Defining the external implementation context: an integrative systematic literature review

Abstract

Background: Proper implementation of evidence-based interventions is necessary for their full impact to be realized. However, the majority of research to date has overlooked facilitators and barriers existing outside the boundaries of the implementing organization(s). Better understanding and measurement of the external implementation context would be particularly beneficial in light of complex health interventions that extend into and interact with the larger environment they are embedded within. We conducted a integrative systematic literature review to identify external context constructs likely to impact implementation of complex evidence-based interventions.

Methods: The review process was iterative due to our goal to inductively develop the identified constructs. Data collection occurred in four primary stages: (1) an initial set of key literature across disciplines was identified and used to inform (2) journal and (3) author searches that, in turn, informed the design of the final (4) database search. Additionally, (5) we conducted citation searches of relevant literature reviews identified in each stage. We carried out an inductive thematic content analysis with the goal of developing homogenous, well-defined, and mutually exclusive categories.

Results: We identified eight external context constructs: (1) professional influences, (2) political support, (3) social climate, (4) local infrastructure, (5) policy and legal climate, (6) relational climate, (7) target population, and (8) funding and economic climate.

Conclusions: This is the first study to our knowledge to use a systematic review process to identify empirically observed external context factors documented to impact implementation. Comparison with four widely-utilized implementation frameworks supports the exhaustiveness of our review process. Future work should focus on the development of more stringent operationalization and measurement of these external constructs.

Keywords: External context; Implementation context; Integrative review; Local context; Outer setting; Systematic review.

Fig. 1

Flow diagram with detailed overview of the literature identification and screening process. Inclusion criteria for search: (1) written in English; (2) describe empirically observed external context factors affecting the implementation of a complex intervention or interventions; and (3) describe an intervention with impact on client- or population-level outcomes. Search exclusion criteria: (1) discussed external context factors as theoretical barriers or facilitators; (2) focused on interventions we understood to only impact organizational- or staff-level outcomes

Fig. 2

Taxonomy of external context constructs identified, their definitions, and frequency of coding in sample. Barrier and facilitator counts refer to the total number of times the issue was mentioned within the sample and do not consider the coding of multiple mentions of the same barrier or facilitator within a single article. Therefore, the document count is a better indicator of the extent to which the construct was discussed within the sample