Promoting Partnership and Impact through Implementation Science and Human-Centered Design: A Commentary on the Special Issue

Abstract

Community partnerships are important for ensuring that school-based research produces knowledge to adequately support the mental health of students, families, and educators. The special issue on university–community partnerships for developing interventions contains an array of studies describing development of both interventions and implementation strategies. These articles have clear relevance to the fields of implementation science and human-centered design, which share similar objectives of promoting the adoption of new innovations. Both disciplines emphasize the adoption of new interventions, iteratively solve real-world problems, consider multiple perspectives, and ultimately focus on individual behavior change. This commentary focuses on the ways that the principles, frameworks, and methods of these two fields relate to one another, the special issue articles, and their orientation toward partnership-driven intervention and implementation strategy development.

Introduction

The special issue on the development of interventions and implementation strategies (Lawson & Owens, 2024) reflects an impressive collection of articles focusing on university–community partnerships. These partnerships are critical to all community-engaged research. However, they hold particular importance for the field of school mental health (SMH) which defines itself based on the influence it can have supporting the people within a specific community setting (i.e., the education sector). Demonstrating the broad utility of such partnerships, the articles in the special issue span a wide range of presenting problems (e.g., trauma intervention, positive behavioral supports, and interventions for emotional disabilities) and reflect multiple tiers of intervention, from universal prevention (e.g., Nguyen et al., 2024; Smith et al., 2024) to more indicated and intensive interventions for higher-need populations (e.g., Locke et al., 2024b). The partnerships described also cover multiple levels of school systems and the actors within them, recognizing the diverse roles relevant to the goals of improving the quality and contextual appropriateness of school-based interventions. These include front-line professionals/practitioners (e.g., educators; Owens et al., 2024), youth (e.g., student interns; Bartuska et al., 2024), and district policymakers (May et al., 2024) among others.

Notably, the special issue has yielded a mixture of studies describing the development of both interventions and implementation strategies (i.e., strategies are methods or techniques used to enhance the adoption, implementation, and sustainment of a program or practice (Proctor et al., 2013)) which reflects the recent growth of implementation research within school mental health. This includes considerably more papers focused on implementation strategies than likely would have resulted from a similar call 10 years ago (Owens et al., 2014) and demonstrates how far the field of school mental health has come over the past decade. The partnerships described are important for achieving goals such as ensuring the feasibility, contextual fit, and ultimate delivery of evidence-based or promising interventions and strategies. These objectives are relevant not only to the field of implementation science, but also to the field of human-centered design (HCD).

Implementation science is the study of methods to promote the uptake of research findings and evidence-based practices (EBP) into routine service delivery (Eccles & Mittman, 2006). In schools and other settings, contemporary implementation science is largely focused on the identification of implementation determinants (i.e., barriers and facilitators) and evaluating the impact of implementation strategies (e.g., training, coaching, audit, and feedback) on implementation outcomes (e.g., adoption, fidelity, and sustainment). HCD (closely related to the concepts of “user-centered design” and “design thinking”) is an approach that aligns innovation development—or redesign—with the needs of the people and settings where those innovations will be used (Norman & Draper, 1986). HCD has its origins in cognitive, organizational, and social psychology and is closely related to the fields of human–computer interaction, human factors engineering, and user-centered design (Lyon et al., 2020a, 2020b). This commentary will focus on the ways that the complementary fields of implementation science and HCD undergird the special issue articles and their orientation toward partnership-driven intervention and implementation strategy development.

Conceptual Alignment

Both implementation science and HCD are highly relevant to partnerships and community involvement in pursuit of shared objectives. Figure 1 displays key areas of overlap and distinction between the two fields. Both disciplines emphasize the adoption of new interventions because of the value they place on innovation and impact (Lyon et al., 2023). Both also iteratively solve real-world problems by generating and evaluating solutions, consider multiple user and community constituent perspectives, and ultimately focus on individual behavior change (i.e., the uptake and sustained use of an innovation). However, while HCD readily changes interventions—sometimes significantly—to ensure alignment with new settings and populations, implementation science tends to value and prioritize intervention fidelity, or “use as intended” (often as dictated by the original intervention developer; Ibrahim & Sidani, 2015). HCD also has a strong orientation toward assessing and understanding the contexts in which products will be used (typically through targeted user engagement) but, with a few notable exceptions (e.g., service design; Pfannstiel, 2023), rarely works to influence an organizational setting directly. In contrast, while implementation science also focuses on individual behavior change, it frequently employs organizational-level strategies geared toward altering a context to make it more conducive to new innovations (e.g., Aarons et al., 2024; Fleddermann et al., 2023; Locke et al., 2024a, 2024b).

