Champions are individuals who demonstrate strong commitment to promoting sustained implementation efforts through their expertise, enthusiasm, and influence, and are known to enable the implementation of evidence-based educational programs. However, existing research has predominantly examined champion effectiveness during implementation and early sustainment phases, with limited attention to their role in long-term program or innovation sustainment. This study investigated how champions influence organisational capacity for sustained program implementation over extended timeframes. A multiple case study design examined champion dynamics across three Australian organisations sustaining implementation of the Abecedarian Approach Australia (3a) for 10 or more years. Semi-structured interviews were conducted with 25 participants, including senior leaders, program managers, educational leaders, and practitioners. Thematic analysis informed by critical realist epistemology identified mechanisms through which champions influenced long-term sustainability. Cross-case analysis suggested the presence of what we term a 'champion paradox': the factors that make champions effective in driving implementation may simultaneously create systemic vulnerabilities that can threaten long-term program sustainability. Across these cases, the paradox appeared to operate through three interconnected mechanisms: (1) knowledge concentration, where expertise accumulates in individuals rather than organisational systems; (2) dependency creation, where organisations become reliant on champions for quality assurance, problem-solving, and program continuity; and (3) system capacity prevention, where champion effectiveness conceals organisational need for systematic capacity building. These mechanisms were interpreted as forming a self-reinforcing cycle that may strengthen champion dependency while inhibiting organisational independent capacity. The champion paradox framework invites reconsideration of widespread assumptions that individual champions inherently strengthen organisational implementation capacity. Findings suggest potential value of a shift from champion-dependent to more system-dependent implementation models, with implications for champion selection and development, organisational design, sustainability assessment, and policy frameworks. Implementation strategies may be strengthened by positioning champions as transitional resources focused on building collective organisational capacity rather than as permanent drivers of program quality.

Cervical cancer (CC) is the leading cause of cancer-related mortality in sub-Saharan Africa (SSA), disproportionally affecting women living with HIV. Integration of CC screening and treatment of precancerous lesions into established HIV care systems supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has resulted in screening of millions of women and treatment of tens of thousands of precancerous lesions. Despite these gains, research has largely focused on patient-level barriers to screening, with limited attention to provider attitudes, organizational climate, and leadership support within PEPFAR-supported HIV clinics. A cross-sectional survey was conducted with 46 clinic staff at seven affiliated faith-based HIV clinics overseen by the Coptic Hope Center for Infectious Diseases in Nairobi County, Kenya. The Coptic Hope Center is funded by PEPFAR through the Centers for Disease Control and Prevention (CDC). Clinic staff completed three validated implementation science instruments: the Evidence-Based Practice Attitude Scale (EBPAS-36), the Implementation Climate Scale (ICS), and the Implementation Leadership Scale (ILS). Total and subscale scores were computed, and Mann-Whitney U tests were conducted to examine associations between staff and clinic characteristics and total scores. Clinic staff reported moderate overall EBPAS-36 scores, median (M) = 3.06 on a 0-4 scale, reflecting positive attitudes towards CC screening implementation. The highest ratings were observed for Feedback, Fit, Openness, and Appeal subscales, indicating both the appeal of current screening methods and openness to novel approaches. ICS(M = 2.36) and ILS (M = 3.62 for staff; 2.71 for supervisors) scores indicated moderate to strong organizational and leadership support, though lower scores on Rewards and Selection for EBP subscales suggest limited institutional incentives. No significant differences were observed by clinic type, staff role and years in position. Staff attitudes, leadership engagement, and organizational climate were broadly supportive of CC screening implementation across PEPFAR-supported clinics in Nairobi, Kenya. As countries in SSA seek to sustain the gains achieved through integrated HIV and CC prevention programs and adapt to evolving donor funding landscapes, preserving positive provider environments is essential to effective service delivery and keeping countries on the path toward CC elimination.

