High quality implementation initiatives have the potential to increase the uptake of prevention programs for families where a parent has a mental illness.
Implementation involves active and planned efforts to mainstream an innovation within an organisation in order to ‘make it happen’.
The four stages of implementation include exploration, installation, initial implementation and full implementation.
Implementation drivers include competency, organisation support and leadership.
While there have been many years of research into the development of interventions and supports for families where a parent has a mental illness, there is a critical need to scale up and reach a substantially greater proportion of the at-risk population.1, 2 High quality implementation initiatives have the potential to increase the uptake of quality prevention programs for this at-risk group.
Implementation science is ‘the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice to improve quality and the effectiveness of health services and care’.3
Implementation is part of a continuum. This continuum includes passive, unplanned, ‘let it happen’ activities. Dissemination, including active and targeted activities to ‘help it happen’. Implementation, including active, planned efforts that ‘make it happen’ enabling an innovation within an organisation to become mainstream.4
Neither information dissemination nor training alone are sufficient. Successful implementation requires a longer-term, multi-levelled approach.4, 6
Active Implementation Framework
The Fixsen et al. Active Implementation Framework has been used to promote the uptake of family programs.6, 7, 9 The model was developed as a guide for the implementation of parenting interventions in early care and education settings. The framework has been used to evaluate the Norwegian implementation of family interventions in hospitals.5, 8
The Active Implementation Framework describes four implementation stages.5, 7, 9
1. Exploration stage
In the exploration stage decisions are made regarding which intervention(s) needs to be considered (e.g. new registration procedures for families at-risk, family conversations, children's support groups, home visits). Other decisions include determining which population needs be reached (i.e. community or state) and which organisations will deliver the intervention (e.g. schools, hospitals, and non-government organisations). Another key task is to establish an implementation/leadership team to support the implementation process. Individuals with knowledge about the program, state or community, program practice, supervision and leadership, finance and policy, may also be included.
2. Installation stage
In the installation stage implementation team members are trained and have a shared understanding of the intervention and their implementation role. In addition to the necessary infrastructure, data support systems and feedback loops are established. A high quality communication system is needed to inform, support and secure participation across the organisation. The implementation team recruits, trains and secures coaching to assist the individuals who are going to deliver the intervention.
3. Initial implementation stage
In the initial implementation stage new services for families and children are delivered. Data collection can assist to determine whether the intervention is being delivered as it is intended, whether the expected number of parents and/or children are being reached and whether the intervention is being delivered according to the planned intensity (e.g. weekly or monthly). Other questions requiring consideration include whether the intervention delivers expected outcomes, (e.g. do personnel follow up on registration procedures, is there better liaison between services, are families, parents and children satisfied with the intervention and do parents and children report a better quality of life).
4. Full implementation stage
In the final full implementation stage, the chosen intervention is integrated into mainstream practice. The implementation team continues to monitor the data to ensure fidelity and to institutionalise continuous improvement and support systems. As leadership commitment is crucial to secure the sustainable delivery of the new intervention, decisions about securing ongoing leadership must be undertaken. Once the intervention is fully implemented at one site, it is time to consider replication to additional sites. The purpose is to support more families and children.
Implementation drivers include competency, organisation support and leadership support.9
For competency, new ways of practice may need to be taught (eg. through training and coaching) to practitioners that have been specifically selected to use the innovation.
Organisation support include the practices and support systems that establish an environment that enables the effective use of innovations. The data system is an essential component for guiding the process of establishing the innovation and assessing the immediate outcomes.
A critical driver is leadership support that can resolve procedural problems. Adaptive leadership strategies are needed when conditions are complex and there is less certainty.
These drivers are integrated and can collectively be used to inform staff behaviour and organisational culture.9
While there are several effective initiatives for families where a parent has a mental illness, these do not reach as many families as is currently required. The successful uptake of preventive innovations requires leadership, long-term commitment, implementation skills and planning, and meaningful interaction between policymakers, service providers, researchers, parents and children, non-government organisations and other stakeholders.
1. Siegenthaler E, Munder T, Egger M. Effect of preventive interventions in mentally ill parents on the mental health of the offspring: Systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry; 2012; 51(1).
2. Falkov A, Goodyear M, Hosman CM, Biebel K, Skogøy BE, Kowalenko N, et al. A systems approach to enhance global efforts to implement family focused mental health interventions. Child & Youth Services. 2015.
3. Eccles MP, Mittman BS. Welcome to implementation science. Implementation science: IS. 2006; 1(1):1-3.
4. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: Systematic review and recommendations. 2004.
5. Halle T, Pausell D, Daily S, Douglass A, Moodie S & Metz A. Implementing parenting interventions in early care and education settings: A guidebook for implementation (OPRE 2015-94). Washington DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Departement of Health and Human Services. 2015.
6. Fixsen DL, Naoom, S F, Blase K A, Friedman RM, Wallace F. Implementation research: A synthesis of the literature. Tampa, Florida: Univerity of South Florida, 2005.
8. Ruud T, Birkeland B, Faugli A, Hagen KA, Hellman A, Hilsen M, Kallander E, Kufås E, Løvås M, Peck G, Skogerbø Å, Skogøy B E, Stavnes K, Thorsen E, Weimand B. Barn som pårørende - Resultater fra en multisenterstudie (Children as next of kin – Results from a multicenter study) (IS-0522), Oslo. 2015.
9. Bertram M, Blase KA, Fixsen DL. Improving programs and outcomes implementation frameworks and organization change. Research on Social Work Practice 25.4 2015; 477-487.