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Cited by 775Health Policy Implementation ScienceHealth Sciences Research and EducationClinical practice guidelines implementation

Enhancing the Impact of Implementation Strategies in Healthcare: A Research Agenda

Open access
Powell, Byron J., Fernandez, Maria E., Williams, Nathaniel J., Aarons, Gregory A., Beidas, Rinad S., Lewis, Cara C., McHugh, Sheena M., Weiner, Bryan J.·2019·Frontiers in Public Health
DOI 10.3389/fpubh.2019.00003PMC PMC6350272
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Abstract

The field of implementation science was developed to better understand the factors that facilitate or impede implementation and generate evidence for implementation strategies. In this article, we briefly review progress in implementation science, and suggest five priorities for enhancing the impact of implementation strategies. Specifically, we suggest the need to: (1) enhance methods for designing and tailoring implementation strategies; (2) specify and test mechanisms of change; (3) conduct more effectiveness research on discrete, multi-faceted, and tailored implementation strategies; (4) increase economic evaluations of implementation strategies; and (5) improve the tracking and reporting of implementation strategies. We believe that pursuing these priorities will advance implementation science by helping us to understand when, where, why, and how implementation strategies improve implementation effectiveness and subsequent health outcomes.

AI snapshot

Written from the paper’s full text.

TL;DR

This research agenda reviews progress in implementation science and proposes five priorities for enhancing the impact of implementation strategies: better design/tailoring, testing mechanisms of change, more effectiveness research, economic evaluations, and improved tracking/reporting. It argues these priorities will clarify when, where, why, and how implementation strategies improve implementation effectiveness and subsequent health outcomes.

Key findings

  • The paper proposes five priorities: (1) enhance methods for designing and tailoring implementation strategies; (2) specify and test mechanisms of change; (3) conduct more effectiveness research on discrete, multi-faceted, and tailored strategies; (4) increase economic evaluations; and (5) improve tracking and reporting of implementation strategies.
  • Table 1 reports median absolute improvements for common strategies: printed educational materials 2.0% (range 0%–11%); educational meetings 6.0% (IQR 1.8%–15.3%); educational outreach 4.8% for prescribing (IQR 3.0–6.5%) and 6.0% for other behaviors (IQR 3.6–16.0%); local opinion leaders 12% (IQR 6.0–14.5%); audit and feedback 4.3% (IQR 0.5–16%); computerized reminders 4.2% (IQR 0.8–18.8%); tailored implementation strategies pooled OR 1.56 (95% CI 1.27–1.93, p < 0.001).
  • Evidence on multifaceted and tailored strategies is mixed: a review of 25 systematic reviews found “no compelling evidence that multifaceted interventions are more effective than single-component interventions,” while a systematic review of 32 studies concluded tailored approaches were more effective than no strategy or a non-tailored strategy, though methods for identifying and prioritizing determinants were often poorly described.
  • Economic evaluations are scarce: in a systematic review of 235 implementation studies, only 10% provided information about implementation costs.

Methods

  • Design: conceptual research agenda and narrative review, not an empirical study; the authors “briefly review progress in implementation science and suggest five priorities.”
  • Data/sample: draws primarily upon the healthcare, behavioral health, and social services literature; no primary sample or dataset is analyzed.
  • Main analysis: synthesizes prior systematic reviews, taxonomies, reporting guidelines, and example studies (Table 2) to propose and illustrate five priorities for research on implementation strategies.

Limitations

  • The paper does not include a formal limitations section; the authors state they draw primarily upon healthcare, behavioral health, and social services literature and “welcome discussion regarding potential applications and enhancements for contexts outside of healthcare, such as community and public health settings.”
  • Evident from the text: as a research agenda/commentary, it does not conduct a systematic review or collect primary data, so the proposed priorities are conceptual and not empirically tested here.
  • Evident from the text: the cited evidence is selective and illustrative rather than exhaustive, and no formal quality appraisal of the cited studies is described.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3389/fpubh.2019.00003

Cites

84 of 84 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 69 cited sources checked · 0 supported · 0 flagged

  • Premisecitation

    No specific method for identifying and prioritizing determinants and selecting implementation strategies has been proven superior.