Practice facilitation is an established strategy for advancing quality improvement in primary care, particularly in chronic disease management. However, knowledge gaps remain regarding its long-term impact, integration of digital tools (e.g., telehealth), and barriers encountered during implementation. This study aimed to address these gaps by evaluating the Agency for Healthcare Research and Quality (AHRQ)-funded Managing Urinary Incontinence (MUI) Initiative, which supported five US institutions in implementing evidence-based, nonsurgical treatments for urinary incontinence (UI) in women. Over a two-year period, we conducted virtual semi-structured interviews and focus groups with 15 practice facilitators from each grantee institution, all of whom worked with a total of 270 practices. Discussions explored their evolving roles, implementation processes, challenges encountered, and strategies for supporting UI care. Data were audio-recorded, transcribed, and subjected to thematic analysis in Dedoose, using a team-developed codebook with dual independent coders. Five major themes emerged: (1) practice facilitator role conceptualization varied across settings and evolved over time; (2) facilitators were central to supporting process improvements with tailored resources; (3) technology integration, such as telehealth and electronic health records (EHRs), was increasingly leveraged but unevenly adopted; (4) substantial barriers included navigating institutional bureaucracy and securing physician champions amidst competing demands; and (5) facilitators implemented strategies for sustaining practice change beyond the funded intervention. Despite successes, facilitators struggled with limitations of time, resources, and systemic constraints. The findings provide actionable insights into the facilitation process for implementing evidence-based UI care, highlighting the importance of adaptive facilitator roles, technology use, and strategies for overcoming barriers and sustaining improvements. This research contributes to practical approaches for implementation in primary care settings.

Understanding how implementation strategies work is vitally important for the deployment of evidence-based practices (EPBs) in healthcare settings. Specifically, mechanistic inquiry provides information on specific targets (e.g., buy-in, saliency) that must be engaged for a strategy to be successful. We used mixed-methods to investigate mechanisms of facilitation as part of a trial to implement S.A.F.E. Firearm, a brief evidence-based practice which includes firearm storage counseling and offering free cable locks in pediatric primary care during well-child visits. We used a mixed-methods approach to ascertain mechanisms. Quantitative analyses determined whether clinic-level adaptive reserve (e.g., mechanism) mediated the impact of facilitation (e.g., strategy) on reach (e.g., primary outcome). Adaptive reserve, evaluated via clinician survey, refers to a clinic's ability to broadly make and sustain change and includes multiple components (i.e., relationship infrastructure, facilitative leadership, sensemaking, teamwork, work environment, and culture of learning). Importantly, adaptive reserve is not the specific capacity to implement a given EBP. Second, qualitative interviews guided by the updated Consolidated Framework for Implementation Research, and analyzed using deductive and inductive approaches, were conducted with pediatric clinicians, clinic change agents, and health system leaders to ascertain other mechanisms. Mixed methods integration occurred at completion of both activities. Quantitative analyses indicated that adaptive reserve did not mediate the effect of facilitation on reach. Qualitative findings illustrated other potential mechanisms of facilitation including: increasing buy-in and saliency to help overcome initial inertia and to support application of training principles in practice; strong collaborative relationships between facilitators and clinics to improve accountability; in-person visits or electronic communications that serve as reminders; reinforcing the why and how of the intervention (sensemaking); and fostering team collaboration to troubleshoot logistical barriers. While prior studies have found that adaptive reserve was related to facilitation, our mediation analysis did not support this hypothesis. Contextual factors may offer potential explanations, particularly a lower-intensity facilitation in this context commensurate with a smaller practice change (e.g., a brief program intended to take < 1 min), but further study is needed. Our qualitative results offer a potentially new mechanistic model of facilitation to be investigated in future studies.

The implementation of evidence-based practices such as kangaroo care (KC), a practice provided in clinical neonatal care, is subject to a complex and dynamic interplay of factors. Using traditional methods to capture and assess this complexity and underlying mechanisms related to implementation, has often proven difficult. This study applied system dynamics and network diffusion modeling to map implementation determinants of KC implementation and to examine underlying implementation mechanisms through which these factors influence the average duration of KC within the complex adaptive implementation system of neonatal intensive care units. A causal loop diagram (CLD) was developed through a systems mapping exercise with 32 multiprofessional KC experts and validated through interviews with participants with lived KC experience. The CLD was subsequently converted into a network graph to derive a network diffusion model. The model estimated the influence of cascades initiated by selected variables ('seeds') on the outcome variable of Average hours of KC provided. The CLD comprised 73 variables and 155 connections across three interconnected domains: parental engagement, workforce capacity and service delivery context. In the network diffusion model,Nurses per ShiftandAvailability of KC Education & Counselinginitiated the strongest influential cascades onaverage time of KC provided. This study demonstrates the utility of integrating system dynamics and network science to investigate complex mechanisms underlying implementation processes. Further applications are needed to validate and refine these methods and to strengthen their contribution to research surrounding implementation mechanisms.

