additional critical challenges in LMICs have also been identified, including:[12]

  • Fragmented service delivery across primary, secondary, and tertiary care levels
  • Limited integration of rehabilitation within broader health systems
  • Inadequate mechanisms for continuity of care across health system levels

Implementation Science Terms

Below are listed many terms that are used in the field of implementation science, please review and reflect upon these key implementation terms and definitions, as they are key thinking about facilitating the implementation of evidence-based rehabilitation interventions.

Box 2: Implementation Science Key Terms and Definitions

  • Implementation refers to the use of any strategies to adopt and integrate evidence-based interventions and to change practice patterns.
  • Implementation Science refers to the study of methods to promote the uptake of research and evidence-based practices into routine practice.
  • Implementation Research refers to the study of the use of strategies to adopt and integrate evidence-based rehabilitation interventions, programs or practices into clinical and community settings.
  • Implementation Practice refers to applying and adapting evidence from implementation research to adapt and tailor implementation models, frameworks and strategies to different contexts and settings
  • Implementation Strategies refers to HOW to enhance the adoption, implementation, and sustainability of evidence-based rehabilitation interventions, programs or practices into normal practice into clinical and community settings.
  • Implementation Facilitation refers to a multi-faceted strategy to help (not tell) professionals to identify, focus on, and address the implementation challenges and leveraging the positive influences related to the evidence-based intervention/innovations
  • Implementation Outcomes refers to the EFFECTS of deliberate strategies to adopt and embed new interventions, programs or practices into real world rehabilitation setting, including: Implementation Outcomes, Service outcomes and Patient Outcomes.

With these key terms established, we can now explore the three critical implementation factors: the intervention itself, the context, and the stakeholders.

Understanding the Intervention

The questions in Box 3 were designed to encourage thought about evidence-based rehabilitation interventions, irrespective of whether you are referring to adopting, implementing or sustaining a new rehabilitation intervention. Below are implementation facilitator questions that are key to exploring and understanding the intervention you want to implement.

Box 3: Exploring and Understanding Interventions

Implementation Facilitators can ask questions like:

  • What is the strength of the evidence underlying the intervention?
  • What is the degree of fit or compatibility of the intervention with current practices or beliefs?
  • What is the relative advantage of the intervention?
  • How much does this intervention cost or what staff training is required?

Rehabilitation intervention evidence is growing every day. Principles and guidance on rehabilitation interventions are increasingly available such as:

  1. NHS Commissioning Guidance for Rehabilitation
  2. World Health Organization Package of Rehabilitation Interventions Information Sheet

Despite the wealth of information, the uptake of this evidence into practice is a slow process, especially in lower-middle income countries. The translation from clinical research to clinical practice can take anywhere between 10-20 years.[13] With so much available information, it is easy to become overwhelmed when deciding what interventions to implement. It is of great benefit to utilise a comprehensive approach to explore and understand the chosen intervention. This is done by focusing on six key intervention topics.

Box 4: Key Intervention Questions to Ask:

  1. How well the intervention might meet identified staff needs (Needs)
  2. Does the intervention fit with current initiatives, priorities, structures and supports, and parent/community values? (Fit)
  3. What training for staff, technology supports, data systems or administration are needed? (Resources)
  4. What evidence exists that outcomes will be expected if the interventions are implemented well? (Evidence)
  5. To what extent is intervention able to be usable and adaptable to changing practice contexts/settings? (Usability)
  6. What capacity exists to implement intervention as intended and to sustain and improve implementation over time. (Capacity)

These six questions are based upon an existing implementation science exploration and planning tool that can also inform evaluation: the Hexagon Discussion and Analysis Tool.

Hexagon Tool

The Hexagon Discussion and Analysis Tool is used by organisations to evaluate the fit and feasibility of implementing programmes within a given context. This tool facilitates team discussion and ensures that diverse perspectives are represented in a discussion of the six contextual fit and feasibility indicators (please see Box 4).[14]

The Hexagon Tool can be used at any stage in the implementation process to determine its fit with the local context. When used early in the process, it can help identify possible new programmes or practices to implement. When used later in the process, it can help diagnose implementation challenges related to contextual fit.[14] Beyond understanding the intervention itself, successful implementation requires careful consideration of the environment in which it will be deployed.