Fig. 1.

Conceptual alignment of Human-Centered Design and Implementation Science. Note HCD: human-centered design and ImpSci: implementation science

Further, implementation science and HCD focus on some common outcomes of their processes, which are clearly reflected in the special issue articles. Most often, these include constructs such as intervention appropriateness, usability, feasibility, and acceptability (i.e., satisfaction) (e.g., Albright et al., 2024; Lawson et al., 2024; Sharkey et al., 2024; Smith et al., 2024; Masia Warner et al., 2024). Although these outcomes may demonstrate some overlap (see Supplemental File 2 in Lyon et al., 2020a, 2020b), they are important variables to track given that they each represent aspects of the experiences that clinicians, clients, or implementation practitioners may have when interfacing with an intervention or implementation strategy.

As reflected in many of the articles, HCD and IS also have increasing diversity, equity, and inclusion (DEI) orientations (Holeman & Kane, 2020; Shelton & Brownson, 2023). Both fields have developed equity-explicit approaches, including the health equity implementation framework (Woodward et al., 2021) and design justice principles (Costanza-Chock, 2020). At least a third of the articles in the current issue explicitly spoke to DEI issues, such as through the development of new equity-explicit interventions (e.g., Owens et al., 2024), focusing on improving the impact of programs that already reach underserved communities (Goodman et al., 2024), or using cultural adaptation models to develop more responsive versions of existing interventions (Masia Warner et al., 2024). Increasingly, HCD and implementation science strive to engage communities and individuals in more equitable ways, and researchers from both traditions sometimes seek to augment their usual methods with approaches that can facilitate more equitable power sharing, such as community-based participatory research (CBPR). This is reflected in a few special issue manuscripts, such as Bartuska and colleagues (2024) who integrated CBPR and HCD to redesign a cognitive behavioral therapy skills intervention in collaboration with high school students.

Implementation Frameworks and Strategies

Approximately half of the papers are very implementation explicit, often using well-known implementation science frameworks. Most notably, this includes the Consolidated Framework for Implementation Research (Damschroeder et al., 2009)—a determinant framework that details influences on implementation across multiple levels—and the exploration, preparation, implementation, and sustainment (EPIS) framework (Moullin et al., 2019)—a process model that guides the translation of research into practice—two of the most widely used frameworks across sectors. For instance, Okamura et al. (2024) used the CFIR to identify implementation barriers and facilitators in rural schools in Hawai ‘i. Albright et al. (2024) applied EPIS to adapt a teacher consultation model for externalizing behavior. As made explicit in Ouellette et al. (2024), there are ample opportunities for partnership and community engagement across all phases of implementation, such as those reflected in EPIS. Taken together, this suggests that the use of implementation frameworks in this issue is largely representative of larger implementation science trends.

In leveraging their community partnerships, many articles focused on the development or adaptation of implementation strategies; although at least one developed both an intervention and corresponding implementation strategies (e.g., Kuriyan et al., 2024). For instance, Collins and colleagues (2024) describe components of the process through which the leadership and organizational change for implementation (LOCI) strategy (Aarons et al., 2017) was redesigned for use in schools. Taking a different tack, Sharkey et al. (2024) and Goodman et al. (2024) both developed trainings for front-line professionals (in trauma-informed practices and cognitive behavioral therapy skills, respectively). This focus on professional development is unsurprising, especially given a recent systematic review of universal prevention programming that found conducting ongoing training is the most common implementation strategy in schools (Baffsky et al., 2023). Such an orientation is also consistent with broader trends in mental health where training has long been a cornerstone strategy for the installation of new and innovative practices (Lyon et al., 2017).

HCD Methods

The field of HCD is highly relevant to the development and adaptation processes described in the articles, regardless of whether the authors invoked specific HCD language. While applications in school mental health are only emerging, some of the special issue articles are very explicit in their use of HCD methods (e.g., Bartuska et al., 2024; Collins et al., 2024; Locke et al., 2024b) whereas others engaged in related adaptation processes (e.g., Pugliese et al., 2024, used focus groups and community expert review to iteratively develop a curriculum for Autistic youth; Masia Warner et al., 2024, applied a cultural adaptation model and involved a variety of constituents to solicit recommendations for modification). Owens and colleagues refer to “co-creation,” a term that overlaps with HCD but also tends to include a much broader array of processes (Greenhalgh et al., 2016). Irrespective of the framing, processes designed to incorporate the perspectives of users and other community members into intervention development with the goals of improving the outcomes mentioned above (i.e., appropriateness, usability, feasibility, and acceptability) are important for effective innovation development.

