Background

The institutions and structures outside a service organization can significantly impact the implementation of evidence-based practices (EBPs). These contextual factors can affect both the implementation strategies [1] and outcomes [2], including the sustained use of EBPs [3]. Factors such as scientific support, funding, legislation, social policy, supportive educational and training structures, variables related to communities, the service environment, leadership, and networks have been identified as crucial for translating evidence into practice [4,5,6,7]. These external context factors have also been recognized as important targets for systematic study [4, 7], and the lack of emphasis on the system and policy levels of implementation has been considered to contribute to suboptimal results in translating evidence to practice [8]. However, the concept ‘external context’, which largely overlaps in meaning with other concepts such as ‘outer setting’ or ‘external environment’, is defined ambiguously and inconsistently across various studies [9, 10]. It also is less frequently the focus of empirical observation in implementation and dissemination research [2, 11, 12]. For these reasons, there is a need to increase the efforts to organize and systematize the findings from existing research literature in a structured way.

In this scoping review, we examined the processes, mechanisms, and social systems traditionally considered as ‘external context’ in relation to the implementation of the Individual Placement and Support (IPS) model. IPS is an EBP in mental health care that integrates vocational rehabilitation and mental health treatment through a multidisciplinary team approach [13]. Meta-analyses have shown that the IPS model effectively supports people with mental disorders to paid employment [14, 15]. The model’s feasibility for different patient groups and the predictive validity of the fidelity model has also been demonstrated [16, 17]. The model was developed in the USA in the 1990s and is now used in many countries, including the USA, Canada, Australia, and several European countries. In addition to building up the evidence base, the model’s creators’ have engaged in several ways to increase the model’s penetration and reach. These efforts include the IPS Learning Collaborative, a two-tier dissemination model for administration representatives and regional support organizations [18, 19]. The model’s originators also have produced standardized guidelines and training materials, published standards for monitoring the implementation quality, participated in training state trainers, and provided summaries of the evaluation and monitoring reports [18, 19]. Despite these efforts, the IPS model has achieved relatively low penetration in service systems across countries [20,21,22].

The motivation to study the external context, specifically with respect to the IPS model, is driven by several converging reasons. First, there is a noticeable overlap in time between the maturing evidence base and reports of challenges in innovation dissemination. Second, since the late 2000s, there has been a growing body of individual studies that identify external contextual factors as barriers affecting the implementation and penetration of IPS. This review attempts to identify potentially consistent trends across existing research findings. Third, the IPS model promotes the ‘recovery approach’. This approach values community inclusion as a pivotal aim of the care process [23, 24]. The recovery approach signifies a society-driven shift in the care paradigm, a shift that is inherently connected to the evolution of the service system which is part of the ‘external context’. Finally, studying a relatively consistent and homogenous intervention may reduce the variability that may occur when summarizing and comparing results from interventions with different foundational principles or methodologies, i.e., differences between interventions may act as confounding variables.

Previously, only one study has attempted to systematically review empirical research on external context constructs that affect the implementation of complex evidence-based health interventions [2]. We searched the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis but identified no current or underway systematic or scoping reviews on our topic. We chose a scoping review and not systematic review methodology as the scope of our review is the context rather than the properties of the intervention, and as the concept ‘external context’ is not unambiguously defined or measured in literature, and the purpose of this study is to discuss the implementation science concepts [23,24,25].

Objectives

We conducted a scoping review to systematically map the empirical research covering the external contextual factors in implementing and scaling up the IPS model and identify existing gaps in knowledge. Our research question was ‘How does external context affect the adoption, implementation, sustainment, and scale-up of the Individual Placement and Support (IPS) Model?’.

Methods

Protocol and registration

We followed the JBI methodology [23, 26] to produce the protocol. We prospectively registered the protocol with the Open Science Framework [27].

