Community-Engaged Implementation Strategies in Occupational Therapy: A Scoping Review

Method

Results

Selection of Evidence Sources

We extracted 3,219 records; 1,785 duplicates were excluded, leaving 1,434 final records for the title and abstract screening (Figure 1). We assessed the full text of 311 articles for eligibility, and reasons for exclusion are listed in Figure 1. Six studies were included in this review (Burrough et al., 2020; Di Rezze et al., 2013; Kang & Foster, 2022; Keegan et al., 2021; Kristensen & Hounsgaard, 2014; Pollock et al., 2017).

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Figure 1.

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews flow diagram.

CEIR Context

The context data for the studies included in the scoping review are provided in Table 1. All studies were published in the past 11 yr, with the oldest one published in 2013. The aims of all studies were to develop implementation strategies or to evaluate their feasibility using qualitative or mixed-methods designs. No advanced study designs, such as randomized controlled trials, were used. Clinical innovations included interventions, assessments, and service models such as goal setting and goal management, neurobehavioral evaluation, and improving occupational therapy practitioners’ knowledge of theories. Three studies targeted children and young adults (Burrough et al., 2020; Di Rezze et al., 2013; Pollock et al., 2017), and 3 studies targeted the adult population (Kang & Foster, 2022; Keegan et al., 2021; Kristensen & Hounsgaard, 2014). Target clinical innovation settings were hospitals, communities, and schools. Of the 6 studies, 4 (Burrough et al., 2020; Di Rezze et al., 2013; Kang & Foster, 2022; Kristensen & Hounsgaard, 2014) used TMFs to inform the implementation process, including traditional interpersonal (e.g., Social Cognitive Theory) and implementation science–specific TMFs (e.g., Knowledge to Action Process Framework). No CER-specific TMFs were used.

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Table 1.

Characteristics of Studies Included in the CEIR Scoping Review

Author/Year	Study Aim	Study Design	Target Population	Clinical Innovation Context	Clinical Innovation	TMFs for Implementation Strategies	Implementation Strategies (Implementation Strategy Groupsa)
Burrough et al. (2020)	To understand the experiences of clinicians implementing PREP intervention	Qualitative knowledge translation intervention	Children and young people with acquired brain injury	Youth neurorehabilitation	PREP	Action research framework	Access new funding (6), conduct local consensus discussions (5), develop educational materials (9), develop and implement tools for quality monitoring (2), distribute educational materials (9), facilitation (8), organize clinician implementation team meetings (5), provide ongoing consultation (9), remind clinicians (7), tailor strategies (4)
Di Rezze et al. (2013)	To explore the translation and dissemination of summary of findings tables of systematic reviews	Mixed methods	Children, youth	School	Autism intervention, constraint-induced movement therapy	Knowledge to Action Process Framework	Assess for readiness and identify barriers and facilitators (2), develop educational materials (9), distribute educational materials (9), tailor strategies (4)
Kang & Foster (2022)	To evaluate a goal setting and goal management system	Feasibility	Adults with chronic disease	Community	Goal setting and goal management	Consolidated Framework for Implementation Research, Social Cognitive Theory, taxonomy of behavior change methods	Conduct educational meetings (9), develop educational materials (9), distribute educational materials (9), make training dynamic (9), promote adaptability (4), shadow other experts (9), audit and feedback (2), facilitation (8), provide ongoing individual consultation (9), use advisory board and work groups (5), involve patients or consumers and family members (1)
Keegan et al. (2021)	To understand OT practitioners’ experience of the community of practice	Action research	Patients in general medicine, emergency, orthopedics, surgical, acute palliative, and intensive care	Nontertiary hospital	Contemporary occupational therapy theories	NA	Organize clinician implementation team meetings (5), conduct educational meetings (9), conduct local needs assessment (2), develop and implement tools for quality monitoring (2), develop an implementation glossary (5)
Kristensen & Hounsgaard (2014)	To evaluate audits and feedback impact on the implementation of evidence-based practice	Action research	Adults with stroke	Hospital	Activity-based intervention, client-centered practice, AMPS, A-ONE, COPM	Action research approach, Theory of Knowledge Translation	Conduct educational meetings (9), use the advisory board and workgroups (5), audit and feedback (2)
Pollock et al. (2017)	To develop and evaluate a multifaceted professional development program	Quantitative and qualitative	Children	School	Capacity-building model of service	NA	Conduct educational meetings (9); conduct local consensus discussions (5); provide ongoing consultation (9); create a learning collaborative (9); develop educational materials (9); distribute educational materials (9); recruit, designate, and train for leadership (5); use train-the-trainer strategies (9); organize clinician implementation team meetings (5); involve patients or consumers and family members (1)

Note. AMPS = Assessment of Motor and Process Skills; A-ONE = Arnadottir OT-ADL Neurobehavioral Evaluation; COPM = Canadian Occupational Performance Measure; NA = not applicable; OT = occupational therapy; PREP = Pathways and Resources for Engagement and Participation; TMF = theories, models, and frameworks.