    “and no specific method has been proven superior (37).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [37] Baker, 2015, Tailored interventions to address determinants of practice, Cochrane Database Syst Rev. source

      Not checked in the free run.

  • Premisecitation

    A review of 20 studies found that implementation strategies were often poorly conceived, with mismatches between strategies and determinants.

    “as evidenced by a review of 20 studies that found that implementation strategies were often poorly conceived, with mismatches between strategies and determinants (e.g., barriers were identified at the team or organizational level, but strategies were not focused on structures and processes at those levels) (42).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [42] Bosch, 2007, Tailoring quality improvement interventions to identified barriers: a multiple case analysis, J Eval Clin Pract. source

      Not checked in the free run.

  • Premisecitation

    Few studies include economic evaluations of implementation strategies.

    “Few studies include economic evaluations of implementation strategies (87, 88).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [87] Vale, 2007, Systematic review of economic evaluations and cost analyses of guideline implementation strategies, Eur J Health Econ. source

      Not checked in the free run.

    • cites [88] Raghavan, 2018, The role of economic evaluation in dissemination and implementation research

      Not checked in the free run.

  • Premisecitation

    It is not common that mechanisms of implementation strategies are even mentioned, much less tested.

    “Unfortunately, it is not common that mechanisms are even mentioned, much less tested (63, 65, 66).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [63] Williams, 2016, Multilevel mechanisms of implementation strategies in mental health: integrating theory, research, and practice, Adm Policy Ment Health Ment Health Serv Res. source

      Not checked in the free run.

    • cites [65] Edmondson, 2018, A systematic review of the inclusion of mechanisms of action in NIH-funded intervention trials to improve medication adherence, Behav Res Ther. source

      Not checked in the free run.

    • cites [66] Williams, 2018, The state of implementation science in child psychology and psychiatry: a review and suggestions to advance the field, J Child Psychol Psychiatry source

      Not checked in the free run.

  • Interpretationreasoning

    Without rigorous methods for tracking implementation strategy use, efforts to understand what strategies were used and whether or not they were effective are stymied.

    “and without rigorous methods for tracking implementation strategy use, efforts to understand what strategies were used and whether or not they were effective are stymied.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: It is often difficult to ascertain which implementation strategies were used and how they might be replicated.
  • May combine two claims. 8
  • Classified as probably not a substantial claim. 11

  • May combine two claims.

    Premisecitation

    There are over 140 randomized trials of audit and feedback, but much remains to learn about when it will work best and why, and how to design reliable and effective audit and feedback strategies across different settings and providers.

    “There are over 140 randomized trials of audit and feedback, but Ivers et al. (83) conclude that there is much to learn about when it will work best and why, and how to design reliable and effective audit and feedback strategies across different settings and providers.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [83] Ivers, 2014, No more ‘business as usual’ with audit and feedback interventions: towards an agenda for a reinvigorated intervention, Implement Sci. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Even when strategies are reported in study protocols or empirical articles, there are numerous problems with their description, including inconsistent labeling; lack of operational definitions; poor description and absence of manuals to guide their use; and lack of a clear theoretical, empirical, or pragmatic justification for how the strategies were developed and applied.

    “Even when strategies are reported in study protocols or empirical articles, there are numerous problems with their description, including inconsistent labeling; lack of operational definitions; poor description and absence of manuals to guide their use; and lack of a clear theoretical, empirical, or pragmatic justification for how the strategies were developed and applied (4).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [4] Proctor, 2013, Implementation strategies: recommendations for specifying and reporting, Implement Sci. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The original COINS study presented a head-to-head trial of two implementation approaches; although one approach was significantly more costly, the implementation outcomes achieved were superior enough to warrant the additional resources.

    “For example, the original COINS study presented a head-to-head trial of two implementation approaches; although one approach was significantly more costly, the implementation outcomes achieved were superior enough to warrant the additional resources (91).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [91] Brown, 2014, Evaluation of two implementation strategies in 51 child county public service systems in two states: results of a cluster randomized head-to-head implementation trial, Implement Sci. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Implementation strategies are too often designed in an unsystematic manner and fail to address key contextual determinants.

