Cited by 197Health Policy Implementation ScienceClinical practice guidelines implementationHealth Sciences Research and Education

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Context and implementation: A concept analysis towards conceptual maturity

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Pfadenhauer, Lisa Maria, Mozygemba, Kati, Gerhardus, Ansgar, Hofmann, Bjørn, Booth, Andrew, Lysdahl, Kristin Bakke, Tummers, Marcia, Burns, Jacob, Rehfuess, Eva Annette·2015·Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen

DOI 10.1016/j.zefq.2015.01.004

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Abstract

Context and implementation of health interventions have received increasing attention over the past decade, in particular with respect to their influence on the effectiveness and reach of complex interventions. The underlying concepts are both considered partially mature, limiting their operationalization in research and practice. We conducted systematic literature searches and pragmatic utility (PU) concept analyses to provide a state-of-the-art assessment of the concepts of "context" and "implementation" in the health sciences to create a common understanding for their use within systematic reviews and HTA. We performed two separate searches, one for context (EMBASE, MEDLINE) and the other for implementation (Google Scholar) to identify relevant models, theories and frameworks. 17 publications on context and 35 articles on implementation met our inclusion criteria. PU concept analysis comprises three guiding principles: selection of the literature, organization and structuring of the literature, and asking analytic questions of the literature. Both concepts were analyzed according to four features of conceptual maturity, i.e., consensual definitions, clear characteristics, fully described preconditions and outcomes, and delineated boundaries. Context and implementation are highly intertwined, with both concepts influencing and interacting with each other. Context is defined as a set of characteristics and circumstances that surround the implementation effort. Implementation is conceptualized as a planned and deliberately initiated effort with the intention to put an intervention into practice. The concept of implementation presents largely consensual definitions and relatively well-defined boundaries, while distinguishing features, preconditions and outcomes are not yet fully articulated. In contrast, definitions of context vary widely, and boundaries with neighbouring concepts, such as setting and environment, are blurred; characteristics, preconditions and outcomes are ill-defined. Therefore, the maturity of both concepts should be further improved to facilitate operationalization in systematic reviews and HTAs.