Eligibility criteria

We followed the ‘Population/Concept/Context’ framework (PCC) recommended by JBI [23] for scoping reviews. We defined our study population to encompass all pertinent stakeholders, including practitioners, researchers, policymakers, state bureaucrats, and leaders of mental health agencies. The concept examined by this scoping review was ‘external context’ which we define as any condition or circumstance external to the agency where the IPS model is executed, as outlined in the model guidelines [28]. We define context along this distinction as ‘local service context’ and ‘external context’.We accepted studies with no country restrictions. We included only peer-reviewed journal articles covering IPS services targeted at persons with any mental disorder written in English. Quantitative, qualitative, and mixed-method studies were included. We excluded studies not meeting the eligibility criteria, e.g., non-English studies, gray literature, theses and conference abstracts, and theoretical studies.

Information sources

We searched the following bibliographic databases: PROSPERO, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports, and APA PsycInfo, Pubmed, Science Direct, ProQuest Social Science Premium Collection (Sociology Collection, Social Science Database, Politics Collection), and Ebsco Psychology/Sociology Databases (CINAHL, SocINDEX, Academic Search Complete). We used assistance from university librarians in choosing the databases.

Search

We conducted database searches using the search terms ["Individual Placement and Support"] and ["Evidence-based supported employment"] individually in all databases. We limited our search to study titles and abstracts and, when possible, selected the option to include only peer-reviewed articles. We conducted the searches first in April 2022, and the searches were updated in January 2023. Our search was restricted to articles published up to December 2022, with no restrictions for the earliest publication dates. We further employed the snowballing technique by reviewing the reference lists of all the studies included after the screening. The number of screened studies was 1 124 in total. The review of additional articles from the reference list search did not lead to any changes in the established theme structure, and no further searches were conducted.

Selection of sources of evidence

The titles and abstracts were uploaded into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). The screening was undertaken independently by two reviewers. The first author and one of the second reviewers (NS, HN, TL, KA-S, AK) assessed the titles and abstracts against the eligibility criteria. Full texts were reviewed when screening produced indecisive results. We solved potential disagreements about study selection with a consensus method with three reviewers. We applied a similar procedure for full-text screening.

Data charting process

The first author created the list of data-charting items and initial code structure to determine the units of analysis to be extracted. The list was updated during the analysis iteratively to produce the best obtainable data description. The process was conducted in collaboration with the co-authors.

Data items

The first author undertook data extraction. The extracted data on article characteristics included year of publication, geographical area, aims, population, methods, and main results. For further thematic analysis, we extracted all text in the results sections of the articles that referred to ‘external context’ and could be associated with those ‘implementation outcomes’ referring to the extent to which the innovation has been implemented or is being delivered [29, 30]. They include adoption, implementation, and sustainment, which refer to local ‘actual implementation outcomes’ [30], as well as penetration and reach, which pertains to corresponding ‘actual’ system-level implementation outcomes. Only sections covering the IPS model were extracted if the articles included observations from multiple EBPs. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [25], we did not conduct quality assessments for the articles.

Synthesis of results

The first author charted, extracted, and classified the data using Atlas.ti (version 9.1.7) software. The extracted data was subjected to abductive thematic analysis. Abductive thematic analysis is a research approach that combines inductive and deductive reasoning to iteratively explore and interpret data, aiming to generate the most plausible explanations for observed phenomena by aligning empirical findings with existing theoretical frameworks or creating new ones [31, 32]. We used an existing and widely used theoretical framework (Consolidated Framework for Implementation Research, CFIR) as the starting point of the data coding. However, we used an inductive approach for categorization and thematization when the empirical data was considered relevant, but the framework did not provide a straightforward way to classify the items or patterns observed in the data. This approach led us to use a two-stage approach to presenting the results. First, we report the results describing the ‘outer setting domain’ [4, 33] determinants of the ‘actual implementation outcomes’ [30], i.e., the results congruent with the CFIR framework. This section is labeled ‘External contextual determinants’ and describes the data in which each text excerpt representing a determinant and implementation outcome association was coded as either ‘Facilitators’ or ‘Barriers’. In this section, we also present those ‘inner setting’ items that may be evaluated as subject to external societal and professional influences or were reported as targets of interventions by the external stakeholder. Second, we describe results associated with the strategies and actions of the different external stakeholders under the label ‘Systems of evidence-to-practice’. These ‘resource systems’ [34] encompass organizations and individuals that shape the external determinants of local implementation or aim at system-level implementation outcomes. Informed by the socio-ecological [7, 35, 36] and complex adaptive [37] systems approaches these ‘resource systems’ were perceived as multi-layered, self-organizing, interacting with each other, with outcomes that are contingent and intrinsically uncertain. We organized the results by stakeholder groups and presented the associations of these items with other external contextual determinants.

