Resources & Services

Selecting a dissemination and implementation (D&I) theory, model or framework (TMF) involves several key considerations to ensure that the chosen TMF(s)  aligns well with your project’s goals, context, and the specific intervention you are implementing. We recommend beginning the process of TMF selection by first answering the following questions:

• What is/are the research questions I’m seeking to answer in this study/project?
• What is the scope of the study/project?
• What is the purpose of the TMF in the context of the study/project?

To answer these questions you may want to create a logic model (1) to help visualize and think through these issues. By guiding you to identify key issues, influences, intervention components, and outcomes, a logic model will help to select the TMF (or modification) that best helps you assess, understand, and guide alignment among the context, your intervention, and implementation strategies.

Depending on the needs of your project, you may need to adapt a TMF or use more than one TMF. Much has been written on how to approach the selection of a D&I TMF and the fact that there are more than 150 TMFs shows that selection can be a complex decision. To view a comprehensive catalog of D&I TMFs, learn more about each, as well as use an interactive webtool designed to assist researchers and implementors with TMF selection and application we recommend you visit dissemination-implementation.org.

 Resources for Further Reading on this Topic:

1.  Nilsen P. (Editor)(2024). Implementation science: Theory and application. Routledge: New York
2. Smith JD, Li DH, Rafferty MR. The Implementation Research Logic Model: a method for planning, executing, reporting, and synthesizing implementation projects. Implement Sci. 2020 Sep 25;15(1):84. doi: 10.1186/s13012-020-01041-8. PMID: 32988389; PMCID: PMC7523057.
3. Tabak, R. G., Nilsen, P., Woodward, E.N., & Chambers, D.A. (2023). The conceptual basis for dissemination and implementation research. In Dissemination and implementation research in health: Translating science to practice. New York: Oxford Publishing. (Pages 86-105).

Adaptations are defined as thoughtful or deliberate modifications made to an intervention with the goal of improving their fit with a given context. Adaptations can either improve or worsen outcomes, but we know that they will happen even if we try to prevent them. Adaptations can be assessed several different ways, including observation, structured interviews, and staff notes. We recommend using multiple methods and triangulating their results.

Basically, an adaptation is a modification to the initial plans for a program. Adaptations can be made to the intervention; implementation strategies; or the setting as well as the phase of your program. There are many types of adaptations and it is helpful to have guidance for conceptualizing, assessing, and addressing them.

        We recommend you use one of the adaptation frameworks discussed in the references below. Experts agree on the need to track and report adaptations, but there is less agreement about if you should guide them during program implementation (most experts agree that pre-implementation adaptations in collaboration with community and clinical partners is important). There is a great deal of active research being conducted on both the assessment and guidance of iterative adaptations (3).

References for Further Reading on the Topic:

1. Baumann, Ana & Stirman, Shannon & Cabassa, Leopoldo. (2023). Adaptation in Dissemination and Implementation Science. 10.1093/oso/9780197660690.003.0008.
2.  Miller, C. J., Barnett, M. L., Baumann, A. A., Gutner, C. A., & Wiltsey-Stirman, S. (2021). The FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare. Implementation Science, 16(1). View this publication here.
3. Rabin B, Cain K, and Glasgow R. Adapting Public Health and Health Services Interventions in Diverse, Real-World Settings: Documentation and Iterative Guidance of Adaptations. Annual Review of Public Health, 2025, in press. (contact author)

In recent years, there has been increasing emphasis on health equity within the field of D&I, with calls to more consistently measure and address disparities as well as adapt strategies to enhance implementation of interventions among minoritized and vulnerable populations. Because D&I methods so heavily emphasize the importance of context, engagement of diverse partners, and multiple priorities and outcomes, they are well suited to advance health equity.

There are multiple dedicated health equity Theories Models and Frameworks (TMFs) that can be used in combination with D&I TMFs (see link below). For instance, the Health Equity Implementation Framework( Woodward reference), which considers implementation factors that may be unique to vulnerable populations, is designed to be used in combination with other types of D&I TMFs.

Additionally, existing D&I TMFs can also be adapted to consider equity more explicitly throughout planning, implementation and evaluation phases. For instance, the Pragmatic Robust Implementation and Sustainability Model (PRISM) has evolved to emphasize the importance of measuring representativeness more explicitly across all implementation and effectiveness outcomes as well as capturing diverse multi-level partner perspectives on context.

For a fuller discussion of how D&I science can help to address health equity, visit Dissemination-Implementation.org's special topics section on health equity as well as the references listed below.

