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Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework
Open accessAbstract
BACKGROUND: Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. METHODS: A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1-5 scale). RESULTS: In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5). CONCLUSION: This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.
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![Fig. 2 PRISMA Flow Diagram of paper selection [62]](/paper-figures/e3e579f31a244cffb47b296a14e9e6cd/systematic-review-of-the-exploration-preparation-implementation-sustainment-epis-figure-2.jpg)
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“For intermediaries and practitioners, they can provide shared language to familiarize stakeholders with implementation and function as practical tools for planning, executing, and evaluating real-world implementation efforts.”
From Ten recommendations for using implementation frameworks in research and practice (2020) · cites this paper as [1]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Although the benefits of RPM are widely proven, its implementation and adoption in routine care has remained challenging.26”
From Implementation of a remote symptom monitoring pathway in oncology care: analysis of real-world experience across 33 cancer centres in France and Belgium (2024) · cites this paper as [26]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Although the benefits of RPM are widely proven, its implementation and adoption in routine care has remained challenging.26”
From Implementation of a remote symptom monitoring pathway in oncology care: analysis of real-world experience across 33 cancer centres in France and Belgium (2024) · cites this paper as [26]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“The implementation of the RPM pathway followed the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation science framework and other validated implementation techniques.17,26,27”
From Implementation of a remote symptom monitoring pathway in oncology care: analysis of real-world experience across 33 cancer centres in France and Belgium (2024) · cites this paper as [26]
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“When used in research, they can guide the design and conduct of studies, inform the theoretical and empirical thinking of research teams, and aid interpretation of findings.”
From Ten recommendations for using implementation frameworks in research and practice (2020) · cites this paper as [1]
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“These applied examples are based on the results of a recent systematic review [1], and the collective experience of the co-authors applying the EPIS framework in national and international implementation efforts.”
From Ten recommendations for using implementation frameworks in research and practice (2020) · cites this paper as [1]
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“The EPIS implementation framework (Aarons et al., 2011) is both a process and determinant framework (Nilsen, 2015) that includes four phases-Exploration, Preparation, Implementation, and Sustainment-each of which includes outer and inner contextual factors, bridging factors linking outer and inner contexts, and innovation factors that collectively are proposed to facilitate EBP implementation and”
From Implementation-as-Usual in Community-Based Organizations Providing Specialized Services to Individuals with Autism Spectrum Disorder: A Mixed Methods Study (2021) · cites this paper as Moullin et al., 2019
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“Additional inner contextual and intervention factors considered prior to adoption decision were derived from the qualitative data and are consistent with those identified in the recent EPIS systematic review (Moullin et al., 2019).”
From Implementation-as-Usual in Community-Based Organizations Providing Specialized Services to Individuals with Autism Spectrum Disorder: A Mixed Methods Study (2021) · cites this paper as Moullin et al., 2019
In the citing paper
“Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so.”
From Ten recommendations for using implementation frameworks in research and practice (2020) · cites this paper as [1]
In the citing paper
“There is great value in effectively using implementation frameworks, models, and theories [1, 2].”
From Ten recommendations for using implementation frameworks in research and practice (2020) · cites this paper as [1]
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“Implementation frameworks often include several implementation determinants (i.e., barriers and enablers) that have been found to influence implementation outcomes [1, 2].”
From Ten recommendations for using implementation frameworks in research and practice (2020) · cites this paper as [1]
In the citing paper
“For the collection and analysis of qualitative data, frameworks such as EPIS or CFIR provide developed and freely available data analytic tools, including pre-populated coding templates and data aggregation matrices [1, 49].”
From Ten recommendations for using implementation frameworks in research and practice (2020) · cites this paper as [1]
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Self-citation
Metadata
- Authors
- Moullin, J. C., Dickson, K. S., Stadnick, N. A., Rabin, B., & Aarons, G. A.
- Affiliations
- Curtin University (AU)
- San Diego State University (US)
- University of California San Diego (US)
- Corresponding author
- Aarons, Gregory A.
- Venue
- Implementation Science
- Published
- 2019-01-05
- Volume
- 14
- Issue
- 1
- Pages
- 1-1
- ISSN
- 1748-5908 (ISSN-L)
- PMC
- PMC6321673
- OpenAlex
- W2907482335
- Cited by
- 1,223
- References
- 84
- Citations by year
- 2026: 184 · 2025: 218 · 2024: 200 · 2023: 208 · 2022: 153 · 2021: 152 · 2020: 74 · 2019: 32
- FWCI
- 18.83
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Implementation Science (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion, cc-by)
- eSpace (Curtin University) (submittedVersion, cc-by)
- Funders
- National Institute on Drug Abuse (R01DA038466, U01DA036233)
- National Institute of Mental Health (R01MH072961, K23MH110602)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Keywords
- implementation research, evidence-based practice implementation, implementation framework, innovation drivers, implementation outcomes, implementation strategies
- MeSH terms
- Implementation Science, Diffusion of Innovation, Humans, Models, Theoretical, Public Health, Research Design, Evidence-Based Practice
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