High-quality implementation research is fundamental to increasing the uptake of evidence-based interventions in healthcare and ultimately improving healthcare delivery and outcomes. However, the development of high-quality implementation research proposals and the identification of the 'best' implementation research proposals to fund are hampered by the lack of criteria for their appraisal. This study describes the development and evaluation of the Implementation Research Proposal Appraisal Criteria (ImpResPAC), a comprehensive tool developed to help research teams identify strengths and weaknesses of their implementation research proposals and provide grant reviews with clear criteria for appraising the conceptual and methodological quality of implementation research proposals. A two-stage sequential mixed-methods design, including content development (stage 1) and a two-round modified e-Delphi (stage 2a & 2b), was employed. Stage 1: Informed by the structure and content of the Implementation Science Research Development (ImpRes) tool and supplementary guide, and a previous study in which five of the ten ImpRes domains were operationalised to develop five ImpResPAC domains, the ImpResPAC development team developed the initial content of ImpResPAC. Purposive and snowball sampling was used to recruit an Expert Advisory Panel (EAP), of individuals that have made a significant contribution to the conceptual and methodological advancement of implementation science. Stage 2a: The EAP provided feedback on ImpResPAC. Based on the feedback, the ImpResPAC development team made extensive revisions to ImpResPAC. Stage 2b: The refined ImpResPAC was shared with the EAP for further feedback and evaluation. Sixty-eight international experts formed the EAP. ImpResPAC includes 71 domain items, each indicative of high-quality implementation research. The domain items are organised over 10 domains each representing a core element of implementation research. Based on feedback, user instructions were refined, and a glossary of terms used in ImpResPAC was developed. ImpResPAC is a comprehensive and transparent quantitative tool to appraise the conceptual and methodological quality of implementation research proposals in healthcare. Application of ImpResPAC has several potential and immediate benefits; it will support research teams identify strengths and weaknesses of their implementation research proposals and in turn develop high-quality proposals, enable grant reviewers to identify the 'best' implementation research proposals to fund, and provide a comprehensive tool to be used by educators to appraise implementation research proposals submitted as part of implementation science teaching and training initiatives.

Tailoring implementation of an evidence-based intervention based on context is well established in implementation science. However, questions remain about tailoring implementation support via an external practice facilitator (henceforth facilitator) and methods and mechanisms of facilitator-driven tailoring. Therefore, this study examines how facilitators supported clinics in a large pragmatic study to identify contextual factors that influenced the selection and application of implementation strategies. We conducted a descriptive qualitative study of facilitator tailoring in a 15-month implementation study to support primary care clinics in increasing screening, brief intervention and referral to treatment (SBIRT), and medication assisted treatment (MAUD) for unhealthy alcohol use. Data included bi-annual interviews and monthly periodic reflections with study-funded facilitators. A framework analysis, informed by the ERIC taxonomy and i-PARIHS, was conducted to categorize and map strategies across diverse examples of clinic factors to identify key techniques of tailoring. Nine facilitators who provided practice support during implementation participated in 20 interviews and 16 periodic reflections. Practice facilitators tailored their implementation support to clinics through four key domains: 1) facilitation structure and process support; 2) technical support for clinical processes; 3) assessing and monitoring support needs over time; and 4) evidence-based intervention and quality improvement skill building support. Though facilitators used common and well-established ERIC implementation strategies in their work with clinics, the techniques used to apply those strategies varied based on clinic factors across multiple levels of context. Tailoring support was found to be both proactive and reactive. According to facilitators, utilizing a tailored approach to implementation benefited clinics by reducing the burden of administrative processes related to facilitation and implementation, improving clinic study enrollment and engagement amidst challenges or disruptions, and increasing engagement in SBIRT and MAUD activities. Our study found that facilitators tailored their support to clinics via their deployment of implementation strategies according to clinic factors in four key domains. Facilitators described tailoring efforts as important for increasing clinic engagement in quality improvement efforts. Future studies should focus on assessing the effectiveness of specific tailoring techniques on performance outcomes.

