Table 4.

Operationalizing power in implementation efforts

	LEVEL 1: EVERYDAY POWER Supports and challenges faced in routine interactions	LEVEL 2: POLICY POWER Governmental and institutional laws and policies that constrain or support individuals	LEVEL 3: STRUCTURAL POWER Systems that impact the link between individual-level and policy-level action	LEVEL 4: ETHICAL POWER The types and spread of norms, ideology, and values in the focal society
Jones 2006 [45]	Engaged community members in developing action plans Designed an approach to power-sharing that focused on leveraging diverse expertise and using collaborative decision-making in designing intervention strategies		Attempted to shift power from healthcare and community service systems to community members and frontline providers by ensuring that community voices were central in developing culturally appropriate resources and programs Altered research processes to support new forms of executing partnerships between academics and practitioners, e.g., through new models of leadership
Swendeman 2009 [53]	Increased agency in sexual practices (e.g., negotiating condom use) and workplace negotiations (e.g., changing work contracts) among sex workers Focused on building individual consciousness around issues facing sex workers Supported self-protection and community mobilization/social support among sex workers Reduced economic vulnerability and increased political participation among sex workers		Engaged in advocacy with stakeholders and powerbrokers, such as local politicians, police, and brothel owners, reframed sex work as valid work, and championed workers’ rights to reduce stigma and marginalization Challenge led by community partners to address structural power dynamics that traditionally disempowered sex workers Created microfinance systems to help women improve their negotiating power in household decision-making	Set an explicit goal (even within this work) of normalizing sex work
McCalman 2013 [48]		Attempted to influence policy by engaging policymakers so that they would craft policy in a different way	Attempted to center Aboriginal people’s participation, responsibility for and control of their own affairs, and the associated ripple effects to family members, organizations, and communities
Baeza 2014 [30]	Examined negative impacts of hierarchical health systems on implementers perceived to be at the lower end of the clinical hierarchy		Emphasized ways hierarchical systems concentrate power for “high-status” practitioners through the use of EBI (vs. relying more on tacit knowledge)
Hamdani 2015 [41]	Identified an opportunity to empower family volunteers to deliver evidence-based care to their children and other local children and train other volunteers. Highlighted how the project worked to reduce stigma related to developmental disorders so that these children would not be excluded from community life.
Kueny 2015 [46]	Examined the role of nurse managers in daily operations, particularly in empowering nurses to take initiative in EBI changes. Identified a crucial role played by nurse managers in facilitating communication between staff nurses and hospital administration, influencing the daily work environment, and ensuring that EBIs were implemented effectively in their units	Examined the impact of external regulatory forces, such as the Joint Commission and national patient safety goals, on nurse managers’ practice change efforts. These policies significantly impact how the EBI is adopted at the unit level Noted nurses’ involvement in shared governance committees as positive among nurse managers, but their level of power for decision-making was sometimes unclear and limited	Focused on the impact of culture, structure, and resources on nurses’ ability to improve care in their units. Highlighted support from nurse manager-comprised management teams that provided mentorship and support for change. Noted nursing committee membership as a way to empower nurses and create practice change. Identified drivers of change, including institutional avenues to receive direct nurse input, empowerment to review and implement EBIs, and open communication across administrative levels.
Conway 2017 [35]	Highlighted patients’ social needs (e.g., housing and employment), which often overshadowed health concerns. Identified client empowerment as a facilitator in the success of self-management. Empowerment, in the participants’ terms, meant being able to tell their own story, identify their own problems and goals, and take control of their conditions through education and support		Attended to the systemic barriers that Indigenous health workers face, particularly the institutional racism within mainstream healthcare services, which discourages Indigenous patients from accessing care. Addressed the lack of support structures within healthcare systems that impact Indigenous health workers’ ability to provide self-management support effectively
Edge 2018 [36]	Highlighted power dynamics adolescents face in routine interactions with healthcare professionals Explored adolescents’ sense of powerlessness stemming from being diagnosed without input and feeling pushed into treatment Acknowledged that researchers may be regarded as agents of power and surveillance and sought to build trust by reducing the distance between community members, health care providers, and academics. Focused on flattening hierarchies between patients and clients		Highlighted the importance of naming and creating learning opportunities to mitigate racial hierarchies, e.g., potential power differences between White therapists and Black clients. This also connected to hierarchy in the healthcare system, e.g., the authority of healthcare professionals over patients, impacting the treatment process
Hartmann 2019 [42]	Discussed the power dynamics in intimate relationships, particularly how male partners influence women’s ability to use HIV prevention methods consistently. The dynamics ranged from opposition to support, with some male partners feeling threatened by women’s autonomous use of HIV prevention products. Extended a model based on the idea that intimate partner violence is intended to disempower female partners, and counseling can help increase a woman’s sense of power over her life and help her develop partner communication and problem-solving skills to reduce violence and increase safer sex in her relationships.		Discussed institutional power within healthcare settings and research trials. Highlighted how healthcare structures must engage male partners and challenge harmful gender norms to increase PrEP adherence. Attempted to shift power dynamics by using structures, including research clinics and community outreach activities, and educating men and supporting women’s empowerment within relationships. Engaged individuals demonstrating leadership in the workshops to become ‘community action team members’ and use their knowledge to educate their communities further. Created safe spaces for men to consider and challenge traditional masculinities and gender relations. Paired participatory workshops that generally have short-term impacts with community mobilization and public awareness activities that worked toward more medium and long-term impacts on gender equality in communities.