Understanding Context

In implementation science, the term context is used to describe and refer to all the potential factors or challenges that may influence adoption, effectiveness and sustainability of interventions. The questions in Box 5 were designed to encourage thinking about the context within which the evidence-based rehabilitation intervention is designed to help patients address the impact of physical, cognitive, psychosocial and mental health problems and conditions. These examples of the implementation facilitator questions are key to understanding the inner and outer context within which the intervention is to be implemented.

Box 5: Exploring and Understanding Context:

Within the Inner context/organisation, implementation facilitators can ask:

  • To what extent is there an openness and readiness for change to implement the new intervention?
  • To what extent does the intervention align with the organisation's priorities and structures?
  • To what extent are the organisation's leadership and senior management supportive of the new intervention?

Within the Outer Context, implementation facilitators can ask:

  • To what extent will external policy drivers, incentives, or regulatory frameworks influence the implementation of interventions?
  • To what extent is there (in)stability in the sector that may influence intervention implementation?
  • To what extent will the inter-organisational networks & relationships influence intervention implementation?

There are multiple contextual factors and levels (inner and outer) related to the organisation that are instrumental to implementation. For example, the inner context is comprised of internal organisation characteristics that drive implementation, such as the institution’s leadership, structures, resources, internal policies, staffing, practices, and provider factors (e.g., attitudes, beliefs). The outer context refers to the external environment that influences organisational implementation. These include policies outside the organisation, consumers, relationships across organisations such as funding agencies, health departments, and advocacy groups.[15]

These inner and outer setting factors also interact with one another and the intervention itself (i.e., how it fits within the organisation and culture) to influence implementation. Evidence is also building about ‘Bridging factors’ that refer to the relationships between the inner and outer contexts to guide implementation (e.g., academic-community partnerships).[15]

Given the increasing information about the Contextual challenges to implementing rehabilitation interventions, it is easy to become overwhelmed when assessing what may be affected by the new implementation intervention. It is beneficial to use a more comprehensive approach to explore and understand the inner and outer contextual factors or challenges across the three implementation phases: Pre-Implementation, Implementation and Sustainment.  

To assess these contextual factors effectively, you first need to understand the implementation outcomes they influence.

Box 6a- Implementation Outcomes Definitions

  • Acceptability is the perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory
  • Adoption is defined as the intention, initial decision, or action to try or employ an innovation or evidence-based practice
  • Appropriateness is the perceived fit, relevance, or compatibility of the innovation or evidence-based practice for a given practice setting, provider, or consumer; and/or perceived fit of the innovation to address a particular issue or problem
  • Fidelity is defined as the degree to which an intervention was implemented as it was prescribed in the original protocol or as it was intended by the program developer
  • Feasibility is defined as the extent to which a new treatment, or an innovation, can be successfully used or carried out within a given agency or setting
  • Sustainability is defined as the extent to which a newly implemented treatment is maintained or institutionalised within a service setting’s ongoing, stable operations
  • Penetration is defined as the integration of a practice within a service setting and its subsystem
  • Cost (incremental or implementation cost) is defined as the cost impact of an implementation effort. Implementation costs vary according to three components.

Box 6 provides examples of key inner and outer contextual factors (barriers or facilitators) at the individual and organisational level – framed as questions that are known to influence implementation outcomes, such as: feasibility, acceptability, appropriateness and fidelity of implementation.