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“33”
Community-Based Mental Health Intervention Skills: Task Shifting in Low- and Middle-Income Settings
Johns, L. D., Power, J., & MacLachlan, M. (2018) · International Perspectives in Psychology · doi:10.1037/ipp0000097 · Cited by 27
How to deal with context? A context-mapping tool for quality and safety in nursing homes and homecare (SAFE-LEAD Context)
Wiig, S., Aase, K., Johannessen, T., Holen-Rabbersvik, E., Thomsen, L. H., van de Bovenkamp, H., Bal, R. A., & Ree, E. (2019) · BMC Research Notes · doi:10.1186/s13104-019-4291-3 · Cited by 25
How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties
Wæhle, H. V., Haugen, A. S., Wiig, S., Søfteland, E., Sevdalis, N., & Harthug, S. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-4965-5 · Cited by 27
Prevention of Cardiovascular Diseases in Community Settings and Primary Health Care: A Pre-Implementation Contextual Analysis Using the Consolidated Framework for Implementation Research
Aerts, N., Anthierens, S., Bogaert, P. V., Peremans, L., & Bastiaens, H. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19148467 · Cited by 26
“Moreover, little is known about how context (Definition: context reflects a set of characteristics and circumstances that consist of active and unique factors that interact, influence, modify, and facilitate or constrain the intervention and its implementation) can influence their implementation [36,37].”
Background
When complexity matters: a step-by-step guide to incorporating a complexity perspective in guideline development for public health and health system interventions
Movsisyan, A., Rehfuess, E. A., & Norris, S. L. (2020) · BMC Medical Research Methodology · doi:10.1186/s12874-020-01132-6 · Cited by 23
“However, public health and health system interventions affect the system in which they are implemented in multiple ways; how they operate and which effects they can achieve depend on a combination of geographical, epidemiological, sociocultural, socio-economic, political, ethical, and legal factors [54, 55].”
BackgroundSelf-citation
Conceptualizing Context and Intervention as a System in Implementation Science: Learning From Complexity Theory Comment on "Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-country Analysis"
Pfadenhauer, L. M. (2021) · International Journal of Health Policy and Management · doi:10.34172/ijhpm.2021.147 · Cited by 26
“1 While spatial aspects such as location and proximity emerged as critical in public health informed by complexity theory, 2,10,13 it has been less frequently taken up by determinant FMTs on implementation in healthcare.”
BackgroundSelf-citation
A Model for Selecting Theoretical Framework through Epistemology of Research Paradigms
Omodan, B. I. (2022) · African Journal of Inter/Multidisciplinary Studies · doi:10.51415/ajims.v4i1.1022 · Cited by 21
Programme Reporting Standards (PRS) for improving the reporting of sexual, reproductive, maternal, newborn, child and adolescent health programmes
Kågesten, A., Tunçalp, Ö., Portela, A. G., Ali, M., Tran, N. T., & Gülmezoglu, A. M. (2017) · BMC Medical Research Methodology · doi:10.1186/s12874-017-0384-7 · Cited by 21
“Insufficient detail on the context and implementation does not only hamper replication and scale-up, but contributes to the gap between research and practice [5].”
BackgroundInfluential
Addressing health equity during design and implementation of health system reform initiatives: a scoping review and framework
Bouckley, T., Peiris, D., Nambiar, D., Mishra, S., Sood, T., Purwar, P., Elshaug, A. G., Landon, B. E., Pearson, S., Schneider, C. H., et al. (2025) · International Journal for Equity in Health · doi:10.1186/s12939-025-02436-z · Cited by 24
“Recognising the dynamic and recursive nature of implementation [8, 31, 32], our proposed framework sits within the design and implementation phase or the ‘ active implementation zone’ as Bullock, Lavis [32] proposed in the process model of implementation from a policy perspective.”
Exploring the intersection of hermeneutics and implementation: a scoping review
MacLeod, M. L. P., McCaffrey, G., Wilson, E., Zimmer, L. V., Snadden, D., Zimmer, P., Jonatansdottir, S., Fyfe, T., Koopmans, E., Ulrich, C., et al. (2023) · Systematic Reviews · doi:10.1186/s13643-023-02176-7 · Cited by 16
A systematic approach to context-mapping to prepare for health interventions: development and validation of the SETTING-tool in four countries
Brakema, E. A., van der Kleij, R., Poot, C. C., Chavannes, N. H., Tsiligianni, I., Walusimbi, S., An, P. L., Sooronbaev, T., Numans, M. E., Crone, M. R., et al. (2021) · BMJ Global Health · doi:10.1136/bmjgh-2020-003221 · Cited by 18
Situational analysis of breast health care systems: Why context matters
Duggan, C. R., Dvaladze, A. L., Scheel, J. R., Stevens, L. M., & Anderson, B. O. (2020) · Cancer · doi:10.1002/cncr.32899 · Cited by 18
“It interacts, influences, modifies, and facilitates or constrains the intervention and its implementation.(23) Moore et al described the importance of measuring contextual factors that shape theories of how the intervention works, as well as contextual factors that both affect, and may be affected by, the implementati…”
