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

Evidence-based interventions (EBIs) proven to be effective in improving client participation and health have been emerging in occupational therapy. However, substantial delays and failures have occurred in disseminating and implementing EBIs into everyday occupational therapy practice (Kinney et al., 2023; Marr, 2017; Weaver et al., 2022). This significant research-to-practice gap can hinder the delivery of high-quality occupational therapy care, thus impeding efforts to improve the people’s health. Community-engaged implementation research (CEIR) has become increasingly popular in addressing this gap and accelerating the translation of EBI to improve health and health equity in communities (Blachman-Demner et al., 2017; Brownson et al., 2021; Holt & Chambers, 2017; Jull et al., 2017).

Community-engaged research (CER), an umbrella term for approaches involving community engagement, is defined as “the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people” (Centers for Disease Control and Prevention, 1997, p. 9). Implementation science is another important and emerging field addressing the delays in and failure to translate EBIs into practice (Curran, 2020). Implementation science focuses on evaluating factors that may influence the implementation of EBIs or other innovations (e.g., clinical guidelines, practice models, theories, assessments), developing implementation strategies to target these factors, and assessing implementation success to improve the uptake of EBIs in real-world settings (Curran, 2020). This line of work has evolved under various disciplines with different names, such as knowledge translation (Koczwara et al., 2016; Powell et al., 2015). Although these disciplines have some nuanced differences, they share more similarities in addressing how to improve the translation of EBIs to the real world to enhance health (Powell et al., 2015). Thus, in alignment with much other literature, including review studies, we consider implementation science and knowledge translation science to be synonymous (Allen et al., 2020; Gertner et al., 2021; Juckett & Robinson, 2018; Juckett et al., 2020; Lewis et al., 2015, 2020; Murrell et al., 2021). Integrating CER and implementation science, or CEIR, can help establish community–academic trust, build allies and resources, develop effective and ecologically valid implementation strategies, and achieve timely translation of EBIs to practice (Bombard et al., 2018; Brownson et al., 2021). It can ultimately improve people’s health (Bombard et al., 2018; Brownson et al., 2021).

In light of these potential benefits, CEIR has been actively promoted in occupational therapy research to facilitate the development of effective implementation strategies and thereby promote the translation of EBIs into practice (Cockburn & Trentham, 2002; Haywood et al., 2019; Letts, 2003; Marr, 2017; Røssvoll et al., 2023; Weaver et al., 2022). Yet, CEIR to develop implementation strategies is not widely used, or at least explicitly specified, in occupational therapy. This could be due to limited knowledge about its necessity, implementation, and reporting in this field. It is essential to synthesize existing evidence for CEIR focused on developing implementation strategies to effectively promote the translation of EBIs into practice.

Therefore, the purpose of this scoping review was to synthesize the existing applications of CEIR, specifically those focusing on developing implementation strategies, in occupational therapy research. Specifically, in this review we aimed to identify (1) CEIR study contexts, (2) the purpose of CEIR, and (3) operationalization of CEIR in occupational therapy research. The synthesized evidence from this review will establish the current science of CEIR focused on developing implementation strategies in occupational therapy research and inform future research directions to improve the translation of EBIs into practice, thereby improving the health and participation of people.

We used the five stages of scoping reviews (Arksey & O’Malley, 2005; Levac et al., 2010). In the first stage, we identified the following research questions:

1. What are the contexts of CEIR focused on developing implementation strategies in occupational therapy research?

2. What is the purpose of CEIR in developing these strategies within occupational therapy?

3. How is CEIR operationalized when developing implementation strategies in occupational therapy research?

In the second stage, we completed a systematic search to answer the research questions. In the third stage, two authors (Eunyoung Kang and Julie Chen) independently screened all extracted records and identified included studies through discussion. In the fourth stage, Kang and Chen extracted data from the included studies using Excel and used thematic analysis (Braun & Clarke, 2006) to analyze implementation strategy specifications (Powell et al., 2015; Waltz et al., 2015), the community engagement continuum (Key et al., 2019), CER principles (Israel et al., 1998), and community engagement outputs (Røssvoll et al., 2023; Staley, 2009). Kang and Chen completed the following six phases of thematic analysis: (1) becoming familiar with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report (Braun & Clarke, 2006). The two coders independently completed Phases 1 to 3 and collaboratively completed the remaining phases. When their coding decisions did not agree, they reached a consensus through discussion. When a discrepancy could not be resolved, the senior author (Erin R. Foster) was consulted. We did not contact the authors of the included studies for additional data. Kang and Chen synthesized the findings using the thematic analysis process (Braun & Clarke, 2006). We provide more details about the analysis and specifications in the “Data Extraction Items and Analysis” section. In the fifth stage, the same two authors collated, summarized, and reported the results. We did not use the sixth stage, integrating expert consultation, because of logistical limitations. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to report the findings (Tricco et al., 2018). The review protocol is not registered.