Box 6: Examples of Key Implementation Contextual factors (barriers or facilitators)

  1. To what extent is there individual and organisational openness and readiness for change to implement the new intervention? (Acceptability)
  2. To what extent does the new intervention align with individual values & beliefs and the organisations priorities and structures? (Appropriateness)
  3. To what extent is the organisations leadership and senior management supportive of the new intervention? (Adoption)
  4. To what extent will the external policy drivers, incentives or regulatory frameworks influence intervention implementation? (Feasibility)
  5. To what extent is there (in)stability in the sector that may influence intervention implementation? (Feasibility)
  6. To what extent will the inter-organisational networks & relationships influence intervention implementation? (Acceptability)

These six questions are based upon several existing implementation science exploration and planning or determinants frameworks that can also inform evaluation. Listed below are commonly used implementation planning frameworks that can identify barriers and facilitators to key implementation outcomes, namely feasibility, acceptability, uptake, and fidelity.

Follow the listed links for more information on these implementation planning frameworks:

While frameworks help identify contextual factors, successful implementation ultimately depends on the people involved.

Stakeholders

Multiple stakeholders are essential to rehabilitation implementation, including frontline rehabilitation professionals, organisational managers, administration staff, clients receiving services, and external staff such as policymakers who fund and make decisions supporting intervention implementation.[16]

Stakeholder engagement throughout the implementation process enhances intervention acceptability, reach (the number of eligible people taking part), and sustainability (changes over time in participation).[16]

Understanding Key Stakeholders

It is important to understand the key stakeholders, including their knowledge, beliefs and capacity to adopt them.

Box 7: Explore and Understand Key Stakeholders

Implementation Facilitators can ask questions about:

  • What beliefs, skills and knowledge exist amongst the stakeholders about the proposed new intervention?
  • What time and resources are available across the stakeholders to facilitate intervention implementation?
  • To what extent is there a collaborative environment amongst stakeholders or are there professional power, authority or boundary issues that may influence intervention implementation?

Engaging Key Stakeholders

Engagement is critical to successful implementation. Recognising that multiple stakeholders have differing roles, interests, and influence, stakeholders should be engaged across multiple levels throughout the implementation process.[16]

Stakeholders can be engaged at different levels, informing, involving, consulting, collaborating, or empowering, based on the International Association for Public Participation (IAP2) spectrum. This approach allows for successful engagement across multiple levels of an implementation ecosystem (policy/legislative, funders, community, organisational, provider, client/patient).

Box 8: Key Stakeholder Engagement Prompts

  1. What is your communication strategy for informing all key stakeholders about the new proposed interventions' strength of evidence and complexity? (Inform, Intervention)
  2. What steps can you take to involve your multiple key stakeholders in the new proposed interventions implementation process? (Involve, Implementation Process)
  3. What beliefs, knowledge, readiness for change and capacity amongst the multiple key stakeholders need consideration in the proposed new intervention in the implementation process (Consult, Implementation Context)
  4. What changes or adaptations to the implementation process and intervention design are required to align with the differing key stakeholder roles, interests, knowledge, readiness for change and capacity to support the planning, adoption and implementation of the new proposed intervention? (Collaborate, Implementation Context)
  5. What is the level of commitment and accountability of the multiple key stakeholders given their differing roles, interests and influence with the planning, implementation and sustainment of the new proposed intervention into routine practice (Empower, Intervention, Implementation Process)

Box 8 is based upon the International Association of Public Participation (IAP2) stakeholder engagement framework and the CFIR framework.

Conclusion

Successful pre-implementation requires three interconnected elements: understanding the intervention (needs, fit, resources, evidence, usability, capacity), assessing the context (inner organisational and outer environmental factors), and engaging stakeholders throughout the process. Together, these elements enhance acceptability, reach, and sustainability of evidence-based rehabilitation interventions.

Optional Resources

Optional Video:

Please view this approximately 13-minute video for a detailed discussion on engaging stakeholders.