    “Implementation strategies are too often designed in an unsystematic manner and fail to address key contextual determinants (13–16).”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [13] Aarons, 2011, Advancing a conceptual model of evidence-based practice implementation in public service sectors, Adm Policy Ment Health Ment Health Serv Res. source

      Not checked in the free run.

    • cites [14] Damschroder, 2009, Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science, Implement Sci. source

      Not checked in the free run.

    • cites [15] Flottorp, 2013, A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice, Implement Sci. source

      Not checked in the free run.

    • cites [16] Benjamin Wolk, 2015 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Median absolute effect sizes across implementation strategies are similar.

    “Grimshaw et al. (34) note that while median absolute effect sizes across implementation strategies are similar (see Table 1), the variation in observed effects within each strategy category suggests that effects may vary based upon whether or not they address determinants (barriers and facilitators).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] Grimshaw, 2012, Knowledge translation of research findings, Implement Sci. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Powell et al. proposed Intervention Mapping, concept mapping, conjoint analysis, and system dynamics modeling as methods to aid the design, selection, and tailoring of implementation strategies.

    “Powell et al. (55) proposed Intervention Mapping (58), concept mapping (59), conjoint analysis (60), and system dynamics modeling (61) as methods to aid the design, selection, and tailoring of strategies.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [55] Powell, 2017, Methods to improve the selection and tailoring of implementation strategies, J Behav Health Serv Res. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Advancing these priorities will lead to a better understanding of when, where, why, and how implementation strategies exert their effects.

    “Advancing these priorities will lead to a better understanding of when, where, why, and how implementation strategies exert their effects (29, 63).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [29] Mittman, Implementation science in health care

      Not checked in the free run.

    • cites [63] Williams, 2016, Multilevel mechanisms of implementation strategies in mental health: integrating theory, research, and practice, Adm Policy Ment Health Ment Health Serv Res. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    A discrete strategy such as outreach visits may include instruction, motivation, planning of improvement, and technical assistance; thus, it may not be accurate to characterize it as a single-component strategy.

    “A discrete strategy such as outreach visits may include instruction, motivation, planning of improvement, and technical assistance; thus, it may not be accurate to characterize it as a single-component strategy.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [41] Wensing, Selecting, tailoring, and implementing knowledge translation interventions

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Failing to improve the quality of reporting in implementation science will negate other advances in the field by hindering replication.

    “Failing to improve the quality of reporting will negate other advances in this area by hindering replication.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The general lack of an a priori rationale for the selection of components in multifaceted implementation strategies makes it difficult to determine how these decisions were made.

    “Grimshaw et al. (34) provide one possible explanation, emphasizing that the general lack of an a priori rationale for the selection of components (i.e., discrete strategies) in multifaceted implementation strategies makes it difficult to determine how these decisions were made.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] Grimshaw, 2012, Knowledge translation of research findings, Implement Sci. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Several resources can inform the use of implementation strategies, including established taxonomies of implementation strategies and behavior change techniques, repositories of systematic reviews, methods for selecting and tailoring implementation strategies, and reporting guidelines that promote replicability.

    “Several resources can inform the use of implementation strategies, including established taxonomies of implementation strategies (6, 7, 24, 25) and behavior change techniques (27, 28), repositories of systematic reviews (38, 103, 104), methods for selecting and tailoring implementation strategies (40, 55, 56), and reporting guidelines that promote replicability (4, 98–100).”
    Quote in the paperNot a substantial claim0 of 9 sources checked
    • cites [6] Powell, 2012, A compilation of strategies for implementing clinical innovations in health and mental health, Med Care Res Rev. source

      Not checked in the free run.

    • cites [7] Powell, 2015, A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project, Implement Sci. source

      Not checked in the free run.

    • cites [24] Data Collection Checklist2002

      Not checked in the free run.

    • cites [25] Mazza, 2013, Refining a taxonomy for guideline implementation: results of an exercise in abstract classification, Implement Sci. source

      Not checked in the free run.

    • cites [27] Michie, 2013, The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions, Ann Behav Med. source

      Not checked in the free run.