Learning collaboratives are a widely used implementation strategy for supporting the spread of complex innovations, but little is known about how learning collaboratives develop and sustain over time. The OncoPRO initiative, a PCORI-funded national learning collaborative focused on implementing remote symptom monitoring (RSM) using electronic patient-reported outcomes (ePROs) in oncology, provides a unique opportunity to explore this process. By examining how OncoPRO fosters collaboration, shares strategies, and adapts to diverse sites, this study offers critical insights into both the development of learning collaboratives and their ability to support the long-term success of complex healthcare initiatives. This study employed a multi-methods implementation science approach to examine the development and first year of the OncoPRO initiative. From conception through year 1 (March 2023-December 2024), OncoPRO provided support to 12 independent health systems. We identified cross-organizational barriers encountered during the development of a national learning collaborative, and the implementation strategies employed to address them, using field notes generated during all OncoPRO-related meetings, site-level communications, and site presentations during meetings. We systematically identified and categorized barriers and implementation strategies using the Consolidated Framework for Implementation Research (CFIR) 2.0 and the Expert Recommendations for Implementing Change (ERIC) frameworks. Strategies were then categorized into domains based on their alignment with each other and learning collaborative implementation components or processes. We identified 29 overarching barriers (e.g., lack of best practices; clinician buy-in) that were addressed through 37 foundational implementation strategies relevant to developing and facilitating the learning collaborative. These implementation strategies were organized into six domains: building a multi-level foundation, engaging and onboarding implementation sites, building shared learning structures, supporting technical rollout, embedding feedback loops and quality monitoring, and stimulating demand for RSM and collaborative participation. Most barriers were addressed using multiple strategies, and individual strategies often targeted several barriers simultaneously. Broad strategies addressing multiple barriers (e.g. build a coalition; identify early adopters) were deployed early to develop a base for the collaborative. As the initiative matured, strategies targeting specific barriers (e.g. develop and implement quality monitoring systems) were added to support site-level operationalization and continuous improvement. This study describes our approach to building a national learning collaborative for ePRO-enabled RSM implementation in oncology, focused on the initial phase of implementation. It offers a case study and potential roadmap for others involved in the initial development of large-scale collaboratives for complex interventions. This descriptive process analysis lays the groundwork for future analyses of implementation variation and strategy effectiveness across participating health systems, and highlights how learning collaboratives can support the implementation of complex quality initiatives like RSM in oncology.

Older adults without digital access, who are attempting to manage their lives within a digital landscape often struggle to maintain their independence. Living on the periphery of their communities, older people without digital access often feel alone.Technology is transforming the world around them, but they are excluded from participating. The lack of digital connection to family and friends and limited availability of essential online products and services can adversely impact their well-being. The purpose of the research was to explore the implementation of the iPad Project, an evidence-based, inter/intragenerational digital equity program for older adults, by studying the interaction of elements, determinants, strategies, mechanisms, and outcomes through the synthesis of an Implementation Research Logic Model(IRLM). This qualitative case study included the completion of semi-structured interviews with 30 study participants and collaborators, a document review, and the creation of an IRLM. Interview questions were derived from relevant constructs in the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change strategies to explore the perspectives of project participants and collaborators. Study participant's responses were thematically analyzed. An in-depth analysis of existing literature, reflexive memos, and iPad Project notes, worksheets, and reports was completed to provide context and supporting information. Qualitative themes, implementation research theory, and document analysis informed the creation of an IRLM of the iPad Project, which displayed how the project was implemented. The IRLM presented the key core and adaptable elements of the iPad Project that contributed to the project's outcomes. Environmental determinants were found to impact these elements by challenging or facilitating project progress. Strategic approaches used to address these changing effects were identified and reflected how the project was managed. The interplay between hypothesized mechanisms and contextual determinants was examined and revealed the underlying influences that shaped the outcomes. The implementation outcomes were highlighted and illustrated the effect of this evidence-based intervention. By identifying the project elements, the environmental determinants, and the strategies that were used to facilitate mechanisms of change and overcome barriers with the IRLM, this study provides guidance for future digital equity research and program implementation.

Clinical champions can be effective for increasing uptake of evidence-based interventions. However, little is known about how to prepare them to be impactful, particularly within large healthcare systems. We present a conceptual model, grounded in the Awareness, Desire, Knowledge, Ability, Reinforcement (ADKAR®) change management framework, to guide training for clinical champions. In 2021, the U.S. Department of Veterans Affairs implemented clinical champions in primary care and mental health services to facilitate uptake of Whole Health, a person-centered holistic approach to healthcare. Our conceptual model was created through iterative team discussions about learnings from our evaluation of Whole Health clinical champion implementation. This evaluation included two rounds of interviews with clinical champions, and three rounds of a practice reflection survey (aligned with ADKAR) administered to champions. Drawing on these data and ADKAR, we developed a conceptual model of how clinical champions can be supported through two complementary and sequential change management processes. The first process is related to their practice change. Clinical champions must start by gaining awareness of and interest in the new practice. They can then develop foundational knowledge and skills to enact it. Finally, they will only maintain the practice if they observe benefits of its use. Once they have progressed through the ADKAR stages in relation to the practice change, the second process they must undertake is in relation to the clinical champion role. They must first understand why clinical champions are needed and have an interest in the role. They then need training and skills for the role (e.g., overcoming barriers, mentorship). Finally, to continue the role over time they must see that champions are making a difference. Only after champions have gone through both processes can they effectively support their colleagues in progressing through the ADKAR stages to implement the change in their practice. Given that clinical champions are a widely used implementation strategy, this work holds promise for improving its impact on implementation and effectiveness outcomes. By supporting tailoring training to where champions are in the change management processes, our data-driven conceptual model can improve champions' effectiveness as change agents.