We convey the findings narratively, highlighting the key aspects and findings of each category. As the thematic categories utilized in our study were mutually non-exclusive and the same data excerpts could be coded with several codes, we avoid double reporting of the items when possible. We present results according to PRISMA-ScR [25], and the completed checklist is in Additional file 1. Descriptive tables were compiled with Stata Statistical Software (Version 17). We used Grammarly (www.grammarly.com) and OpenAI’s Chat-GPT 3 (https://chat.openai.com/chat, version 13) for proofreading purposes.

Results

Selection of sources of evidence

The search and screening results at each stage are shown as a PRISMA flow chart in Fig. 1. We screened unique 1124 titles and abstracts and 113 full-text documents. Of those, 59 original research papers met the eligibility criteria. The full list of included studies can be found in Additional file 2, and the record of excluded full-text studies can be found in Additional file 3.

Fig. 1
figure 1

PRISMA flow diagram

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Characteristics of sources of evidence

Eight out of 59 included studies used quantitative methodologies, 33 qualitative, and 18 mixed methods. Twenty-four were conducted in the USA, 7 in the Netherlands, 6 in Sweden, and 4 in Canada, Australia, and England. The remaining 10 studies were conducted in other countries. The year of publication ranged from 1998 to 2022 (median = 2017). The study aims reflected high variability in the scope of investigations, ranging from those interested in implementation processes and evaluation, through stakeholder perspectives and experiences, to comparative and regional analysis. Descriptive data about the included studies are presented in Table 1.

Table 1 Descriptive characteristics of included studies
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Table 2 displays the characteristics of evidence sources, presenting the frequency of observations and the sources by thematic categories. Table 2 also shows the frequencies of observations for each determinant cross-tabulated by each implementation outcome. Implementation stood out as the dominant outcome, covered in 46 articles, while adoption and penetration/reach were discussed in 29 and 26 of the articles, respectively. Sustainment found the least attention (n = 16). The data prominently showcased local determinants, including work infrastructure (n = 34), mission alignment (n = 33), and culture (n = 29), emphasizing their significance in the adoption and implementation phases. Of these, mission alignment was highly prevalent in sustainment articles. The concept of agency leaders was discussed in 38 articles, and their role was highly present in adoption, implementation, and sustainment articles. Researchers (n = 11) and political/administrative decision-makers (n = 25) were most frequently cited in articles concerning sustainment and penetration/reach. They had in common their frequent association with national strategies (n = 25), while the former was more often associated with evaluation, monitoring, and feedback (n = 25) and the latter with financing (n = 41). Discussion on sustainment and penetration/reach also frequently associated with national strategies, legislative context (n = 31), and financing. External support professionals (n = 20) were relatively highly represented in the articles on sustainment. Figure 2 is a diagram that depicts the relative positions of categories and directions of influence between them in a conceptual model.