    • cites [28] Kok, 2016, A taxonomy of behaviour change methods: an intervention mapping approach, Health Psychol Rev. source

      Not checked in the free run.

    • cites [38] Cochrane Effective Practice Organisation of Care Group2013

      Not checked in the free run.

    • cites [103] Health Systems Evidence2012

      Not checked in the free run.

    • cites [104] Interventions Database2011

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationnone given

    Implementation science has advanced considerably, yielding a more robust understanding of implementation strategies.

    “Implementation science has advanced considerably, yielding a more robust understanding of implementation strategies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Standards for Reporting Implementation Studies and Neta et al. reporting framework emphasize how critical it is to report on the multilevel context of implementation.

    “Though not specific to the reporting of implementation strategies, the Standards for Reporting Implementation Studies (101) and Neta et al. (102) reporting framework emphasizes how critical it is to report on the multilevel context of implementation.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [101] Pinnock, 2015, Developing standards for reporting implementation studies of complex interventions (StaRI): a systematic review and e-Delphi, Implement Sci. source

      Not checked in the free run.

    • cites [102] Neta, 2015, A framework for enhancing the value of research for dissemination and implementation, Am J Public Health source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Definitions of discrete and multifaceted strategies are problematic.

    “Wensing et al. (41) offer a complementary perspective, noting that definitions of discrete and multifaceted strategies are problematic.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [41] Wensing, Selecting, tailoring, and implementing knowledge translation interventions

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    A number of reporting guidelines could be leveraged to improve descriptions of strategies.

    “A number of reporting guidelines could be leveraged to improve descriptions of strategies (4, 96–100).”
    Quote in the paperNot a substantial claim0 of 6 sources checked
    • cites [4] Proctor, 2013, Implementation strategies: recommendations for specifying and reporting, Implement Sci. source

      Not checked in the free run.

    • cites [96] Colquhoun, 2014, Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies, Implement Sci. source

      Not checked in the free run.

    • cites [97] Bragge, 2017, AIMD - a validated, simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies, BMC Med Res Methodol. source

      Not checked in the free run.

    • cites [98] Hoffman, 2014, Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide, BMJ source

      Not checked in the free run.

    • cites [99] WIDER Recommendations to Improve Reporting of the Content of Behaviour Change Interventions2008

      Not checked in the free run.

    • cites [100] Albrecht, 2013, Development of a checklist to assess the quality of reporting of knowledge translation interventions using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations, Implement Sci. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Nadeem et al.'s review of learning collaboratives concluded that reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active quality improvement collaborative ingredients linked to improved care.

    “For example, Nadeem et al. (95) review of learning collaboratives concluded that, “reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active quality improvement collaborative ingredients linked to improved care.””
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [95] Nadeem, 2013, Understanding the components of quality improvement collaboratives: a systematic literature review, Milbank Q source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Poor reporting of implementation strategies clouds the interpretation of results, precludes replication in research and practice, and limits the ability to synthesize findings across studies.

    “Poor reporting clouds the interpretation of results, precludes replication in research and practice, and limits our ability to synthesize findings across studies (4, 92).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [4] Proctor, 2013, Implementation strategies: recommendations for specifying and reporting, Implement Sci. source

      Not checked in the free run.

    • cites [92] Michie, 2009, Specifying and reporting complex behaviour change interventions: the need for a scientific method, Implement Sci. source

      Not checked in the free run.

17 of 17

  • The paper relies on this without support.

    Clinical problems, clinical and public health interventions, settings, individuals, and contextual factors are highly heterogeneous.

    “Given that clinical problems, clinical and public health interventions, settings, individuals, and contextual factors are highly heterogeneous, there is much to gain from developing generalizable processes for designing and tailoring strategies.”

  • The paper relies on this without support.

    It is often difficult to ascertain which implementation strategies were used and how they might be replicated.

    “It is often difficult to ascertain which implementation strategies were used and how they might be replicated.”

  • The paper relies on this without support.

    Part of the challenge is the iterative nature of implementation.

