By Allison Metz and Annette Boaz
Should implementation science make more room for consultation, collaboration and co-creation with stakeholders? Would finding more active roles for stakeholders in implementation science be a promising approach to increasing the use of research evidence for improvements in policy and services?
The goal of implementation science is to promote the sustainable implementation of research evidence at scale to improve population outcomes, especially in health and human services. Nevertheless, the mobilization of research evidence on the frontlines of health and human services has been quite limited, especially in public agencies serving the vast majority of consumers.
This lack of impact has led us to ask some searching questions about how we go about implementing research evidence, including to what extent stakeholders are a genuine part of the implementation process.
The lack of attention to participatory processes and stakeholder involvement in most implementation science frameworks and methods deserves critical analysis. Specifically, implementation science does not explicitly discuss the involvement of service beneficiaries in the development or implementation of evidence.
There is, however, the beginning of a discussion about the importance of collaboration and consultation processes in implementation, with Rycroft Malone and colleagues (2013) providing a compelling argument for valuing implementation as a collaborative act, noting that collaboration leads to the following:
- Knowledge and evidence that is more implementable
- Infrastructure that brings research evidence and implementation closer together
- Attention to local needs and increased relevance and impact of implementation activity
- Enhanced capacity and capability of implementation
How can this thinking be progressed? The implementation science literature commonly describes implementation as occurring in discernible stages or phases. Could collaboration processes be infused into stage-based implementation approaches? For example, early stages of implementation call for needs assessments and selection of approaches to meet population needs.
The active involvement of service beneficiaries in these processes would ensure attention to local needs and increased relevance of the approach for consumers. Later stages of implementation emphasize the use of data for continuous improvement. Involving consumers in the interpretation of data, prioritization of continuous improvement strategies, and assessment of the benefit of improvement strategies would support the contexualization and sustainability of evidence-based approaches over time.
But would the use of collaboration strategies with current implementation science frameworks be enough to improve outcomes? As one of us (Boaz, et al., 2016) has pointed out, implementation science typically focuses on promoting the use of research evidence, an inherently “top down” agenda.
Including consumers in stage-based work runs the risk of symbolic inclusion – giving consumers and stakeholders “a seat at the table” without thinking through strategies that would promote their authentic involvement in developing, implementing and improving evidence to achieve socially meaningful outcomes. Focusing on the use of research evidence also runs the risk of emphasizing transformational change when consumers are also interested in “small-scale” changes that could more readily address challenges they face.
We therefore suggest that implementation science may be strengthened by participatory processes that involve a greater shift in power to the consumer than collaboration or consultation processes. As Katrin Prager points out in her blog post, not all participatory processes are the same with regard to “who is involved, who initiated the process and for what reason, the anticipated outcomes, the duration, the context in which it takes place, and who has control over the process.”
Prager refers to Arnstein’s Ladder (1969) which describes how different stakeholder processes are associated with varying shifts in power toward the participants. Translating such a shift in power to implementation science would require a co-creation process where service beneficiaries are intensely engaged at every stage in order to jointly produce a mutually valued outcome.
Indeed we may need to fully rethink certain implementation science constructs that are taken for granted. What if we reworked the stage-based approach to more carefully account for the messy, dynamic, and iterative process that is the hallmark of effective co-creation? Rather than moving through stage-based activities set a priori, what if we facilitated the development of co-creation processes that promote a participatory approach to creating, using, and implementing evidence that shifts power toward the consumer?
As Voorberg and colleages (2014) have pointed out, such processes include developing a communication infrastructure to facilitate interactions among stakeholders, supporting stakeholders to involve others as valuable partners, ensuring the involvement of service users in the generation of evidence, and developing the social capital required to create sustainable relations among stakeholders.
Such processes will identify and challenge the power dynamics inherent in the use of research evidence and implementation science. However, the result may be well be an opportunity to build and sustain the use of relevant, contextualized evidence with greater impacts.
Rethinking the role of stakeholders in implementation science raises many questions, including:
- Do these concepts (implementation and co-creation) blend or are they oil and water?
- Would co-creation ideas need to adapt too?
- Is more consultation better than nothing?
We’d love to hear your views.
Arnstein, S. R. (1969). A ladder of citizen participation. Journal of the American Institute of Planners, 35, 4: 216-224.
Boaz, A., Robert, G., Locock, L., Sturmey, G., Gager, M., Vougioukajou S., Ziebland, S., and Fielden, J. (2016). What patients do and their impact on implementation. Journal of Health Organization and Management, 30, 2: 258-278.