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Recommended Reading:

References

  1. ↑ Ellis J, Band R, Kinsella K, Cheetham-Blake T, James E, Ewings S, Rogers A. Optimising and profiling pre-implementation contexts to create and implement a public health network intervention for tackling loneliness. Implementation Science. 2020 Dec;15(1):1-1.
  2. ↑ Morris JH, Bernhardsson S, Bird ML, Connell L, Lynch E, Jarvis K, Kayes NM, Miller K, Mudge S, Fisher R. Implementation in rehabilitation: a roadmap for practitioners and researchers. Disability and rehabilitation. 2020 Oct 22;42(22):3265-74.
  3. ↑ Roseen EJ, Welch SA, Stout N, Bean JF, Friedly JL, Mittman BS. An introduction to implementation science in rehabilitation medicine. PM&R. 2025 Nov;17:S6-20.
  4. ↑ YouTube. Implementation Science Introduction | Implementation Scientists. Available from: https://www.youtube.com/watch?v=i_l5OsxAxao [last accessed 23/04/2022]
  5. ↑ Alonge O, Rodriguez DC, Brandes N, Geng E, Reveiz L, Peters DH. How is implementation research applied to advance health in low-income and middle-income countries?. BMJ Global Health. 2019 Mar 1;4(2):e001257.
  6. ↑ Ridde V. Need for more and better implementation science in global health. BMJ Global Health. 2016 Aug 1;1(2):e000115.
  7. ↑ Semeere AS, Semitala FC, Lunkuse O, Katahoire A, Sewankambo NK, Kamya MR. An assessment of implementation science research capacity in Uganda. Health research policy and systems. 2021 Dec;19(1):1-0.
  8. ↑ Bachani AM, Bentley JA, Kautsar H, Neill R, Trujillo AJ. Suggesting global insights to local challenges: expanding financing of rehabilitation services in low and middle-income countries. Frontiers in Rehabilitation Sciences. 2024 Apr 22;5:1305033.
  9. ↑ Maart RA, Mji G, Morris LD, Ernstzen DV. The Rehabilitation Landscape in a Low-to-Middle-Income Country: Stakeholder Perspectives and Policy Implications—A Qualitative Study. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 2024 Oct;61:00469580241271973.
  10. ↑ Leonard E, de Kock I, Bam W. Barriers and facilitators to implementing evidence-based health innovations in low-and middle-income countries: a systematic literature review. Evaluation and Program Planning. 2020 Oct 1;82:101832.
  11. ↑ Grimmer K, Louw Q, Dizon JM, Brown SM, Ernstzen D, Wiysonge CS. A South African experience in applying the adopt–contextualise–adapt framework to stroke rehabilitation clinical practice guidelines. Health Research Policy and Systems. 2019 Dec;17(1):1-4.
  12. ↑ Waterworth CJ, Smith F, Kiefel-Johnson F, Pryor W, Marella M. Integration of rehabilitation services in primary, secondary, and tertiary levels of health care systems in low-and middle-income countries: a scoping review. Disability and rehabilitation. 2024 Dec 3;46(25):5965-76.
  13. ↑ Novak I, te Velde A, Hines A, Stanton E, Mc Namara M, Paton MC, Finch-Edmondson M, Morgan C. Rehabilitation Evidence-Based Decision-Making: The READ Model. Frontiers in Rehabilitation Sciences. 2021:51.
  14. ↑ 14.0 14.1 National Implementation Research Network. The Hexagon: An Exploration Tool. Available from: https://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/imce/documents/NIRN%20Hexagon%20Discussion%20Analysis%20Tool_September2020_1.pdf (accessed 23/04/2022).
  15. ↑ 15.0 15.1 Paré G, Sicotte C, Poba-Nzaou P, Balouzakis G. Clinicians' perceptions of organizational readiness for change in the context of clinical information system projects: insights from two cross-sectional surveys. Implementation Science. 2011 Dec;6(1):1-4.
  16. ↑ 16.0 16.1 16.2 Holcomb J, Ferguson GM, Sun J, Walton GH, Highfield L. Stakeholder engagement in adoption, implementation, and sustainment of an evidence-based intervention to increase mammography adherence among low-income women. Journal of Cancer Education. 2021 Mar 22:1-0.
  17. ↑ Youtube. Implementation Strategies | IRL. Available from: https://www.youtube.com/watch?v=eMesZs9R0L8[last accessed 11/05/2022]
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