Harmonizing intervention, context, and implementation strategies with Context-Driven Co-Design (CD2)

Extant approaches to close the gap between implementation evidence and practice have been unsuccessful due in part to overreliance on researcher engagement. In practice, change is often driven by mid-level managers. We developed Context-Driven Co-Design (CD2) to equip mid-level managers with a theory- and evidence-based approach to implementation planning.

We used a two-pronged design. First, we engaged six established implementation researchers in a modified Delphi process, involving two hour-long meetings and asynchronous feedback to develop and refine a CD2 prototype. Second, we piloted an in-person CD2 training and conducted an hour-long focus group to solicit feedback from mid-level managers on the potential value of CD2 for addressing implementation challenges and opportunities for improving the training. We incorporated focus group feedback and iteratively refined CD2 materials, codified each step of the approach, and further articulated CD2's key features through two empirical applications.

Delphi panelists unanimously agreed that prototype content would be best delivered through interactive training. The resulting one-time, three-hour in-person training was piloted with 17 mid-level managers affiliated with the National Cancer Institute Community Oncology Research Program who were often tasked with implementing cancer care delivery interventions and research protocols. Focus group participants (N = 5) appreciated the training's practical tools, suggested that the training should focus on a common intervention, and requested more opportunities for peer learning before and after the training. CD2, further refined through subsequent empirical application, involves three steps: (1) agreeing upon an intervention to address a clinical problem and identifying the intervention's effectiveness-driving features; (2) understanding the context in which the intervention will be implemented, including potential end-users, their workflows, and features of their environment; and (3) co-design session(s) to identify intervention adaptations, context modifications, and exogenous implementation strategies needed to facilitate the intervention's implementation.

We codified CD2, a theory-driven approach to harmonizing interventions, implementation contexts, and implementation strategies. Mid-level managers found CD2 to be an appropriate and acceptable approach to implementation planning. CD2 is consistent with perspectives that advocate humility and deference of researchers to individuals and contexts that biomedical research often positions as subjects. Future work is needed to enhance CD2's feasibility and scalability.