Table 2 Frequency of observations and sources of evidence: frequencies presented in total and divided into facilitators and barriers by implementation outcome
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Fig. 2
figure 2

Associations between the systems of evidence-to-practice, external contextual determinants, and implementation outcomes: a conceptual model

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External contextual determinants

Policies and laws: national strategies and systemic integration

National or regional strategies were described as promoting the uptake and implementation of IPS [38] and appeared to be backed by administrative decisions about responsibility-sharing or funding. These policies included national mental health strategies [39], guidelines [40], and agreements on implementation support issues [18, 19]. The IPS model was perceived as a contributor to the strategic goal of implementing the recovery approach and serving as a vehicle for producing system reform at national and regional levels [18]. Congruence with other national policy goals and frameworks, such as social inclusion [39] and participation [41], was found to facilitate the incorporation of IPS principles into national mental health care policies. Systematic approaches in providing implementation support could support national strategies [42] whereas a mismatch between overarching national strategies and a lack of programs to implement IPS to achieve the goals of these strategies was reported to lead to lower penetration or adaptation of the IPS model [39, 43, 44].

One feature of the national strategies was the aim of expanding the clientele from persons with severe mental disorders such as psychotic disorders to those with any mental disorder, leading to implementing IPS in various care settings, e.g., forensic or psychiatric housing programs [45, 46]. The implications of different work infrastructures on implementation are discussed in a separate section below (work infrastructure).

Policies and laws: legislative context

Legislative contexts concerning mental health and employment were reported to impact the implementation of the IPS model. Laws that mandate employment services for individuals with severe mental illness [47] or policies redirecting services from activities not following the IPS model [48] increased the adoption of IPS programs. On the other hand, the availability of competing practices [49,50,51], procedures mandated by policies but not supported by research, such as work capacity assessments [52,53,54] or mandated lengthy referral processes [54], were reportedly at odds with the implementation of IPS with adherence to model guidelines. Social insurance criteria that excluded clients based on expected employment outcomes [55] or received benefit types [56] were also reported as barriers. The policy of allocating decision-making and management of services to local authorities was reported to hinder adoption due to low prioritization at the local level [41]. Laws and regulations related to sharing client information and access to data and mandated use of multiple information systems were reported to complicate the implementation of IPS [44, 57, 58]. Legally mandated limitations on using data could be circumvented by strategic actions by the administrative authorities or local leaders [18, 44].

Financing

The availability of funding was critical for adopting and implementing IPS across the settings. National or regional development projects were often used in the adoption phase [59, 60]. Sustained direct funding schemes through health ministries or other governmental organizations were used to increase the use or adoption within the service system or provide the necessary flexibility to implement the model as intended at the local level [38, 48, 60]. A state-level funding mechanism was associated with statewide uptake of the model [49]. Payments based on achieved results were reported to facilitate sustained implementation [49, 61]. Many studies reported that a well-managed transition from projects to sustained programs was a critical period.

Specific funding mechanisms were reported as barriers to the successful implementation of IPS. Payment models that were based on specific medical diagnoses rather than outcomes [62, 63] and separate or divided sources of funding [18, 41, 42, 51] hindered the implementation. Set or predefined funding duration to funding [41, 46, 57, 59, 64], restrictions on financing employment services as health services [51, 65], and rules that penalize short employment contracts [51] were also perceived to impact the quality of implementation negatively. Funding contracts covering a broader set of programs could include criteria conflicting with the IPS fidelity criteria [50, 63].

Training and technical assistance

Training and technical assistance were reported to facilitate the implementation of IPS. Sources for training and assistance included support from national, state, and regional organizations [66, 67] and IPS/EBP development projects [42, 68], as well as openly available guidelines and training material provided by the program’s developers [55]. These supports reportedly helped those putting the model into practice with goal setting and providing a sense of purpose [44, 50], helped providers to work systematically according to protocols and improved their knowledge of evidence-based practices [44, 68], and provided opportunities to share knowledge and experiences with other sites [55]. Agency leaders [44] and staff [62, 69] were reported to benefit from initial training and assistance [65].