Background
How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions
Haenssgen, M. J., Charoenboon, N., Do, N. T. T., Althaus, T., Zaw, Y. K., Wertheim, H. F. L., & Lubell, Y. (2019) · Trials · doi:10.1186/s13063-019-3215-9 · Cited by 18
Evidence-based practices in pressure ulcer prevention: Lost in implementation?
Balzer, K., & Kottner, J. (2015) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2015.08.006 · Cited by 16
En Route to Implementation Science 3.0
Albers, B., Shlonsky, A., & Mildon, R. L. (2020) · Springer eBooks · doi:10.1007/978-3-030-03874-8_1 · Cited by 18
Understanding resilience, self-reliance and increasing country voice: a clash of ideologies in global health
Shawar, Y. R., Neill, R., Kunnuji, M. O. N., Manoj, M., & Shiffman, J. (2023) · BMJ Global Health · doi:10.1136/bmjgh-2022-010895 · Cited by 14
Implementation of Complex Suicide Prevention Interventions: Insights into Barriers, Facilitators and Lessons Learned
Krishnamoorthy, S., Mathieu, S. L., Armstrong, G. T., Ross, V. L., Francis, J., Reifels, L., & Kõlves, K. (2024) · Archives of Suicide Research · doi:10.1080/13811118.2024.2368127 · Cited by 14
“Therefore, context and implementation are deeply intertwined (Pfadenhauer et al., 2015).”
Assessing the maturity of the “Family Centered Care” concept: A review of concept analyses studies
Al‐Motlaq, M., Foster, M., Zgambo, M., & Neill, S. (2024) · Journal of Pediatric Nursing · doi:10.1016/j.pedn.2024.09.004 · Cited by 12
The health-related quality of life, mental health and mental illnesses of patients with inclusion body myositis (IBM): results of a mixed methods systematic review
Senn, K. C., Gumbert, L., Thiele, S., Krause, S., Walter, M. C., & Nagels, K. (2022) · Orphanet Journal of Rare Diseases · doi:10.1186/s13023-022-02382-x · Cited by 12
“Eligibility criteria The focused context of the included studies was based on the recommendations of PROGRESS-Plus [24], PRISMA Equity Extension [25] and CICI Framework [26].”
Method
Adapting population health interventions for new contexts: qualitative interviews understanding the experiences, practices and challenges of researchers, funders and journal editors
Copeland, L., Littlecott, H., Couturiaux, D., Hoddinott, P., Segrott, J., Murphy, S., Moore, G. F., & Evans, R. (2022) · BMJ Open · doi:10.1136/bmjopen-2022-066451 · Cited by 13
How to deal with context? Evaluation of the SAFE-LEAD Context Tool for quality and safety in nursing home and homecare services
Holen-Rabbersvik, E., Ullebust, B., Ree, E., Schibevaag, L., Hurup-Thomsen, L., Strømme, T., Aase, K., Aase, I., Ellis, L. A., & Wiig, S. (2020) · Tidsskrift for omsorgsforskning · doi:10.18261/issn.2387-5984-2020-02-07 · Cited by 11
Contextual factors influencing physicians’ perception of antibiotic prescribing in primary care in Germany — a prospective observational study
Queder, A., Arnold, C., Wensing, M., & Poß-Doering, R. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-07701-3 · Cited by 10
“Even though the concept of context is widely used in health services research, a consistent definition and application in practice still lacks [9].”
Background
Implementation between text and work—a qualitative study of a readmission prevention program targeting elderly patients
Lehn, S. F., Thuesen, J., Bunkenborg, G., Zwisler, A., & Rod, M. H. (2018) · Implementation Science · doi:10.1186/s13012-018-0730-0 · Cited by 11
“The literature agrees that context has an important influence on the implementation process and outcome [6, 7].”
Background
Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study
Lyng, H. B., Ree, E., Strømme, T., Johannessen, T., Aase, I., Ullebust, B., Thomsen, L. H., Holen-Rabbersvik, E., Schibevaag, L., Bates, D. W., et al. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-10985-2 · Cited by 10
Core values and local guarantees of dignity in the care of older persons – Application, obstacles and further actions
Kihlgren, A. L., Pejner, M. N., & James, I. (2020) · Scandinavian Journal of Caring Sciences · doi:10.1111/scs.12878 · Cited by 10
A scoping review of outer context constructs in dissemination and implementation science theories, models, and frameworks
Escoffery, C., Sekar, S., Allen, C. G., Madrigal, L., Haardöerfer, R., & Mertens, A. C. (2023) · Translational Behavioral Medicine · doi:10.1093/tbm/ibac115 · Cited by 11
Evaluation of interprofessional care processes for patients treated with oral anticancer drugs
Kinnaer, L., Kenis, I., Foulon, V., & Hecke, A. V. (2021) · Journal of Interprofessional Care · doi:10.1080/13561820.2021.1929103 · Cited by 9
Will the implementation process for goal-oriented primary care succeed? A qualitative study investigating five perceived attributes of goal-oriented care
Huybrechts, I., Declercq, A., Verté, E., Boeckxstaens, P., Raeymaeckers, P., & Anthierens, S. (2023) · Social Science & Medicine · doi:10.1016/j.socscimed.2023.116048 · Cited by 9
Capturing the Role of Context in Complex System Change: An Application of the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to an Integrated Care Organisation in the UK