The methods and techniques employed in HCD are varied and range from those that are likely familiar to school-based researchers (e.g., focus groups) to more specialized approaches (e.g., cognitive walkthroughs and prototyping). In 2019, Dopp and colleagues presented 30 HCD strategies with relevance to implementation researchers and practitioners which can serve as a useful resource for promoting the application of HCD in school mental health, as well as a range of other service sectors. HCD methods and processes are typically conceptualized as playing out iteratively over time, beginning with the discovery of user and context needs, continuing into ideation and prototyping, and progressing into evaluation to determine the extent to which identified needs were met (ISO, 1999; Lyon et al., 2019). In the current special issue, many of the papers reflect different phases of related design processes, each of which may require different associated methods. This includes both (1) generative methods and (2) information gathering/evaluation methods. For instance, Bartuska et al. (2024) engaged in thoughtful initial ideation (i.e., generating multiple solutions to design problems) but had not yet progressed into developing or evaluating prototypes. Collins et al. (2024) applied a systematic usability testing method––the Cognitive Walkthrough for Implementation Strategies––to evaluate an implementation strategy prototype and drive continued iterative refinement. In a broader example, Owens and colleagues (2024) described a more extended process in which they engaged in iterative development across multiple phases.

Adaptation Processes and Targets

Given the wealth of evidence-based interventions for youth mental health in schools and beyond (Fabiano & Evans, 2019), adaptation of existing approaches may be more advantageous than development of new ones. In this sense, strategic adaptation of interventions can be considered an implementation strategy in its own right because its goal is to actively improve the use of research evidence and EBP (Lyon & Bruns, 2019). HCD methods provide an important pathway for adaptation for the school context given that HCD is applicable to an array of health services research products (Lyon et al., 2020a, 2020b), including client-facing interventions, implementation strategies, and digital technologies. Interventions and strategies themselves may be digital, analog, or a combination of the two.

Nearly all the interventions—and many of the implementation strategies—developed in the articles in this issue were adaptations of existing innovations. Reasons for adaptation included improving contextual appropriateness (e.g., Locke et al., 2024b) and cultural appropriateness (e.g., Masia Warner et al., 2024), among others. Some projects in this special issue developed digital technologies as a component of interventions or strategies, such as online training (Goodman et al., 2024) or a digital platform to support PBIS implementation (Owens et al., 2024). Locke and colleagues’ (2024b) ACT SMARTER toolkit is not limited to a digital medium but leverages a web-based interface. Collins et al. (2024) redesigned an implementation strategy that is delivered by live facilitators, either in person or remotely. Even among the projects that were most HCD explicit, many did not focus on digital solutions. Far from problematic, this reflects the broad applicability of HCD methods and helps to push back against the tendency to over-anchor on digital solutions when applying those methods. Indeed, while building apps, designing websites, or leveraging wearable technologies can reduce some implementation and access barriers, “going digital” can simultaneously introduce others that limit the ultimate reach of the innovation (Lyon, 2021).

Conclusion

Partnerships take effort to develop and maintain and, as noted by Goodman et al. (2024), it is important to “spend time in community spaces” to forge the relationships necessary for meaningful collaboration. Partnerships forged for different purposes may, appropriately, look different and vary regarding how much researchers truly share power with community members. Arnstein’s (1969) ladder of participation provides one simple framework for placing a partnership on a spectrum ranging from manipulation (a form of nonparticipation) to full citizen control, which may be helpful for conceptualizing partnerships intended to improve the quality of school mental health services. Like many implementation and design processes, partnerships and their impacts are often best captured by mixed or qualitative methods, which is clearly reflected in the collection of articles in this special issue. Finally, it is important to reflect on the fact that nearly all the projects were completed during the unprecedented COVID years, which inevitably required an endless series of pivots and reconsiderations to meet the needs of partners while prioritizing safety. Regardless of whether the articles explicitly incorporated implementation science or HCD, they are aligned with the principles of those fields and their shared emphasis on meaningful and effective community and user engagement to improve innovation adoption.