Evaluation, monitoring, and feedback

National, state, and regional organizations [19, 42, 67] and outside experts were used to conduct evaluations and monitoring of the implementation of IPS that were often reported in conjunction with training and technical assistance. Routinely assessing implementation was perceived to help ensure that the model is implemented as intended over time [62], and imposing continuous evaluation by agency leaders may increase the probability of the sustainment of the program [70]. In some cases, fidelity above a certain threshold was used as a prerequisite for funding by national or regional decision-making organizations [71]. Disseminating the results on the effectiveness of IPS reportedly increased the model's adoption [18], and evaluations and monitoring were used to motivate leaders to maintain or reinstate high-fidelity services [40]. In contrast, the lack of results from monitoring or evaluations could discourage agency leaders from following national guidelines that promoted the use of IPS [46].

Local factors affected by external context

Mission alignment

Both the recovery approach [41, 59, 63, 72] and evidence-based policy commitment [69, 73] were reported to facilitate the reorienting of organizational goals to be consistent with IPS implementation and sustainment. The shift in organizational goals was associated with the de-implementation of vocational services that lacked evidence-based support and were supported by structural changes and financial arrangements through administrative decisions [74].

The non-alignment with organizational goals was reported to hinder the model’s implementation. The model could be at odds with existing organizational goals based on traditional medical or vocational services [75, 76]. These goals could be mandated by existing rules and regulations [53]. Challenges were reported when collaborating partners from different organizations had different goals in their respective organizations [52, 53, 60, 77], which could lead to giving lower priority to collaborating with the IPS team [52, 70].

Culture

Acceptance of the model by the professionals, professional norms, and local attitudes was reported as important for the uptake and implementation of the model. Understanding the program logic [60, 73] and recognizing unmet user needs [72, 78] were associated with the changes in acceptance of the model and professional norms. Several studies found that influencing practitioners’ professional norms and attitudes was an important goal during the adoption period. During this time, practitioners could learn about the rights and needs of users, the benefits of IPS, and community resources; changes in these attitudes would lead to better implementation results [55, 58, 72, 79]. Receiving training and support from site managers and national organizations [65], experiencing bringing together service functions as intended, and sharing success stories [58] were perceived to facilitate the implementation and sustainment of the model.

In several studies, the practitioners were reported to view IPS as conflicting with the core beliefs or principles of care. The practitioners may see employment or financial self-sufficiency as a not crucial outcome for health services [49, 70, 77], or they may see IPS as an inferior or unnecessary service [46, 63, 77]. Negative attitudes about the capabilities of the target group could lead to lower referrals to IPS [41, 44, 57, 65, 80], referrals to employment services not supported by research [48, 55, 57], exclusion from the service [55, 80], inadequately bringing together service functions [48, 65], and poor collaboration with external partners [53, 63].

Work infrastructure

IPS was implemented within mental health services, outside of mental health services, or as a collaboration between different organizations. Programs in community mental health settings rated higher fidelity than those in rehabilitation centers, housing units, or independent programs [45, 81, 82]. Providing the service in a mental health care setting was reported to lead to higher and shorter referral processes. Transforming a work setting to a high-fidelity IPS service was reported to require creating or protecting designated or reserved staff roles, adjusting the number of clients assigned to a single professional, or renegotiating the existing job descriptions [62, 69, 74]. The infrastructure related to continuous support was reported to promote the model’s sustainment [70].

In the situations where multiple organizations implemented the model together, strategies and agreements on financial matters [54, 83], identifying shared clients [83], and practical arrangements such as office space [83] and designated contact persons [64] were reported to facilitate implementation. The willingness to share expertise and the complementary experiences of different stakeholders [46] can also help with implementation. On the other hand, organizations that are expected to collaborate may resort to conflicting service processes [52, 53, 56, 60]. In situations where multiple organizations worked together, the absence of formal agreements led to poor referrals [54] and hindered effective implementation [41].

Systems of evidence-to-practice

Researchers

Researchers’ active involvement in developing and implementing strategies for disseminating the IPS model included collaborating directly with political and administrative decision-making, national and regional support organizations, and the implementing agencies. In the USA, the promotion of the decision-makers’ participation in the learning community was found to encourage interagency collaboration at the state level [47], including arrangements for state-level funding [66, 84] and evaluation and training support [47, 84], resulting in a higher number of IPS programs per state population and faster growth in penetration [84]. In Australia, national-level advocacy included a group of researchers promoting the IPS model to state and federal politicians and government department administrators, leading to decisions related to funding and development projects [40].

