Selecting Implementation Strategies: Barriers, Facilitators and Justification
Identify determinants of practice, match strategies to local barriers and justify choices with theory, empirical evidence and pragmatic constraints before implementation.
Editorial context
Adapted and summarized by PHC-Nepal from the uploaded WHO/TDR training slides Module3_Chaptwer2.pdf, developed with technical support from EPFL. The upload does not establish a publication date. This is an independent educational summary, not a WHO-endorsed course or certificate. Historical infectious-disease examples illustrate research methods; they are not current Nepal statistics or clinical protocols.
Key points
- Diagnose barriers before selecting a strategy.
- The TICD checklist groups determinants into seven domains.
- Theory, empirical evidence and practical feasibility support a transparent choice.
- Tailor with stakeholders and check unintended effects.
Why strategy selection needs justification
A familiar activity is not necessarily a suitable response. Training will not solve a shortage caused by a broken ordering process, and a reminder may not help a person who cannot afford transport. Match the strategy to the mechanism producing the gap.
The chapter recommends identifying needs, barriers and facilitators through formal assessment, conceptual models, literature and stakeholder discussion. Use these approaches to challenge assumptions rather than to justify a decision already made.
Seven domains of determinants
Flottorp and colleagues' 2013 TICD checklist synthesizes determinants of practice across seven domains. It is a structured prompt for assessment, not a diagnosis that can replace local evidence.
- Guideline factors
- Individual health professional factors
- Patient factors
- Professional interactions
- Incentives and resources
- Capacity for organizational change
- Social, political and legal factors
Match barriers to possible responses
If staff lack a particular skill, focused training with supervised practice may be plausible. If responsibilities are unclear, clarifying workflow and accountability may be more relevant. If clients distrust the service, engagement and listening may be needed before communication materials are designed.
A facilitator is something that can enable change, such as supportive leadership or an established community network. Identify how it could be used without overloading the people who provide it. Avoid treating ‘patient factors’ as blame; access and service design shape behaviour.
Theory, evidence and pragmatic rationale
A clear justification explains how the strategy is expected to work, what prior studies support it and whether it is feasible locally. Practical constraints include staff time, cost, supply availability, authority and the ability to sustain the change.
The chapter cites methods for selection and tailoring, including stakeholder-engaged approaches. There is no universal best strategy. When evidence is uncertain, use a carefully monitored pilot and state what observations would prompt revision or stopping.
Keep a decision record
For each proposed component, record the barrier addressed, evidence, mechanism, responsible actor, resources and outcome. Review this with implementers and affected groups before finalizing the protocol.
Historical insecticide-treated-net examples demonstrate the reasoning process. A current Nepal project should use current local disease guidance, policy and supply information rather than importing the course's old programme assumptions.
Sources and further reading
Use the linked institutions for current definitions, regulations, programmes and statistics.
- WHO TDR: Implementation research toolkit—Workbook (2014)
Official foundational toolkit for bottlenecks, stakeholders, questions and implementation of findings.
- Flottorp et al.: A checklist for identifying determinants of practice (2013)
Systematic synthesis of barriers and facilitators across seven domains.
- Proctor et al.: Implementation strategies—recommendations for specifying and reporting (2013)
Seven dimensions for specifying implementation strategies.
- Powell et al.: Methods to improve selection and tailoring of implementation strategies (2015)
Stakeholder-engaged methods for choosing and tailoring strategies.
Related learning note
Implementation ResearchWhat Is Implementation Research? Concepts, Scope and Three Core PhasesUnderstand implementation research, how it differs from intervention and health systems research, and how teams define problems, design strategies and test delivery in real settings.Educational notice: This article summarizes historical and public-health material. It does not replace current national protocols, clinical judgement or care from a qualified professional.