^aImplementation strategy groups are as follows: (1) Engage consumers, (2) use evaluative and iterative strategies, (3) change infrastructure, (4) adapt and tailor to the context, (5) develop stakeholder interrelationships, (6) use financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) train and educate stakeholders (Waltz et al., 2015).

Twenty-three implementation strategies were used; the most commonly used ones were conducting educational meetings, distributing educational materials, and developing educational materials. Figure 2 depicts the number of studies that used each individual strategy and the proportion of strategy groups used: Strategies 1 to 8, “train and educate stakeholders” (44%); Strategy 9, “provide interactive assistance” (5%); Strategy 10, “support clinicians” (2%); Strategy 11, “utilize financial strategies” (2%); Strategies 12 to 16, “develop stakeholder interrelationships” (21%); Strategies 17 and 18, “adapt and tailor to the context” (7%); Strategies 19 to 22, “use evaluative and iterative strategies” (14%); and Strategy 23, “engage consumers” (5%). None of the strategies were from the change infrastructure group.

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Figure 2.

Number of studies that used each implementation strategy.

Discussion

The purpose of this review was to examine and synthesize the existing CEIR that focuses on implementation strategies in occupational therapy. We examined the target populations, practice settings, clinical innovations, and other characteristics of existing studies to understand the context of CEIR in occupational therapy. We further analyzed the purpose of CEIR, who community partners are, what types of community engagement activities are used, and how the findings from these activities inform the overall research process. We found that CEIR is emerging across various target populations (e.g., adults, pediatrics), practice settings (e.g., community), and clinical innovations (e.g., intervention, practice model). Studies to date have mainly focused on laying implementation research groundwork in collaboration with occupational therapy practitioners. They have used various community engagement activities and the findings from these activities to inform all phases of the research process. This review provides synthesized knowledge on the current state of CEIR and implications to guide advanced CEIR in occupational therapy research.

Occupational therapy practitioners recruited through the researchers’ existing networks were the most frequently involved partners, with other partners, such as clients, administrators, clinical leadership, and policy-makers, often being left out. Because the included studies did not clarify their rationale for community partner selection, we do not know why some partners were selected and others were not. It may be that the researchers were unaware of the potential contributions that diverse community partners can make, which would be an important knowledge gap in current research. Although leveraging existing networks is acceptable and beneficial, reaching out to new and diverse communities who are not yet part of the community–academia partnership promotes the expansion of implementation efforts to broader communities, including traditionally underserved ones. Collaborating with diverse partners can help us achieve better implementation outcomes and health equity (Baumann & Cabassa, 2020; Brownson et al., 2021; Holt & Chambers, 2017). However, it is important to acknowledge that involving multiple partners can be resource intensive, challenging, and less feasible for all studies. Using a systematic approach such as implementation mapping, specifically needs and asset assessment and implementer identification (Task 1), is crucial in determining essential community partners (Fernandez et al., 2019). Thus, while striving for diverse and equitable collaboration, it is important to systematically evaluate the targeted implementation context and involve appropriate partners to conduct high-quality and efficient CEIR in future occupational therapy research.

All of the included studies promoted active community engagement by using either community-based participatory research or community-driven or -led approaches. For instance, on the one hand, Kang and Foster (2022) used community-based participatory research by having the research team develop the initial research question but using an equal decision-making process to codevelop a new goal setting and goal management system with clients and occupational therapy practitioners. On the other hand, Keegan et al. (2021) used a community-driven or -led approach in that an occupational therapy practitioner reached out to the researchers and initiated collaboration on the project to improve professional development of the practitioners in community. Although there are variations among the included studies, this finding suggests that CEIR that focuses on implementation strategies in occupational therapy research works to establish an equal and bidirectional community–academia partnership and translate the community’s needs and perspectives into implementation efforts in general. Thus, we may expect that the implementation strategies developed from these studies are more likely to be ecologically valid in improving the implementation of EBIs.

However, because occupational therapy practitioners were the main partners in the included studies, the perspectives of other partners, such as clients, administrators, and policy-makers, have not been fully incorporated. Future research should aim to broaden the scope of community–academia partnerships to better address the needs of wider, diverse communities. In addition, we should note that less active forms of community engagement also have benefits, such as far less burden on community partners (Key et al., 2019). Therefore, it is necessary to actively use and develop innovative community engagement activities or strategies to incorporate the target community’s needs and perspectives without overburdening them to achieve better implementation outcomes (Baumann & Cabassa, 2020).

Multiple community engagement activities, such as focus groups, pilot testing, and group discussion, were used, yet these are somewhat traditional methods. It would be worthwhile to explore innovative community engagement activities used in other fields, such as user panels, committees, and workshops, to explore their potential to inform CEIR in occupational therapy research (Pedersen et al., 2022). Creating and validating more effective community engagement methods can help researchers conduct CEIR at the more active end of the community engagement continuum with less community burden. More innovative community engagement activities can be particularly helpful to broaden the reach to diverse communities.

