Commentary on the importance of theory in Implementation Science research

At the core of effective implementation is change; whether it be changing individual-level behaviors, changing organizations and systems, or changing the way groups and teams work; promoting effective change is critical to achieving outcomes. To promote effective change, we cannot neglect the role of theory. Theory provides the missing link from problem to intervention to outcome, helping us understand why and how the world works. Theory can shed light on why people do not want to change, how change strategies work, and why we see the outcomes we see in our research. Several of this month’s featured articles underscore the importance of theory in our research, while highlighting room for improvement in our use of theory (Birken et al., Colquhoun et al., Johnson et al.). Birken et al. set the stage by discussing the misuse, underuse, and superficial use of theory in implementation science. With a call to action for behavior change (Bennett & Shelton) and the use of entirely new methods to enhance our understanding of behavior change interventions (Michie et al.), we cannot forget the integral role that theory should play in our research.

First, we should increase our use of theory to underpin our research. As discussed by Colquhoun et al., theory was “rarely invoked” in the design of a prominent implementation strategy: audit and feedback. The authors report that the effects of audit and feedback plateaued in 2003, and posit that this stagnation could be partially attributed to a lack of theoretical understanding. Individual behavior change theories explain why people do or do not change their behavior and, if we do not have an in-depth understanding of the problem at hand, our interventions may be targeted at the incorrect behavioral change lever, muting our effect on outcomes. Second, in applying theory, we should be discerning in our selection of theory to ensure we are shedding the right light on the problem at hand. As noted by Birken et al., selection of theory is often “haphazard or driven by convenience or prior exposure.” We must take the time to consider the objective of our research and select a theory that is best suited to deepening our understanding of the task at hand. Finally, we should challenge ourselves to apply theory in rigorous ways. Johnson et al. present a mediation analysis where they investigated the direct and indirect effects of coaching activities on implementation fidelity. Mediation analysis is one technique for empirically investigating theory, as it allows researchers to investigate the causal chain between an intervention and outcome. As we move forward with our charge to put evidence into practice, we should take care to rigorously and meaningfully apply theory to deepen the quality and generalizability of our work.

G. G. Bennett and R. C. Shelton. Extending Our Reach for Greater Impact. Health Education & Behavior, 0(0), 1090198117736354.

S. A. Birken, B. J. Powell, C. M. Shea, E. R. Haines, M. Alexis Kirk, J. Leeman, C. Rohweder, L. Damschroder and J. Presseau. (2017). Criteria for selecting implementation science theories and frameworks: results from an international survey. Implement Sci, 12(1), 124.

H. L. Colquhoun, K. Carroll, K. W. Eva, J. M. Grimshaw, N. Ivers, S. Michie, A. Sales and J. C. Brehaut. (2017). Advancing the literature on designing audit and feedback interventions: identifying theory-informed hypotheses. Implementation Science, 12(1), 117.

S. R. Johnson, E. T. Pas, C. P. Bradshaw and N. S. Ialongo. (2017). Promoting Teachers’ Implementation of Classroom-Based Prevention Programming Through Coaching: The Mediating Role of the Coach-Teacher Relationship. Adm Policy Ment Health.

S. Michie, J. Thomas, M. Johnston, P. M. Aonghusa, J. Shawe-Taylor, M. P. Kelly, L. A. Deleris, A. N. Finnerty, M. M. Marques, E. Norris, A. O’Mara-Eves and R. West. (2017). The Human Behaviour-Change Project: harnessing the power of artificial intelligence and machine learning for evidence synthesis and interpretation. Implementation Science, 12(1), 121.