We were in the middle of our journal club, discussing the chapter “Historical Roots of Dissemination and Implementation Science” by Dearing, Kee, and Peng in Dissemination and Implementation Research in Health (Brownson, Colditz, and Proctor, eds) per a request to cover the historical development of implementation science. One of my colleagues who is newer to implementation science said, “It seems like implementation science is such an inclusive field where so many perspectives are welcome.”
I really appreciated this comment, and it has been sitting with me ever since. In one sense, I realized this inclusivity has made me feel at home as an anthropologist in an interdisciplinary field. I have been working across disciplines my entire career and it is rare for the anthropological perspective to be fully embraced and respected for what it brings to the table. We are often just too different from positivist science and hypothesis testing. Implementation science’s acknowledgement of the criticality of context and multiple perspectives is what I believe helps anthropologists feel at home in the field. From a bigger picture perspective, this is a strength of implementation science. The ability to integrate multiple disciplines allows the field to draw on so many traditions, which have deeply studied how behavioral, organizational, and societal change and diffusion happen and to engage their theoretical and mechanistic theories as we try to ensure all people receive evidence-based care.
The paradox—knowing the opposite is also true—has also been sitting with me. As implementation science has matured, I’m afraid we’ve become a less inclusive field. I know I have at times felt less at home as an anthropologist in implementation science. I’ve also stuck with implementation science because I know we are working to establish ourselves as a science in a biomedical world where prediction is critical. In this space, we seek confidence that a medication or procedure works as close to 100% of the time as possible. And in implementation science, if we can predict what strategy addresses a particular barrier through an underlying mechanism, we can have a significant impact on ensuring an evidence-based practice is reaching those who will most benefit.
At the same time, this predictability narrows the lens. It is rare to hang out with a group of implementation scientists without hearing a self-deprecating joke about how many theories, models, or frameworks (TMFs) we have or the vast number of implementation strategies. Sometimes I argue, this is because we are a young field, and tests of hypotheses and predictive modeling will help us to reduce those numbers. Other times I argue that behavioral, organizational, and societal change and diffusion are so complex we need all of the TMFs and strategies and the best we can do is understand the local context and perspectives to help them implement the intervention effectively. (I am an anthropologist after all.)
So many paradoxes. Inclusive or exclusive? Prediction and generalizability or context and complexity? Yet, I think the fact that we are sitting in these paradoxes means we’re doing something right. In that space, I will treasure the moments I feel at home and sit in the discomfort when the tensions pull me in opposite directions. Here implementation science will grow in its impact.
To My Iowa Colleagues
At University of Iowa, our implementation science community tends toward the side of context, multiple perspectives, and relishing the complexity of creating change. This has roots in the Iowa City VA Health Care System’s Center for Access and Delivery Research and Evaluation (CADRE) where we have a strong qualitative and ethnographic core that supports much of the implementation science at CADRE. Its name says it all: the Ethnographic Methods and Implementation Core (EMIC). (I recommend you look up the meaning of emic if you never have.) However, I would love to see us learn to embrace the quest for predictability in our implementation science community at Iowa. Without more members who are well versed in how to measure and test change, we get too comfortable in one side of the paradox. We risk creating a house where only one group feels at home. My goal for our community at Iowa is to create a vibrant space of paradox where we all feel at home—and all allow ourselves the discomfort of being challenged to think in paradoxical ways.