Implementation science is concerned with identification and uptake of evidence-informed strategies into routine health care, with the goals of improving the quality of health care services and effecting positive outcomes for patients, families, and communities.[63,64] Implementation science differs from quality improvement initiatives in that the explicit goal of implementation science is to promote the utilization of evidence-informed practices through the critical examination of behaviours and factors that affect the use of these practices.[63,64] Implementation science research examines the effectiveness of the evidence-informed strategies in context (i.e., real-world settings and population),[65] and provides an opportunity to systematically examine the organizational social context that promotes or hinders the integration of mental health services into primary care.[66] This examination is often complex, as organization contexts are affected by culture and climate,[67] structures and processes (e.g., policies, procedures, governance), extant knowledge, and technologies (e.g., built environment, equipment, tool kits, resources) that promote the integration of mental health services.[66] Overall, the emphasis of implementation science research is to remove barriers to services, and to adapt treatment protocols to local context, with the ultimate goals of maximizing patient treatment outcomes.[49]
Explanatory models of illness differ in various cultures, and are an important aspect of cross-cultural psychiatry.[68-71] Health is often socially constructed,[72] and so different ethnic groups may vary in their understanding of mental health symptoms, perceived causes, severity and treatment.[73] Depression is typically viewed in the Chinese culture as a physical health disorder, rather than a mental health problem.[57-59,74] This conceptualization influences the understanding,[75] presentation[76] and disclosure[77] of depressive symptoms and behavior.[78] These considerations demand a culturally sensitive interpretation of research findings and contextual understanding of the patient, and their role in the treatment journey. For example, in pediatric primary care settings, culture influences the uptake of mental health services more so than context.[66] Implementation science research enables us to understand how to better adapt interventions for depressive disorders based on these considerations, to determine “what works, how and why,”[65 p.2] as well as to examine the efficacy of these approaches in promoting research uptake.[65]
Both patients and health care providers can influence the implementation of evidence-informed practices in predictable and unpredictable ways.[79] Behavioral expectations in primary care are guided by values and norms shared by health care practitioners.[66,67] These expectations determine how work is done and the organizational culture which in turn influences both experiences and general well-being of the health care practitioner.[66,67,80] Implementation science research enables an understanding of the complex systems that can contribute to the effective delivery of direct mental health services, and can guide multi-level interventions to organize effective mental health services within primary care and specialized care settings. ‘Fit’, which is the basis of implementation science research “addresses the application of interventions in ‘real world’ settings with the view to understanding what works, how and why, in specific context, and testing approaches to improve their implementation and effective uptake [2].”[65 p.1] Implementation science concerns itself with the goal of “‘intention to reach’, rather than ‘intention to treat’”,[65 p. 2] to maximize the impact of evidence-informed practices on population health.65 Mixed-methods research designs (e.g., integrating quantitative and qualitative data, methods, and/or methodologies) provide an opportunity to expose convergent and divergent findings related to organizational social context (e.g., cultural diversity, distrust, and affect) within the health care system thus has been recommended for implementation science research.[67] Implementation science research is further guided by methodological approaches that are participatory or involve co-creating implementation strategies, as these approaches permit adaptations to the changing context, involve patients, health care providers and policy makers, and promote continuous improvement implementation strategies to ensure sustainability.[65]