Worum 2020 [56]		Described the ways policies and political decisions shape the ability of physiotherapists to implement EBIs in fall prevention. Includes attention to the way a lack of understanding long-term benefit, combined with little immediate economic benefit led to low priority placed on fall prevention. Also described public policies, politicians, and organizational culture as influencing factors for EBI implementation.	Detailed how leadership and organizational culture influence physiotherapists’ ability to use EBIs. Leadership plays a critical role in empowering physiotherapists by providing the necessary resources, support, and a culture that values continuous professional development and EBI implementation. Leaders who understand the importance of EBIs can increase organizational readiness and foster an empowering environment
Bjonness 2020 [33]	Described how power dynamics influenced shared decision-making (or lack thereof) related to treatment and provider-patient concordance. Also discussed ways that diagnoses reduced patients to a set of problems. The adolescents in the study discussed the power dynamics in their day-to-day interactions with healthcare professionals. An example was being diagnosed or labeled without input, and the feeling of being pushed into treatment they did not initiate, which created a sense of powerlessness.		Highlighted the hierarchical nature of the healthcare system, particularly in how the authority of healthcare professionals over adolescents affects the treatment process. Related, organizational culture was noted to influence teamwork and clinicians’ attitudes and leadership.
Matheson 2020 [47]		Described the government-funded Healthy Families NZ initiative, which is part of a national policy approach to strengthening the health prevention system. The centering of industry needs and exclusion of community voice in local alcohol licensing processes was highlighted as an example of how a lack of community agency impacted implementation of prevention efforts	Described the institutional structures involved in implementing the initiative, including groups comprised of leaders from various sectors, including health, local government, business, and education, who work to influence transformational change at the community level. Disrupting the status quo and addressing power imbalances was part of the work. One of the outcomes it achieved was to improve information sharing between communities, policymakers, and other decision-makers.
Mugo 2020 [49]		Highlighted how the Kenya Ministry of Health played a critical role in incorporating the study approach into national HIV testing policies. By integrating the findings into the national HIV testing guidelines and endorsing the index case testing model, the ministry used its hierarchical power to influence national scale-up of the intervention. This demonstrates the role of national-level policies in driving the adoption of healthcare innovations
O’Hara 2021 [50]	Examined attitudes of individual prisoners and of individual prison administrators toward methadone maintenance treatment, and impact on treatment access and acceptance	Highlighted the challenges in scaling up methadone maintenance treatment (MMT) despite administrative coordination and support from three high-level ministries. Identified scale-up challenges related to low coverage and resistance, driven in part by prison subcultures and social hierarchies Examined the role of “rigid treatment policies” on perceptions and trust and acceptance of evidence-based solutions.	Examined prison hierarchies and the influence of informal prisoner governance systems on MMT uptake. These informal hierarchies often discouraged or outright blocked prisoners from enrolling in MMT due to cultural norms and economic interests tied to drug trafficking within the prison system. This power structure often undermined the formal governance and policies intended to provide health interventions like MMT
Ekawati 2021 [38]	Highlighted the power imbalance enacted in daily interactions between healthcare providers, i.e., general practitioners, nurses, midwives, and patients. For example, patients often complied with the instructions of doctors without fully understanding or questioning them. Examined acceptability and feasibility of implementing specified care pathways, in relation to primary care providers’ experiences and whether they had a positive experience and a sense of practice improvement including while navigating hierarchical interprofessional relationships	Addressed the influence of regulations from the local health office. Emphasized the need for more supporting policy to reinforce primary care practice	Identified differential clinical resources as a key impediment to implementation, though not as large of a barrier as interprofessional hierarchy.
Piat 2022 [51]	Assessed whether implementation team members valued stakeholder inclusion and felt “free to express their opinions, in an inclusive environment where people shared a strong interest in recovery.” Documented “challenging group dynamics” when conflict emerged between tenants and staff and how this was perceived by implementation team members. For service users/tenants, this was one of the first times they had ever been engaged in planning and implementation.