The US Learning Collaborative, a researcher-led initiative for disseminating the IPS model, has also produced numerous research collaborations supporting the model’s spread across the settings [19]. These collaborations were found in the form of partnering with the developers of the model to produce new evidence or support implementation [18, 40, 51, 59], training experts at the national level [40], or collaborating with those putting the model into practice directly [48, 51].

Political/administrative decision-makers

The model’s penetration was facilitated by decisions by the state politicians and administration [18, 40, 48, 55] or local political decision-makers [77, 85]. The dedication and enthusiasm of actors at the administration level were reported to facilitate the necessary collaborations [41, 48, 49, 62]. Enthusiastic state IPS coordinators and administrative authorities were reported to foster a culture shift in agencies, leading to high-fidelity implementation and sustained model use [49, 71].

Political/administrative decision-making was reported to induce changes in national policies. Recurrent funding decisions [48] and funding designated for IPS were reported as a facilitator of local implementation and service system penetration [49]. Also, decisions to change policy regulations and protocols, rules for referring to services, and providing support resources for implementing the model were reported to support the system-level adoption of the model [18, 49]. Enforcing national strategies and guidelines was reported to stipulate political or administrative decision-making at the local level [38]. Administrative collaboration, including coordination, consensus-building, or formal agreements between responsible agencies [18, 51, 54] or professional networks [83], reportedly facilitated coordinated referral processes and joint data collection efforts, resulting in higher penetration [49, 50] and quality of services at the aggregate level [18].

Administrators’ commitment to models not supported by research [49] and the lack of state-level collaboration between administrators in different agencies were associated with non-aligned strategies for employment services for the target group [47]. Studies also reported the ambiguity that decision-makers face when facing different potential service models [41, 70] and when considering increasing the penetration outside the specialized mental health care system [41]. One study reported ambiguity in that the strategies might recognize the significance of enhancing employment rates for individuals with mental disorders but consistent implementation plans were lacking [39]. In addition, administrative hesitancy was linked to the lack of power in decision-making [70, 83].

External support professionals

National or regional supporting organizations were reported to promote collaboration, funding, training, and evaluation. Their form varied from organizations created to support individual IPS projects [18, 19, 46, 67] to quality improvement collaborations involving several EBPs [42, 68] and contracting support services from other sites that implement the service [18]. These collaborations often included partnerships with and resources from university researchers [18, 66]. Implementing these supports could be a feature of a dissemination plan [49], and the number of active IPS programs was associated with the number of national trainers [19].

Support organizations could help the implementing sites to create implementation strategies [65, 83], budget plans involving one or more agencies [62], and encourage agency leaders to proceed with the implementation in problematic situations [83]. Training, technical assistance, fidelity, and outcome monitoring were often reported as critical aspects of implementation support [18, 46, 49, 83, 86]. Evaluation and monitoring data were reported to have been used to increase accountability and motivate decision-makers to increase funding [18, 49]. Centralized enforcement of adherence to model guidelines and outcome monitoring was found to improve the quality of implementation over time across sites [49]. Fidelity and outcome monitoring also reportedly facilitated both national consensus-building and supervision based on achieved results at the local level [18].

Poor or lack of national implementation support was reported to lead to fewer links and communications between academics and implementing agencies and low leadership involvement [44]. Removal of regional leadership and a decline in national/regional training and evaluation supports were found to lead to lower quality implementation of once-sustained programs [40]. Short timeframes for national development projects that provided external support for local sites were associated with challenges in achieving organizational structural changes in the service-producing organizations [46, 68].

