Understanding implementation mechanisms: a randomized controlled trial in schools aimed at testing the effectiveness of implementation strategies and their mechanisms of change

There is an urgent need for more knowledge on effective implementation strategies, as two-thirds of implementation efforts fail to achieve the intended change, and half have no effect on outcomes of interest. These implementation failures are partly due to the limited understanding of how implementation strategies work - the mechanisms of change through which implementation strategies affect implementation.


This project addresses the research-to-practice gap by incorporating mediation analyses into a cluster randomized controlled trial that compares the effectiveness of two implementation strategies for implementing the Guideline for the prevention of mental ill-health at the workplace in schools. Schools are chosen as the setting for implementation given the high prevalence of mental ill-health among teachers. Moreover, they lack a structured approach to the prevention of mental ill-health. The aim of the project is to investigate how implementation strategies affect the defined mechanisms and guideline implementation. The mechanisms of the following implementation strategies will be compared: a discrete strategy that includes an educational meeting (control group) and a multifaceted strategy (intervention group) that combines the educational meeting with workshops, implementation teams and evaluative and iterative strategies (e.g. Plan-Do-Study-Act cycles). Our hypothesis is that schools that receive the multifaceted implementation strategy will show a greater increase in guideline adherence at follow-up than schools that only participate in an educational meeting.


Mechanisms that will be tested include hypothesized mediators originating from the individual behavior change theory COM-B. The project will be conducted in primary schools in municipalities in Sweden. Adherence to the guideline will be assessed at baseline and 6, 12- and 24-months follow-up, and mediators at baseline and 3, 6, 9, 12- and 24-months follow-up. Mixed methods will be used.

Researchers, project time, and financing

Participating researchers are Lydia Kwak (project-leader), Christina Björklund, Byron Powell, Irene Jensen, Charlotte Wåhlin, Kjerstin Stigmar, Liselotte Schäfer Elinder and Gunnar Bergström.

The project period is 2020-2023

The project is financed by FORTE


Lydia Kwak

Lecturer senior