Overview of Implementation Change Methods

In implementation research and practice, one is often trying to simultaneously change the behaviors or conditions of multiple people (e.g., patients/clients, clinicians/providers, managers/leaders) using various types of change methods (e.g., education, support, infrastructure creation, policy change). Accurately attributing different functions and effects to the right change methods is critical to understanding a project’s successes and areas for adjustment.

There are three types of changes methods that we differentiate based on their intended targets, desired outcomes, and theory of action.

1. Health interventions are clinical, behavioral, or biomedical innovations designed to directly improve recipients’ (patients/clients) health outcomes (e.g., prevent disease occurrence, reduce severity of disease, improve quality of life).

2. Implementation strategies are actions taken to improve utilization of an intervention at the health system or provider level (e.g., policy change to improve reimbursement, provider training, provider audit and feedback, and colocation of services).

3. Adjunctive interventions are change methods that target recipients of a health intervention and are designed to increase their motivation, self-efficacy, or capacity for initiating, adhering to, or engaging with the health intervention initially (i.e., uptake) and over time (i.e., adherence). Adjunctive interventions enhance recipients’ attitudes and behaviors towards utilizing a health intervention, but have no direct causal link to health status. Thus, they are supplemental: not always necessary and never sufficient to achieve a health outcome.

Why Are Adjunctive Interventions Important? Examples from COVID

Efforts to mitigate the COVID-19 pandemic with vaccines highlight the need to think about adjunctive interventions. The SARS-CoV-2 coronavirus vaccine is the health intervention because it directly prevents COVID-19 illness in patients. In the United States, implementation strategies to scale up vaccination focused on facilitating recipient’s access via offering vaccinations at typical healthcare locations staffed by nurses (e.g., primary and urgent care), pharmacies, public health departments, community-based organizations, and other entities (e.g., churches). Financial strategies were also invoked by federal and local governments to eliminate cost-related barriers to recipients, and dissemination strategies were deployed to educate clinicians and the public about vaccine safety and effectiveness.

However, as of May 10, 2023, only 81 percent of the population had received at least one dose, and 70 percent were fully vaccinated (one or two doses). The below-target vaccination rates were not due to lack of availability for the vast majority of Americans, as evidenced by only 68 percent of distributed doses being administered; rather, individual uptake of vaccines was insufficient due to stigma, hesitancy, and misinformation, resulting in the majority of unused vaccines expiring (estimated 1.1 billion doses globally). Adjunctive interventions were needed to motivate and capacitate eligible people to use them.