Implementation Science: Sustainment Stage

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

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

Introduction

Individual, organisational and system readiness and capacity for change are recognised precursors to the successful implementation of complex changes in rehabilitation settings. Wensing et al. provide a warning about successful longtime intervention implementation with the "reminder that implementation needs attention, that it is never sufficient to produce and disseminate information for changing behaviour, organizations and systems." This sustainment stage completes the implementation cycle: pre-implementation identified barriers, implementation deployed strategies, evaluation assessed effectiveness, and now sustainment ensures evidence-based practices become embedded in routine operations. Sustainment refers to the continuous use of these practices, as intended, over time in ongoing operations, often involving adaptation to dynamic contexts. While implementation science has focused mainly on initial uptake, sustainment receives less attention despite being critical for long-term impact.

Sustainability vs Sustainment

While the concept of sustainability is still maturing in implementation science, a useful distinction has emerged:

• Sustainability the extent to which an intervention delivers intended benefits over time after external donor support ends
• Sustainment the continued enactment of processes, practices, and work routines learned through an intervention

This page focuses on sustainment, aligning with implementation facilitation practice approaches that emphasise ongoing organisational learning and adaptation.

Challenges to Implementation Sustainment

There are multiple challenges to adopting and implementing evidence-based rehabilitation intervention in lower-middle income countries (LMICs); sustainment of any intervention efforts remains difficult.

Examples of challenges to successful implementation in LMICs:

1. Cultural differences
2. Cost barriers
3. Accessibility
4. Quality

Sustainability challenges are particularly acute in LMICs where health system capacity constraints, workforce shortages, and funding limitations create ongoing barriers. Key barriers to sustainment include intervention complexity, inadequate program familiarity, limited human resources, lack of workplace support, and high staff turnover.  Furthermore, the limited health system capacity, poor application of evidence-based interventions, inadequate involvement of local implementers, and high staff turnover also were reported to hinder the use of public health interventions.

Systematic stakeholder engagement throughout implementation stages, including sustainment, improves long-term adoption and maintenance of interventions. Sustainment planning must begin during pre-implementation by identifying determinants of sustainment related to organisational and contextual factors.

During the sustainment phase, interventions become embedded through stable funding and ongoing monitoring. Both inner organizational and outer environmental contexts influence sustainment success. Implementation facilitators should systematically assess these contextual factors (Box 14).

Box 14:  Implementation Facilitator Sustainment Questions Inner

Context of Sustainment:

• To what extent is there leadership, an evidence-based practice culture, and a support network that is supporting intervention sustainment?
• To what extent is there role clarity, a support system and coaching that is supporting intervention sustainment?
• To what extent is there staffing processes, procedures and capacity that is supporting intervention sustainment?

Outer context of Sustainment

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

The questions in Box 14 are informed by the EPIS (Exploration, Preparation, Implementation, Sustainment) framework, which emphasises the distinct requirements of each implementation stage.

Addressing sustainment challenges requires building organisational capacity to support evidence-based practices over time. Implementation facilitation capacity building involves developing the knowledge, skills, and systems necessary to maintain interventions in routine practice.

Implementation Facilitation Capacity Building

Effective implementation of interventions requires:

1. Tailoring implementation processes to individual settings
2. Involving multiple stakeholders
3. Applying diverse implementation strategies

Implementation facilitation capacity, ie: knowledge and skills, when applied to implementation science can create supportive environments to implement evidence-based rehabilitation interventions. However, implementation facilitation capacity building is also a process (not a single event) that needs to occur in individuals, organisations and systems. In practice, implementation facilitation capacity building is a long-term and iterative process, as much an organisational change process as a technical skill building process. Implementation efforts need to be authorised and supported on an ongoing basis if interventions are to be successfully adopted, implemented and sustained in routine practice. 

Recognising the multiple organisational determinants of capacity building can help to build a strong implementation science culture within an organisation. Implementation science evaluators and specialists identify three key determinants of capacity building.

The three determinants of capacity building

The three key determinants of capacity building:

1. Organisational environment: the motivations to develop and plan pre-implementation, implementation, evaluation and sustainment; leadership and trust; conduct and use the implementation evidence; and the existence of a culture of implementation inquiry and learning
2. Workforce capacity: the staff skills, abilities and involvement in the design, conduct and evaluation of implementation efforts
3. Resource availability: the available and dedicated funding, time and tools to plan, conduct and use implementation evidence to inform adoption, implementation and sustainment of rehabilitation interventions

Summary

Successful sustainment begins during pre-implementation planning by identifying determinants of sustainability, engaging stakeholders comprehensively, and building organizational capacity. Inner and outer contextual factors continuously influence whether interventions become embedded in routine practice. Implementation facilitation must address the organisational environment, workforce capacity, and resource availability to support long-term sustainment. In LMICs, where resource constraints and system challenges are pronounced, intentional sustainment planning is essential to ensure evidence-based rehabilitation interventions deliver lasting benefits.

Recommended Additional Learning Resources

Optional Video:

Please view this approximately 13-minute video for a detailed description of the sustainment stage of implementation science.

Online Journals:

• Implementation Science provides a unique, multidisciplinary platform for research on implementation strategies, including their development, outcomes, economics, process by which effects are achieved, and factors associated with implementation outcomes.
• Implementation Research and Practice is an international, peer-reviewed, open access journal publishing interdisciplinary research that advances the implementation of effective approaches to assess, prevent, and treat mental health, substance use, or other addictive behaviors, in the general population or among those at-risk or suffering from these disorders.  

Journal Articles:

• Kennedy A, Eccles MP, Mittman BS. Welcome to implementation science. Implementation Science. 2006;1(1). 1.
• Nilsen, P. Making sense of implementation theories, models and frameworks. Implementation Science. 2015: 10(53).

• Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Implementation research: what it is and how to do it. BMJ. 2013 Nov 20;347.
• Proctor EK, Powell BJ, Baumann AA, Hamilton AM, Santens RL. Writing implementation research grant proposals: ten key ingredients. Implementation Science. 2012 Dec;7(1):1-3.
• Smith JD, Li DH, Rafferty MR. The implementation research logic model: a method for planning, executing, reporting, and synthesizing implementation projects. Implementation Science. 2020 Dec;15(1):1-2.

• Wensing M, Sales A, Armstrong R, Wilson P. Implementation science in times of Covid-19. Implementation science. 2020 Dec;15(1):1-4.

Websites:

1. The Global Alliance for Chronic Diseases Implementation Science e-Hub
2. The University of Washington Implementation Science Resource Hub
3. The Consolidated Framework for Implementation Research (CFIR)
4. The Melbourne Academic Centre for Health Implementation Science Seminar Series  (Free)
5. Global Implementation Society