The inclusion criteria were peer-reviewed full-text articles in English that (1) used CER, operationally defined as a study that explicitly stated that CER was used, or other similar study types (e.g., community-based participatory research, participatory research, action research) to develop implementation strategies; (2) had implementation strategies targeting one or more occupational therapy–specific clinical innovations, operationally defined as intervention, assessment, guideline, theory, or service delivery model; and (3) used any empirical or nonempirical study design (e.g., mixed-methods study, randomized controlled trials, qualitative studies, protocol). The CER criterion is consistent with those used in other CER reviews (Chimberengwa & Naidoo, 2020; Julian McFarlane et al., 2022; McElfish et al., 2019; Onakomaiya et al., 2023). A substantial amount of high-quality evidence from rehabilitation-specific, implementation science–specific, and general fields has explicitly clarified that the terms implementation science and knowledge translation should be considered synonyms because they overlap significantly (Allen et al., 2020; Gertner et al., 2021; Juckett & Robinson, 2018; Juckett et al., 2020; Koczwara et al., 2016; Lewis et al., 2015, 2020; Murrell et al., 2021; Powell et al., 2015; Viglione et al., 2023). Consequently, many existing review studies, including those in the occupational therapy and rehabilitation fields, have used these terms interchangeably (Allen et al., 2020; Gertner et al., 2021; Juckett & Robinson, 2018; Juckett et al., 2020; Lewis et al., 2015, 2020; Murrell et al., 2021). More important, as suggested by Powell et al. (2015), synthesizing evidence from both implementation science and knowledge translation offers greater benefits and applicability to the evidence generated in this review for occupational therapy. Therefore, in this review we did not differentiate between implementation science and knowledge translation and included evidence from both areas. This approach allowed us to comprehensively review evidence related to both knowledge translation and implementation science.

The exclusion criteria were articles that (1) were conference papers, abstracts, dissertations, reviews, and editorials or (2) had implementers or interventionists other than occupational therapy practitioners (e.g., implementation strategies or clinical innovations targeted to other professionals, such as physicians or occupational therapy students).

A medical librarian (Kim L. Lipsey) completed a structured literature search in PubMed/MEDLINE, Embase, CINAHL, Scopus, and Clarivate Web of Science Core Collection, from the inception of each database through September 2022. The search was executed using the following standardized indexing terms and keywords: community-based participatory research, implementation science, and occupational therapy. Table A.1 in the Supplemental Material shows the full search strategy (available online with this article at https://research.aota.org/ajot).

We extracted the first author’s last name; publication year; study aims; study design; target client population; clinical innovation; clinical innovation context; theories, models, and frameworks (TMFs) used to inform implementation strategy development; implementation strategy; and implementation strategy group. We coded individual implementation strategies and their groups using existing specifications (Powell et al., 2015; Waltz et al., 2015). These specifications provide 73 implementation strategies in the following nine groups: engage consumers, use evaluative and iterative strategies, change infrastructure, adapt and tailor to the context, develop stakeholder interrelationships, use financial strategies, support clinicians, provide interactive assistance, and train and educate stakeholders (Powell et al., 2015; Waltz et al., 2015).

Although implementation science research encompasses various aspects, such as exploring implementation determinants, using TMF to inform implementation efforts, and evaluating implementation outcomes, this review specifically focuses on implementation strategies (Bauer et al., 2015; Curran, 2020; Lobb & Colditz, 2013). This focus was chosen because implementation strategies are often the initial and most fundamental step in implementation research, aside from the exploration of implementation determinants. Given the nascent stage of implementation science in the occupational therapy context, we deemed it appropriate to start with implementation strategies. Although we considered the exploration of implementation determinants, we concluded that this approach might not produce a high-quality and practical evidence synthesis, because it often involves premature stages of implementation (in which implementation goals are not yet established, and researchers explore the implementation context to prepare future efforts).