Rycroft-Malone, J., Wilkinson, J., Burton, C. R., Harvey, G., McCormack, B., Graham, I., and Staniszewska, S. (2013). Collaborative action around implementation in collaborations for leadership in applied health research and care: Towards a programme theory. Journal of Health Services Research & Policy, 18, 3 (supplementary): 13-26.
Voorberg, W. H., Bekkers, V. J., and Tummers, L. G. (2015). A systematic review of co-creation and co-production: Embarking on the social innovation journey. Public Management Review, 17, 9: 1333-1357.
To find out more about implementation science see:
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. and Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (Publication No.231), University of South Florida: Tampa, United States of America. Online: http://ctndisseminationlibrary.org/PDF/nirnmonograph.pdf
Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science, 10: Article 53. Online (DOI): 10.1186/s13012-015-0242-0
Biography: Allison Metz, Ph.D., is a developmental psychologist, Director of the National Implementation Research Network (NIRN), and Senior Scientist at the Frank Porter Graham Child Development Institute at The University of North Carolina at Chapel Hill. Allison specializes in the implementation, mainstreaming, and scaling of evidence to achieve social impact for children and families in a range of human service and education areas, with an emphasis on child welfare and early childhood service contexts. Among many projects, Allison is studying how to effectively co-create the conditions to sustain the use of research evidence in public child welfare through a project funded by the William T. Grant Foundation. Allison serves on the Board of Directors for the Global Implementation Initiative.She is a principal investigator of the Co-Creative Capacity Pursuit funded by the National Socio-Environmental Synthesis Center (SESYNC).
Biography: Annette Boaz is a professor in the Centre for Health and Social Care Research at Kingston and St George’s Universities, London. She is a social scientist with research interests in research engagement, research impact and evaluation. She supports a number of initiatives aimed at increasing capacity for research use including the UK National Institute for Health Research Knowledge Mobilization Fellowship scheme and the UK Implementation Network. She is the Joint Managing Editor of the journal Evidence & Policy. She is a member of the Co-Creative Capacity Pursuit funded by the National Socio-Environmental Synthesis Center (SESYNC).
This blog post is one of a series resulting from the first meeting in April 2016 of the Co-Creative Capacity Pursuit. This pursuit is part of the theme Building Resources for Action-Oriented Team Science funded by the US National Socio-Environmental Synthesis Center (SESYNC).
3 thoughts on “Where are the stakeholders in implementation science?”
Hello Allison and Annette, We are discussing Implementation Research this week on the HIFA forum in collaboration with WHO, TDR and The Lancet. http://www.hifa.org/news/new-discussion-implementation-research-engaging-everyone-not-just-scientists
I was interested to read your comments on stakeholder engagement. Two learning points for me have been that engagement is an important defining factor for implementation research. But the nature and level of this engagement is dependent to on the IR question. Certainly the definition of the question itself should be informed by stakeholders, especially frontline health workers, as they have the best knowledge of practical challenges and barriers.
I was also interested to read your provocative statement: “Implementation science typically focuses on promoting the use of research evidence, an inherently “top down” agenda.”
My view is that IR is (mostly or always) only worthwhile if it is clear that successful implementation of the intervention would lead to health benefits. These interventions must previously have been shown to be effective through prior clinical and other research. For example, IR that looks at how to improve the availability of amoxicillin for children with pneumonia is clearly important, whereas IR to implement an intervention that has questionable efficacy has arguably much less value.
I look forward to further discussion here and on HIFA! http://www.hifa.org
Excellent piece. You raise some very important questions. Thanks also for the reference to Annette’s 2016 paper. I look forward to reading that. In Canada we have a national initiative (well….it’s a series of regional initiatives linked up) call henStrategy for Patient Oriented Research (SPOR). The US has the Patient-Centered Outcomes Research Institute (PCORI). I wonder if they have considered the reverse: the role of implementation science in patient engaged research for patient benefit?
Dear Allison and Annette,
I love the blog and agree that science needs to better consider usability, the enabling environment and needs, attitudes and beliefs of different stakeholders.
Do these concepts (implementation and co-creation) blend or are they oil and water? They should blend but frequently don’t. Co-creation is a very participatory approach at odds with many quantitative researchers. The blend needed is for more quantitative scientists to work with qualitative researchers when it comes to implementation and policy uptake.
Would co-creation ideas need to adapt too? Yes
Is more consultation better than nothing? Yes provided it does not waste busy/impoverished people’s time.
Keep these blogs coming!