In this review, CEIR has a disproportionate representation of community engagement outputs that focus on implementation strategies. Current CEIR reflects the community’s perspectives well in research question development, implementation strategy adaptation, and implementation. However, it gives less attention to the translation of the community’s needs into recruitment, data collection, dissemination, and sustainability processes. This discrepancy may be because the studies included in this scoping review mainly focused on developing implementation strategies, and they might not be ready to recruit participants, collect data, or disseminate and sustain their findings. As CEIR in occupational therapy evolves, there will be a growing need for intentional efforts to reflect the community’s perspectives throughout the entire research process.

Although there were no distinct community engagement activity pattern differences between community-based participatory research and community-driven or -led studies, only community-driven or -led studies had dissemination and sustainability outputs by having the community partner as coauthor and involving the partner in sustainability planning, respectively. Dissemination and sustainability are tasks that are usually addressed after the completion of the research project. In contrast, other outputs are more often completed during the project, suggesting that these outputs may require a more active and longer-term form of community engagement. Although we acknowledge that not all studies have the resources to do so, we echo that it is important to collaborate with community partners throughout the entire research process, from study conception to sustainability stages.

Most studies used various CER principles with the following exceptions: approach health from positive and ecological perspectives, commitment to sustainability, and disseminate gained knowledge and findings to all community partners. We should note that the included studies may have used these principles but did not explicitly state them in the article. For instance, Kang and Foster (2022) did not specify their use of the principle approach health from positive and ecological perspectives. However, a new follow-up publication to Kang and Foster (2022) indicates that their intervention was indeed developed following that principle (Kang, 2023; Kang et al., 2023).

The comparative absence of explicit efforts to disseminate gained knowledge and findings to partners and commitment to sustainability suggests that current CEIR in occupational therapy relies on community partners during research but may not properly give back to the community through dissemination and sustainability efforts. Such practice has a potential risk of exploiting the community in the research process, which can be unethical and hinder the building of long-lasting bidirectional community–academia partnerships. We encourage researchers to work on building competency to advance CEIR, such as acknowledging the values of community engagement in implementation research, learning community characteristics, and promoting collaborative decision-making (Shea et al., 2017). These intentional efforts will help to cultivate equitable CEIR by promoting reciprocal community–academia interactions.

Current CEIR that focuses on implementation strategies in occupational therapy mostly uses the implementation strategies grouped under “train and educate stakeholders.” The most commonly used strategies in this group were conducting educational meetings and distributing and developing educational materials. This finding indicates that the current implementation strategies from CEIR mainly target occupational therapy practitioners, suggesting that they rely heavily on them to improve EBI implementation. Although providers are key personnel in implementation efforts, literature advocates the need to evaluate and address multilevel implementation strategies for achieving implementation success (Damschroder et al., 2009; Powell et al., 2015, 2019). Future CEIR should endeavor to address multilevel implementation factors across patient, provider, organizational, and policy levels. In addition, future research can explore goals for the translation of clinical innovation, identify common barriers and facilitators, and determine individual strategies to enhance the translation of EBIs into occupational therapy practice. This synthesis could lead to more effective exploration, intervention, and testing of key determinants, ultimately promoting the efficient translation of these interventions into real-world settings.

Limitations

Because of the heterogeneity among the included studies, this review did not produce evidence generalizable to a specific population or context. We may have missed relevant studies if they did not explicitly mention the use of CER or other relevant study designs or were not captured by our search strategies. We intended to minimize the risk of including studies without a clear CER focus by using conservative eligibility criteria. At the same time, this review is likely comprehensive because we used extensive systematic search strategies built by a medical librarian expert. Insufficient and unclear descriptions of the included studies may also have limited our ability to capture all data transparently, a common problem in the occupational therapy and implementation science fields (Proctor et al., 2013; Whyte & Hart, 2003). For instance, the included studies did not always use an implementation strategy reporting guide. By having two independent coders, we endeavored to accurately capture all informative data. Using standardized reporting guides would also help to improve the reporting of CEIR in occupational therapy research (Lengnick-Hall et al., 2022; Pinnock et al., 2017; Powell et al., 2019; Proctor et al., 2013).

Implications for Occupational Therapy Practice

This scoping review has the following implications for occupational therapy practice:

▪ CER can be used along with dissemination and implementation TMF to systematically guide CEIR in occupational therapy practice.

Conclusion

We found that CEIR, which focuses on implementation strategies involving a range of community engagement activities and outputs combined with CER principles, has begun to emerge in occupational therapy research to establish the groundwork to accelerate the translation of EBIs into practice. The studies included in this review relied heavily on occupational therapy practitioners from existing partnership networks in developing implementation strategies. In turn, most developed implementation strategies were designed to target occupational therapy practitioners without addressing other important implementation factors, such as client, organizational, community, system, and policy factors. This approach can potentially overburden occupational therapy practitioners rather than effectively support community partners. It could also fail to comprehensively address complex, multilevel implementation factors. By using the identified community engagement activities and outputs and exploring innovative community engagement methods in collaboration with more diverse partners, the field of occupational therapy will be able to build more equitable and sustainable community–academia partnerships. This will help accelerate the translation of EBIs into occupational therapy clinical practice and ultimately contribute to improving the participation and health of all people.

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