Agency leaders

Senior leaders, often motivated by the recovery approach and the evidence base [48, 59, 63], were the actors who promoted ‘systemic transformation’ [51] and placed the IPS within a broader area of strategy for psychosocial services provided by the care organization [72]. Committed senior leaders communicated the importance of the recovery approach and services tailored to each person’s specific needs, which was reported to lead to higher quality services [62, 71, 87]. Prioritizing and enforcing strategies and actions, often using the steering group, was decisive as it affected several aspects of the effort, including the affecting organizational policy, promoting the program’s credibility among the professionals, the methods for cooperation, and the financing decisions [51, 55, 62, 63, 70, 71, 83]. Senior leaders’ commitment to the guidelines to ensure the IPS program is being implemented as intended [40, 54] and enforcing fidelity monitoring [40, 70] were reported to facilitate sustained implementation. In the situations where multiple organizations worked together, combining leadership outside the provider organization was perceived beneficial for implementation [59].

Agency senior leaders’ failure to align the IPS model principles with organizational goals and inadequate agency prioritization [44, 65, 71, 77] led to poorer implementation or non-sustainment. Lack of enthusiasm and promotion of the model [70, 71], not being able to channel funding [65, 77], and not using performance-related indicators [46] can also hinder its implementation or sustainment. Failure of steering groups to commit or their dissolution after the project period was reported to cause a cessation of funding or poor coordination with external partners [56, 77].

Discussion

Summary of evidence

We investigated and identified the external contextual factors that can influence the adoption, implementation, sustainment, and scale-up of the Individual Placement and Support (IPS) model, an evidence-based practice (EBP) for acquiring employment for persons with mental disorders. In this scoping review, we found that policies and laws, financing, and administratively instituted support resources were consistently conceived as facilitators or barriers to implementation across diverse settings in Western countries. Organizational mission alignment, culture, and work infrastructure were also identified as externally influenced factors that facilitated or hindered the implementation. Furthermore, we found these determinants of local implementation to be affected by strategies and actions of researchers, political and administrative decision-makers, external support professionals, and the implementing organization’s leaders support. Collectively, these actors formed and participated in complex nationally or regionally varying constellations facilitating or hindering the local implementation effort and model’s penetration into service systems.

To study how external contextual factors can affect implementation processes at the local level [4, 5, 88], we used CFIR framework [4, 33] categories as the starting point of our data analysis. It allowed us to classify the data coherently to a variable degree depending on the variables, and the framework-to-data fit may be considered moderate. Our results indicate several areas where the CFIR framework did not give the best attainable framework-to-data match. First, we introduced ‘evaluation and monitoring’ and ‘training and technical assistance’ as external context categories. These items could have been coded as enactments of ‘national strategies’ or omitted from this analysis by categorizing them under CFIR’s implementation process domain. Given the high prevalence of these items in the data and their relative position to other concepts, including these items as external contextual provided an improved framework-to-data match. We also considered including these items feasible, as facilitation of implementation is considered a central or important feature in other implementation frameworks [36, 89]. Second, we refined the CFIR categorization by distinguishing between ‘national strategies and systemic integration’ and ‘legislative context’ as separate subcategories within the ‘policies and laws’ category. This decision does not represent a deviation from CFIR but acknowledges the qualitative difference between the items, supported by the prevalence in data and distinctiveness of the items. A comparable distinction has been made in other frameworks [5, 89]. The legislative context category included observations on many broader structural policy arrangements outside the healthcare administration’s decision-making power, which may be important when considering strategies for the model expansion in real-world settings.

The most significant deviation from CFIR was how external stakeholders were considered. The analytical choice in this study was to perceive their role through the lens of socio-ecological systems [7, 35, 36], which allows the incorporation of the agency of different stakeholders. The most significant difference to CFIR was to include observations describing the stakeholders’ strategies and actions that were directed not solely towards local implementation efforts but also towards affecting the other external contextual determinants and scaling up efforts [29, 30]. The proposed ‘systems of evidence-to-practice’ category holds findings that could be considered in CFIR’s ‘partnerships and connections’ category, ‘implementation process domain’, or be excluded from the analysis to the extent they did not directly refer to the external influences on the local organization. Implementation science theorists have called after studies incorporated observations on multi-level strategies [10] or accountability mechanisms reflecting both the organizational and systemic levels [90,91,92]. With this regard, our classification resulted in improved framework-to-data match and narrowed the gap in knowledge with regard to the real-world processes through which different key stakeholders, namely researchers, political and administrative decision-makers, and support organizations, actively promote the translation of the evidence to actual implementation outcomes.