Additionally, in this review we examined the use of TMF in conjunction with implementation strategies because it is commonly known that implementation efforts in other fields are often conducted without systematic guidance from these theoretical underpinnings (Colquhoun et al., 2010; Davies et al., 2010; Liang et al., 2017; Tinkle et al., 2013). We anticipated that the situation might be similar in the occupational therapy field (Juckett et al., 2019). If this is indeed the case, we believed it would be more meaningful to examine and highlight their use in occupational therapy research. Therefore, we chose to include articles regardless of their use of TMF, especially considering the expected limited number of occupational therapy research studies focusing on implementation strategies.

We extracted the purpose of CEIR as stated by the authors of each article.

We extracted the community partners involved, partner recruitment method, community engagement continuum, activity, and outputs using CER principles. We identified engaged partners (e.g., clients, care partners, occupational therapy practitioners) and activities used (e.g., literature review, one-on-one interview, focus group) from the first several included studies. We then used those items to form our initial coding framework. We updated the coding framework to add new items found during data extraction or to consolidate repetitive or extraneous items. We included research question development, study design, recruitment, implementation strategy adaptation, data collection, result analysis, implementation, dissemination, and sustainability as community engagement output themes, adapted from Røssvoll et al. (2023) and Staley (2009).

We coded the community engagement continuum according to how actively the community was involved in the research process using the following categories (Key et al., 2019):

• ▪ No community involvement: The community is not involved in the research.

• ▪ Community informed: The community may or may not be informed or included in the research.

• ▪ Community consultation: The community provides input and feedback.

• ▪ Community participation: The community has some active role in conducting the research.

• ▪ Community initiated: The community initiates the research.

• ▪ Community-based participatory research: The community shares equal decision-making and ownership.

• ▪ Community driven or led: The community owns or leads the research.

We coded CER principles according to the following nine principles (Israel et al., 1998): (1) Acknowledge community partner as a unit of identity, (2) enhance the community’s strengths and resources, (3) promote collaborative partnerships in all research phases, (4) integrate knowledge and action for mutual benefit of all community partners, (5) promote a colearning and empowering process that addresses social inequalities, (6) involve a cyclical and iterative research process, (7) approach health from positive and ecological perspectives, (8) disseminate gained knowledge and findings to all community partners, and (9) commit to sustainability.

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).

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.

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.

Table 2 shows each study’s stated purpose for the CEIR community partners involved, how they were recruited, and the CER principles used. The most common purposes for using CEIR were to establish the community–academia partnership, build implementation capacity, and inform implementation strategy development. All studies had occupational therapists as community partners. Other partners included clients, care partners, and organization representatives. Half of the studies used existing partnerships for recruitment. Two did not specify their recruitment methods.

All principles were used at least once in the included studies, with all studies using Principle 3, facilitate collaborative partnerships in all phases of the research, and Principle 6, involve a cyclical and iterative process:

Five of the 6 studies used Principle 4, integrate knowledge and action for mutual benefit of all partners. Two quotes from Keegan et al. (2021) highlight the use of this principle:

Four of the 6 studies used Principle 2, builds on strengths and resources within the community, and Principle 5, promotes a colearning and empowering process that attends to social inequalities.

Three of the 6 studies used Principle 8, disseminate findings and knowledge gained to all partners:

One study each used Principle 1, recognizes community as a unit of identity; Principle 7, addresses health from both positive and ecological perspectives; and Principle 9, commitment to sustainability:

Table 3 shows each study’s community engagement continuum, activity, and output. Two studies used a community-driven or -led approach, and the other 4 used community-based participatory research. Six community engagement activities were used, with the most commonly used activity being the focus group method. Community engagement outputs included all phases of implementation research, from research question development to sustainability. All studies had community engagement outputs in research question development and implementation strategy adaptation. The least commonly addressed community engagement outputs were recruitment, data collection, dissemination, and sustainability, all of which were used only once.

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.

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).

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.

• ▪ Collaboration with diverse existing and new community and academic partners can establish equitable and sustainable community–academia partnerships and enhance the dissemination and implementation of EBIs in occupational therapy practice.

• ▪ Comprehensive evaluation of EBI implementation barriers and facilitators across client, provider, organizational, community, system, and policy levels can enable better understanding of the implementation context in each unique practice context.

• ▪ The development of multilevel implementation strategies to effectively support occupational therapy practitioners and EBI implementation should be promoted rather than putting more burden on individual practitioners.

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.