References for Further Reading on the Topic

1. Woodward EN, Matthieu MM, Uchendu US, Rogal S, Kirchner JE. The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment. Implement Sci. 2019;14(1):26.
2. Stephanie L. Fitzpatrick, Beth A. Glenn, O Kenrik Duru, Chandra L. Ford. Health Equity in Dissemination and Implementation Science. In: Ross C. Brownson, Graham A. Coldtz, Enola K. Proctor, ed. Dissemination and Implementation Research in Health. Oxford University Press; 2023.
3. Jolles MP, Fort MP, Glasgow RE. Aligning the planning, development, and implementation of complex interventions to local contexts with an equity focus: application of the PRISM/RE-AIM Framework. Int J Equity Health. 2024;23(1):41.

Sustainability refers to the capacity to maintain a program after implementation or research evaluation period. Sustainment refers to the actual continuation of the program and its impact. D&I can help address these issues in several ways:

1. Encouraging the selection of implementation strategies to enhance sustainability from the beginning ;
2.  Assessing and reporting back to decision-makers on outcomes important to them including reach, effectiveness, equity, and cost.
3. By assessing and guiding adaptations to sustain a program. This is an increasingly researched topic in D&I. In the references below there are tested and new sustainability frameworks as well as sustainability assessment tools.

References for Further Reading on the Topic

1. Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013). The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Science, 8(1), 117. https://doi.org/10.1186/1748-5908-8-117
2. Kwan, B. M., Brownson, R. C., Glasgow, R. E., Morrato, E. H., & Luke, D. A. (2022). Designing for Dissemination and Sustainability to Promote Equitable Impacts on Health. Annual Review of Public Health, 43(1), 331-353. https://doi.org/10.1146/annurev-publhealth-052220-112457
3. Luke, D. A., Calhoun, A., Robichaux, C. B., Elliott, M. B., & Moreland-Russell, S. (2014). The Program Sustainability Assessment Tool: A New Instrument for Public Health Programs. Preventing Chronic Disease, 11, E12. View the Program Sustainability Assessment Tool publication   Visit the Program Sustainment Assessment Tool website.
4. Moullin, J. C., Sklar, M., Ehrhart, M. G., Green, A., & Aarons, G. A. (2021). Provider REport of Sustainment Scale (PRESS): development and validation of a brief measure of inner context sustainment. Implementation Science, 16(1). View this publication here.

Costs are central to D&I science for several reasons. Conceptually they are one of the strongest predictors of adoption (scale up or dissemination), successful implementation and sustainment. Pragmatically, in discussions with potential adopting settings about participation if questions about costs cannot be answered, it is unlikely the site will participate.

For more straightforward costing of implementation, it is usually not necessary to have an economist. For more complex analyses such as business impact, return on investment(ROI), cost effectiveness and benefit, it is advisable to partner with an economist. Regardless, it is important to assess and report costs using standard procedures as described in the references below.

Two useful cost strategies are to conduct:

1. ‘Back of the envelope’ (or more formal) cost estimates during a project planning stage to check on if an intervention is at all feasible given setting resources, time, etc.
2. Replication cost analyses, which involve estimating what it will cost different types of settings to implement a successful program in a research study.

Resources for Further Reading on this Topic:

1. Dopp, Alex & Walker, Simon & Raghavan, Ramesh. (2023). The Role of Economic Evaluation in Dissemination and Implementation Research. 10.1093/oso/9780197660690.003.0011.
2. Cidav Z, Mandell D, Pyne J, Beidas R, Curran G, Marcus S. A pragmatic method for costing implementation strategies using time-driven activity-based costing. Implement Sci. May 5 2020;15(1):28. doi:10.1186/s13012-020-00993-1
3. Cronin J,  Gritz M, Eisman A, et al. A Costing Guidebook for Implementation Scientists. 2023. Retrieved August 23, 2023 

The term learning health system (LHS) refers to the idea of a health system that is able to seamlessly integrate new practices based on learnings from its own data as well as external evidence. This is accomplished via an information technology infrastructure that allows for data from ongoing clinical care to be continuously analyzed; and what is learned is integrated into rapid improvements in care delivery, akin to an audit and feedback loop. To date, LHS is an aspirational idea, but some health systems are investing heavily in LHS infrastructure because of its potential benefits to both patients and the system.