Asthana, S., Gradinger, F., Elston, J., Martin, S., & Byng, R. (2020) · International Journal of Integrated Care · doi:10.5334/ijic.5196 · Cited by 9
Process evaluation of the scale-up of integrated diabetes and hypertension care in Belgium, Cambodia and Slovenia (the SCUBY Project): a study protocol
Martens, M., Wouters, E., van Olmen, J., Klemenc–Ketiš, Z., Chhim, S., Chham, S., Buffel, V., Danhieux, K., Stojnić, N., Zavrnik, Č., et al. (2022) · BMJ Open · doi:10.1136/bmjopen-2022-062151 · Cited by 8
How to Support the Referral Towards Group Antenatal Care in Belgian Primary Healthcare Organizations: A Qualitative Study
Talrich, F., Damme, A. V., Bastiaens, H., Bergs, J., Rijnders, M. E. B., & Beeckman, K. (2023) · International Journal of Women s Health · doi:10.2147/ijwh.s384269 · Cited by 9
“These strategies might ensure that GANC will be adopted and sustained.(37) However, GANC organizations still need to explore which strategies are adequate and applicable within their specific context.”
Background
An Ethnographic study of unhealthy alcohol use in a Danish Emergency Department
Sivertsen, D. M., Becker, U., Andersen, O., & Kirk, J. W. (2021) · Addiction Science & Clinical Practice · doi:10.1186/s13722-021-00269-z · Cited by 10
Institutional capacity assessment in the lens of implementation research: Capacity of the local institutions in delivering WASH services at Cox’s Bazar district, Bangladesh
Rahman, M. M., Alam, M.-U., Luies, S. K., Ferdous, S., Mamun, Z., Rahman, M. J., Biswas, D., Ananya, T. H., Asadullah, Kamal, A., et al. (2024) · PLoS ONE · doi:10.1371/journal.pone.0297000 · Cited by 7
“Having an explicit understanding of the context is essential for planning implementation research in a particular sector [28].”
Kontext als impliziter und expliziter Gegenstand der Versorgungsforschung
Demirer, I., Nellessen-Martens, G., & Ansmann, L. (2024) · Springer eBooks · doi:10.1007/978-3-658-42863-1_2 · Cited by 7
Organisational implementation climate in implementing internet-based cognitive behaviour therapy for depression
Vis, C., Kleiboer, A. M., Mol, M., Pedersen, C. D., Finch, T. L., Smit, J. H., Riper, H. M., Albaina, O., Cavallo, M., Dozeman, E., et al. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-08041-y · Cited by 8
“Furthermore, the organisational context in which the service delivery and implementation takes place, is of particular relevance as it forms the ‘biotope’ in which patients and service deliverers act and interact to create health and healthcare [21, 22].”
Background
Perspectives on seamless collaboration between primary and secondary care for oral anticancer treatments
Kinnaer, L., Kenis, I., Foulon, V., & Hecke, A. V. (2023) · Journal of Interprofessional Care · doi:10.1080/13561820.2022.2143486 · Cited by 7
“Implementation theories and frameworks were therefore consulted to develop the topic guide for SC (Damschroder et al., 2009; Pfadenhauer et al., 2015), part of which focused on perceptions of seamless collaboration (Table 1).”
Background
A qualitative study of the implementation and organization of the national Greenlandic addiction treatment service
Flyger, J., Larsen, C. V. L., Jensen, E., Niclasen, B. V.-L., & Nielsen, A. S. (2024) · Frontiers in Health Services · doi:10.3389/frhs.2024.1219787 · Cited by 6
“The analysis illustrated that context and setting very much matter in the implementation (38, 39), and that may be particularly profound when implementing an intervention like Allor ﬁ k in a country like Greenland with vast distances and cultural differences on all levels.”
Background
Context and Complexity in Telemedicine Evaluation: Work Domain Analysis in a Surgical Setting
Aminoff, H., & Meijer, S. (2021) · JMIR Perioperative Medicine · doi:10.2196/26580 · Cited by 7
EMANCIPATION THROUGH NURSING WITHIN THE CONTEXT OF HEALTH DISPARITIES
Moreno‐Lacalle, R. C., & Locsin, R. C. (2019) · Belitung Nursing Journal · doi:10.33546/bnj.760 · Cited by 6
“However, because of its excessive use, Pfadenhauer et al. (2015) criticized the method arguing that it has become overly simplistic (adding little value to nursing scholarship) hence eschewing the practical and theoretical value of concept analysis to nursing practice.”
Method
Mechanisms and contextual factors related to key elements of a successful integrated community-based approach aimed at reducing socioeconomic health inequalities in the Netherlands: A realist evaluation perspective
Wilderink, L., Visscher, A., Bakker, I. M. C., Schuit, A. J., Seidell, J. C., & Renders, C. M. (2023) · PLoS ONE · doi:10.1371/journal.pone.0284903 · Cited by 5
The Role of Contextual Determinants in Implementation of Complex Suicide Prevention Interventions: An Application of the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework
Krishnamoorthy, S., Armstrong, G., Ross, V. L., Mathieu, S. L., & Kõlves, K. (2025) · The International Journal of Health Planning and Management · doi:10.1002/hpm.3911 · Cited by 4
A realist synthesis of staff-based primary health care interventions addressing universal health coverage
D’Apice, C., Ghirotto, L., Bassi, M. C., Artioli, G., & Sarli, L. (2022) · Journal of Global Health · doi:10.7189/jogh.12.04035 · Cited by 6

