Many ways to view the issue

Stakeholders are actors, including individuals, groups, and organisations, with a vested interest in the policy, practice, or intervention undergoing large-scale implementation. Each stakeholder possesses distinct perspectives, unique needs, and varying levels of resources that can either facilitate or impede implementation efforts.

Research teams are obligated to identify all relevant stakeholders, often through systematic stakeholder mapping exercises. Subsequently, they must develop and execute tailored communication and engagement strategies that effectively address the motivations, positions, and influence of each stakeholder.

Converging the streams

Summary coming soon.

Communication skills

At the core of impactful and meaningful stakeholder engagement are strong communication skills. Researchers must move beyond their “academic comfort zone” and cultivate genuine trust, respect, and rapport with all stakeholders. Whether investigators are presenting to policymakers in a formal dialogue or facilitating a community discussion, building relationships is paramount. While not every team member needs to possess every communication skill, leveraging the diverse talents within a team throughout the project lifecycle can be highly effective.

Key reading

• Using the multiple streams model to elicit an initial programme theory (2023) Martens M et al. BMJ Global Health 8:e012637.
• Demystifying knowledge translation: Learning from the community (2005) Bowen S & Martens P. J Health Serv Res Policy 10(4): 203–211.
• Supporting the routine use of evidence during the policy-making process: a WHO checklist (2023) World Health Organization – EVIPNet team.

Perfect design

To optimally select and refine a study design, investigators must first clearly define the research question’s nature. Is it primarily descriptive, aimed at characterising a phenomenon; predictive, seeking to forecast outcomes; or causal, aiming to establish a cause-and-effect relationship? Beyond strictly scientific considerations, the chosen design will also be influenced by practical constraints such as funding priorities, policy demands, the availability of reliable outcome data, stakeholder engagement, and the feasibility of implementing appropriate controls. Research teams should be able to rigorously justify all decisions relating to study design and necessary modifications.

Strategies at scale

The selection and design of scale-up strategies must be informed by a comprehensive understanding of the intervention, its objectives, and the effectiveness of strategies employed during pilot phases. A robust approach requires mapping strategies from contextual factors through mechanisms to desired outcomes. This demands a deep understanding of context, theoretical frameworks, and rigorous documentation throughout the process.

A balancing act

Distinguishing between ‘core’ and ‘peripheral’ components of an intervention or its associated scale-up strategies can be challenging. Boundaries are often blurred and shift by context. However, this differentiation is essential: compromising core elements or the underlying programme logic can affect effectiveness. Adaptation is common in scale-up research as priorities evolve; researchers can mitigate risks by carefully documenting changes and rationale.

Key reading

• Scaling Interventions to Manage Chronic Disease (2024) – McGinty EE et al. Prev Sci 25(Suppl 1): 96–108.
• Implementation strategies: recommendations for specifying and reporting (2013) – Proctor EK et al. Implementation Sci 8: 139.
• Adapting interventions to new contexts – the ADAPT guidance (2021) – Moore G et al. BMJ 374: n1679.

Indicators of success

Summary coming soon

The evaluation landscape

Rigorous evaluation is informing evidence-based decision-making for policymakers and practitioners. While outcome evaluations, such as randomised controlled trials or natural experiments, are crucial for establishing efficacy, they may not fully address questions of generalisability beyond one setting. Moreover, while outcome evaluations can indicate whether inequities are affected by the intervention in question, understanding the mechanisms driving these effects requires a more in-depth analysis of cause and effect than solely examining outcomes.

A comprehensive assessment involves integrating outcome, process, and cost-effectiveness evaluations. By combining these different perspectives, researchers can gain a more complete understanding of implementation impact, identify areas for improvement, and provide the necessary depth to inform policy and practice effectively.

Planning for sustainability

The long-term continuation of interventions implemented at scale starts with a clear vision of what successful sustainability looks like for a given project. This vision is only achievable through the relationships developed during the pilot and during scale-up: sustainability is a relational, shared process between interdependent groups and individuals. Sustainability planning increases the likelihood of long-term success, helping teams shift focus from research-led efforts to shared ownership by local, regional, and national stakeholders.

Ultimately, sustainability requires a shift in sharing costs, resources, responsibilities, and momentum away from the research team and into the hands of stakeholders and implementers who can maintain delivery and improvement over time.

Key reading

• Process evaluation in the field: global learnings from seven implementation research hypertension projects in low- and middle-income countries (2019) Limbani F et al. BMC Public Health
• Process evaluation of complex interventions in non-communicable and neglected tropical diseases in low- and middle-income countries: a scoping review (2022) Lazo-Porras M et al. BMJ Open
• Economic evaluation: a reader’s guide to studies of cost-effectiveness (2022) Abbott JH et al. Arch Physiother
• How does cost-effectiveness analysis inform health-care decisions? (2021) Kim DD & Basu A. AMA J Ethics
• Sustainability components – webpage | The Center for Implementation