    “Part of the challenge is the iterative nature of implementation.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Two different articles share the same PubMed and PMC identifiers

    Minor

    References 17 and 54 describe different articles, but both list PMID 26923462 and PMC4770686. Those identifiers cannot identify both articles.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 16

  1. Vinson, 2018, Dissemination and implementation research in community and public health settings, 355
  2. Powell, 2019, Implementation strategies, 98
  3. Chambers, 2013, Partnership: a fundamental component of dissemination and implementation research, Psychiatr Serv., 64, 509, 10.1176/appi.ps.201300032 · DOI
  4. Mittman, Implementation science in health care, 400
  5. Wensing, Selecting, tailoring, and implementing knowledge translation interventions, 94
  6. Bunger, 2016, Can learning collaboratives support implementation by rewiring professional networks?, Adm Policy Ment Health Ment Health Serv Res., 43, 79, 10.1007/s10488-014-0621-x · DOI
  7. Michie, Changing behaviour to improve clinical practice and policy, 41
  8. Grol, Development and selection of strategies for improving patient care, 165
  9. Bartholomew, 2016, Planning Health Promotion Programs: An Intervention Mapping Approach
  10. Aarons, 2012, Mixed methods for implementation research: application to evidence-based practice implementation and staff turnover in community-based organizations providing child welfare services, Child Maltreat., 17, 67, 10.1177/1077559511426908 · DOI
  11. Michie, 2016, From theory-inspired to theory-based interventions: a protocol for developing and testing a methodology for linking behaviour change techniques to theoretical mechanisms of action, Ann Behav Med., 52, 501, 10.1007/s12160-016-9816-6 · DOI · Paper page
  12. 2009, Initial National Priorities for Comparative Effectiveness Research
  13. Hysong, 2009, Audit and feedback features impact effectiveness on care quality, Med Care, 47, 356, 10.1097/MLR.0b013e3181893f6b · DOI · Paper page
  14. Collins, 2007, The multiphase optimization strategy (MOST) and the sequential multiple assignment randomized trial (SMART): new methods for more potent eHealth interventions, Am J Prev Med., 32, S112, 10.1016/j.amepre.2007.01.022 · DOI · Paper page
  15. Raghavan, 2018, The role of economic evaluation in dissemination and implementation research, 89
  16. Hoagwood, 2011, Implementation salvage strategies: maximizing methodological flexibility in children's mental health research, 4th Annual NIH Conference on the Science of Dissemination and Implementation.

Cited by

Sorted by citations

Authors
Powell, B. J., Fernandez, M. E., Williams, N. J., Aarons, G. A., Beidas, R. S., Lewis, C. C., McHugh, S. M., & Weiner, B. J.
Affiliations
  • University of North Carolina at Chapel Hill (US)
  • Boise State University (US)
  • University of California San Diego (US)
  • Leonard Davis Institute of Health Economics (US)
  • Kaiser Permanente Washington Health Research Institute (US)
  • University College Cork (IE)
  • University of Washington (US)
Corresponding author
Powell, Byron J.
ORCID
Venue
Frontiers in Public Health
Publisher
Frontiers Media SA
Published
2019-01-22
Volume
7
Pages
3-3
ISSN
2296-2565 (ISSN-L)
DOI
10.3389/fpubh.2019.00003
PMC
PMC6350272
OpenAlex
W2912050878
Semantic Scholar
a595c855fc37d861efaf6aa2a5b8d60b03a50017
Cited by
775
References
84
Citations by year
2026: 74 · 2025: 84 · 2024: 166 · 2023: 116 · 2022: 136 · 2021: 102 · 2020: 70 · 2019: 24 · 2018: 1
FWCI
113.09
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Public Health (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Arrow@dit (Dublin Institute of Technology) (acceptedVersion)
  • Carolina Digital Repository (University of North Carolina at Chapel Hill) (submittedVersion, cc-by)
  • Cork Open Research Archive (University College Cork, Ireland) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • UNC Libraries
Funders
National Institutes of Health (K01MH113806, R25MH104660, UL1TR002489, R01MH106510, R01MH103310, P30A1050410, R25MH080916, P50MH113840, R21MH109878)
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 strategies, implementation science, healthcare implementation, implementation effectiveness, mechanisms of change, multi-faceted intervention, economic evaluation, research priorities

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