Authors: Pfadenhauer, L. M., Mozygemba, K., Gerhardus, A., Hofmann, B., Booth, A., Lysdahl, K. B., Tummers, M., Burns, J., & Rehfuess, E. A.
Affiliations: Institut für Medizinische Informationsverarbeitung, Biometrie und Epidemiologie (DE)
University of Bremen (DE)
University of Oslo (NO)
University of Sheffield (GB)
Radboud University Medical Center (NL)
Corresponding author: Pfadenhauer, Lisa Maria
ORCID: Pfadenhauer, Lisa Maria
Mozygemba, Kati
Gerhardus, Ansgar
Hofmann, Bjørn
Booth, Andrew
Lysdahl, Kristin Bakke
Tummers, Marcia
Burns, Jacob
Rehfuess, Eva Annette
Venue: Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen
Publisher: Elsevier BV
Published: 2015
Volume: 109
Issue: 2
Pages: 103-114
ISSN: 1865-9217 (ISSN-L)
DOI: 10.1016/j.zefq.2015.01.004
OpenAlex: W1998641377
Semantic Scholar: 93ddce6a560b6dc55062e4dc9a2f4794ee4d6531
Cited by: 189
References: 88
Citations by year: 2026: 7 · 2025: 11 · 2024: 29 · 2023: 18 · 2022: 29 · 2021: 28 · 2020: 23 · 2019: 13 · 2018: 17 · 2017: 9 · 2016: 3 · 2015: 2
FWCI: 19.00
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: Zeitschrift für Evidenz Fortbildung und Qualität im Gesundheitswesen (publishedVersion)
PubMed (publishedVersion)
White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
Radboud Repository (Radboud University) (submittedVersion)
Topics: Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
Keywords: context, implementation, health interventions, complex interventions, conceptual analysis, health technology assessment, operationalization
MeSH terms: Delivery of Health Care, Germany, Health Plan Implementation, Humans, Technology Assessment, Biomedical, Evidence-Based Medicine, Guideline Adherence

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Context and implementation: A concept analysis towards conceptual maturity

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