By pairing D&I frameworks and methods with LHS infrastructure, implementation teams can use conceptual models and D&I tools to monitor the progress of implementation, effectiveness and disparities in LHS applications. This reduces the resources needed to collect the data and improves the timeliness of data delivery allowing for frequent evaluations of both implementation outcomes and changes in key contextual factors from which implementers can select targeted adaptations to enhance contextual fit, effectiveness and equity.

Resources for Further Reading on this Topic:

1. Trinkley KE, Ho PM, Glasgow RE, Huebschmann AG. How Dissemination and Implementation Science Can Contribute to the Advancement of Learning Health Systems. Acad Med. 2022 Oct 1;97(10):1447-1458. doi: 10.1097/ACM.0000000000004801. Epub 2022 Sep 23. PMID: 35796045; PMCID: PMC9547828.
2. Trinkley KE, Wright G, Allen LA, Bennett TD, Glasgow RE, Hale G, Heckman S, Huebschmann AG, Kahn MG, Kao DP, Lin CT, Malone DC, Matlock DD, Wells L, Wysocki V, Zhang S, Suresh K. Sustained Effect of Clinical Decision Support for Heart Failure: A Natural Experiment Using Implementation Science. Appl Clin Inform. 2023 Oct;14(5):822-832. doi: 10.1055/s-0043-1775566. Epub 2023 Oct 18. PMID: 37852249; PMCID: PMC10584394.
3. Lindsell, CJ, et al. Learning From What We Do, and Doing What WeLearn: A Learning Health Care System in Action ,Acad Med. 2021;96:1291–1299. First published online February 23, 2021.  doi: 10.1097/ACM.0000000000004021

Context is very important in Dissemination and Implementation (D&I) science because there are multiple and varied factors in every environment that affect implementation. These multiple and varied factors are often referred to “determinants” which can be further categorized as “barriers” and “facilitators” of implementation.

By understanding Context, we can define the determinants and adapt:

1. The intervention
2. Implementation strategies used
3. Even the context itself to improve the “fit” to context (see figure below)
   

Adapting like this can enhance the feasibility, effectiveness, equity and sustainability of a intervention. It’s important to understand that Context is multi-level (e.g. individual, implementation setting and staff, system, and policy levels and relationships among these levels) and dynamic so assessments to understand changes in Context are needed over time.

Resources for Further Reading on this Topic:

       Figure from Damschroder et al 2009¹

1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50. doi: 10.1186/1748-5908-4-50. PMID: 19664226; PMCID: PMC2736161.
2. McCreight MS, Rabin BA, Glasgow RE, Ayele RA, Leonard CA, Gilmartin HM, Frank JW, Hess PL, Burke RE, Battaglia CT. Using the Practical, Robust Implementation and Sustainability Model (PRISM) to qualitatively assess multilevel contextual factors to help plan, implement, evaluate, and disseminate health services programs. Transl Behav Med. 2019 Nov 25;9(6):1002-1011. doi: 10.1093/tbm/ibz085. PMID: 31170296.
3. Squires JE, Graham ID, Santos WJ, Hutchinson AM; ICON Team. The Implementation in Context (ICON) Framework: A meta-framework of context domains, attributes and features in healthcare. Health Res Policy Syst. 2023 Aug 7;21(1):81. doi: 10.1186/s12961-023-01028-z. PMID: 37550737; PMCID: PMC10408185.

The Practical, Robust Implementation and Sustainability Model (PRISM) is a versatile and commonly used Dissemination and Implementation (D&I) framework that enhances the RE-AIM model by adding context and a focus on equity. RE-AIM - Reach, Effectiveness, Adoption, Implementation and Maintenance - serve as the outcome domains of PRISM.

PRISM’s contextual domains consider various environmental factors, such as intervention characteristics, implementation infrastructure, organizational values and perspectives at multiple levels, and the external environment­ (e.g. policies and guidelines) all influence implementation of health interventions. This context-sensitive approach helps ensure that interventions are suitable for the setting they are implemented in, thereby improving their real-world effectiveness. 

PRISM also incorporates an equity focus by encouraging the inclusion of diverse perspectives to better understand the implementation context.  The model encourages designing interventions that measure disparities in care delivery and health outcomes making them transparent, and in doing so, addressable.

Resources for Further Reading on this Topic:

1. https://re-aim.org/learn/prism/
   
2. Glasgow, R.E., Trinkley, K.E., Ford, B. et al. The Application and Evolution of the Practical, Robust Implementation and Sustainability Model (PRISM): History and Innovations. Glob Implement Res Appl (2024). https://doi.org/10.1007/s43477-024-00134-6