The Known Unknowns: Gaps in Implementation Science of Multisector Integration and Exploring Contextual Factors for Effective Implementation

Background: Cross-sector integration between health and non-health (e.g., housing, education, employment) is increasingly encouraged to address holistic needs of communities. However, previous reviews highlighted high-level gaps in understanding the context and implementation of these interventions.

 

Approach: This multi-phase study aims to understand the implementation of multisector integration. As a quality improvement professional and researcher, insights gained through discussions with patients, health professionals, and social care providers revealed a need improve integration between health and non-health (i.e., housing, employment, education).

The first phase (completed) mapped the reporting landscape of multisectoral integrated primary care using a scoping review.

 

Six data bases were searched between May-April 2024 for the following concepts: primary care, integrated care, and multisector partnership. The review included primary studies on primary care integrating with non-health services or organisations. Building on recent reviews, and to provide more focused analysis, this review included studies published between 2019-2024 for any patient population, globally. Data was collected on study characteristics (e.g., study population), intervention characteristics (e.g., degree of integration) and constructs from the comprehensive Consolidated Framework for Implementation Research domains (CFIR) (Innovation, Outer setting, Inner Setting, Individuals, Implementation Process).

 

The second phase (2025-2027) aims to understand how internal and external contextual factors activate underlying mechanisms to drive effective cross-organizational integration. This comparative study will examine two case studies of integration between a primary care organization and a non-health organization (in Aberdeen, Scotland, and Montreal, Canada). The Scoping Rev

iew results, and leadership and patient engagement will inform context, mechanism, outcome configurations (CMOCs), which will be tested in realist evaluation case studies. The realist evaluation will be mixed-methods research, which includes interviews with leaders, observational notes, document analysis, and descriptive service use statistics.

 

Results: The scoping review included 73 studies, with focusing on integration between primary care and housing. Results showed that the ‘innovation’ domain was the most covered construct compared with other CFIR domains. This indicates that while there is still inadequate reporting of intervention elements, other domains received even less overall reporting, leaving a gap in the understanding key elements related to outer setting, inner setting, individuals, and implementation processes.

 

 Additionally, 7 studies mentioned implementation-related theories, models and frameworks (TMFs) and leadership involvement. On average, those 7 studies reported 27.6 of 58 of the CFIR constructs (28%), which is 11.9 more implementation-related constructs than the average included study.

 

Implications: This review sheds light on the reporting of multisector interventions, highlighting detailed gaps in the domains of implementation process, outer setting, and inner setting. To achieve greater collective impact, implementation research should focus on these domains and increase focus on implementation TMFs and leaders.

 

The upcoming comparative case studies will build on these insights to develop a realist, middle-range theory explaining how contextual factors shape multisector integration effectiveness. Preliminary findings from one of the case studies will be shared in this presentation, as well as outlining the process for the development of a realist middle-range theory, which allows for transferability of results to similar settings.