Our results support considering certain ‘inner setting’ items such as ‘mission alignment’, ‘culture’, and ‘work infrastructure’ as factors influenced by the broader structure of societal norms and arrangements. They were present in data describing the external and organizational contextual features’ interaction and often targets of interventions by the external facilitators. These items represent one facet of the non-distinctiveness of the line between the outer and inner contexts [4]. Similar items were also included in the taxonomy of external context items affecting the implementation of complex evidence-based health interventions by Watson et al. [2]. To conclude, our analysis led to a slightly modified list of CFIR’s ‘outer setting domain’ categories which we labeled as ‘enabling structures’, denoting the core components affecting the implementation and scale-up efforts.

Our analysis suggests several areas for further studies. First, our study confirms a knowledge gap: the external context factors were a systematically under-emphasized area of empirical research [2, 10, 11] and mainly described in an exploratory fashion [2] also within empirical IPS research. Second, the heterogeneity and perceived variability in the quality of the data suggest that deliberate efforts should be directed to establish more stringent operational definitions of external context. Our conceptual model represents a plausible way to organize the complexity of ‘external contextual’ items and stakeholder relationships needed for such research. Future studies would also benefit from the use of clearly defined and operationalized implementation outcomes. Differentiating between outcomes could prompt researchers to concentrate on under-researched areas. The most significant knowledge gap highlighted by our data is the studies dedicated specifically to sustainment outcomes, followed by system-level outcomes. Third, future studies should move the non-systematic approach to socio-ecological systems that partake in translating evidence to practice. Extending the study of the implementation strategies and their implementation [1] to external stakeholders with their respective organizational contextual underpinnings, potentially with the help of organizational theories [10, 93], could improve the findings’ completeness and real-world relevance. Finally, our results highlight leadership’s moderating role in context-implementation relationships not only when considering local organizational contexts [94, 95] but also when accounting for external contextual influences, marking it as a crucial topic for future studies.

Strengths and limitations

Our study has several strengths, including being strictly based on studies reporting empirical insights concerning the actual implementation and excluding theoretical or descriptive accounts, the large number of reviewed articles, the focus on a single well-defined intervention, and the heterogeneity of the organizational and societal settings from which our results were derived. However, there are several limitations to consider. First, the generalizability of our findings outside IPS implementation may be limited. This is because different health sectors, organizational settings, and EBPs each have unique characteristics that may require distinct implementation frameworks and models [96]. Second, the generalizability is bounded by all included studies being conducted in rich developed countries. Third, our results may be subject to author bias as a considerable portion of the reviewed literature was written by researchers associated with the model’s creation and early expansion. As an abductive thematic analysis, the results of this study may be biased by the authors’ judgments. Also, coding for thematic analysis was solely conducted by the first author, potentially impacting the reliability and validity of the results. Fourth, in line with our protocol and PRISMA-ScR guidelines, we did not systematically assess the quality of the included studies. We acknowledge, however, that such an assessment would have enhanced the reliability of our results, given the perceived variance in the quality of the data analyzed. In this study, we have aimed to reduce these biases by following a standardized reporting protocol for scoping reviews [25] and being explicit about the analytical choices.

Conclusions

Our scoping review provides an empirically based perspective for discussing the role of the external contextual factors affecting EBP implementation and scale-up. Our study summarises empirical research that reports structural, policy, and legal levels and support systems as facilitators or barriers to the implementation effort. Our findings highlight the importance of different stakeholders’ unique characteristics and collaboration at different socio-ecological system levels. The results indicate gaps in knowledge in implementation science and offer suggestions for future research.