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Education strategies are the most commonly used in pediatric rehabilitation implementation research: a scoping review

Implementation Science Communications volume 6, Article number: 5 (2025) Cite this article

A Correction to this article was published on 31 January 2025

This article has been updated

Abstract

Background

Approximately one in six children has a disability, and effective, evidence-based rehabilitation can ameliorate the impact of these conditions over the lifespan. However, implementing interventions in real-world settings remains a challenge. This scoping review aimed to summarize the characteristics, implementation strategies, and outcomes of implementation studies in pediatric rehabilitation.

Methods

A comprehensive search was conducted in PubMed/MEDLINE, EMBASE, CINAHL, SCOPUS, and Web of Science from the database inception to December 2, 2022. Studies testing implementation strategies in pediatric rehabilitation interventions were included. Data extracted included study characteristics (e.g., country, intervention type, field of rehabilitation), implementation strategies characterized using the Expert Recommendations for Implementing Change taxonomy, and outcomes based on the Implementation Outcomes Framework.

Results

Of the 11,740 studies identified, 44 met the inclusion criteria. Most studies were conducted in the United States (n = 15, 34%) or Canada (n = 10, 23%) and used a mixed-methods design (n = 13, 30%). Interventions primarily targeted motor skills (n = 19, 43%) and were conducted in outpatient settings (n = 14, 32%) or homes (n = 11, 23%). The most commonly used implementation strategies were “train and educate key informant” (n = 21, 48%) and “use evaluative/iterative strategies” (n = 19, 43%). Feasibility (n = 19, 43%) and acceptability (n = 16, 36%) were the most frequently targeted implementation outcomes.

Conclusions

Reporting implementation strategies and outcomes in pediatric rehabilitation studies is limited and highly variable. Most strategies focused on developing and sharing educational materials, while administrative and systems-level interventions were largely absent. Standardized documentation of implementation strategies and outcomes could advance the field’s understanding of the effective development of interventions designed for implementation, encouraging faster uptake of effective interventions.

Peer Review reports

Background

The rate of disability emerging in childhood is rising and can be expensive throughout the lifespan [1, 2]. Approximately one in six children experience some form of disability and often require short- or long-term rehabilitation services (i.e., physical, occupational, and speech therapy) [3]. Supporting children with disabilities is likely to remain a challenge for years to come, as prevalence has been rising since the early 1990s [1, 3]. Despite the increasing need for pediatric rehabilitation services, outcomes often fall short of expectations due to fragmented care, inconsistent application of evidence-based practices, and inadequate support systems [4, 5]. Well-coordinated and evidence-based rehabilitation is essential to maximize function in all areas of development, prevent or minimize the consequences of disability, provide the necessary care and support for families, and decrease costly duplication and administrative delays [6, 7]. However, the field of rehabilitation science has yet to adopt a systematic approach to developing, testing, and evaluating implementation strategies. Consequently, many effective interventions are not acceptable, adoptable, or sustainable in real-world pediatric rehabilitation settings [8,9,10].

Rehabilitation practitioners face multiple challenges when incorporating evidence-based therapy into practice [11,12,13]. There are a range of reasons why interventions that have been found to be effective and feasible fail to translate into routine practice. These include inadequate implementation plans, over-reliance on dissemination as the sole strategy, complexity, time constraints, and cost issues [14, 15]. Additionally, interventions may face barriers such as lack of key informant engagement, insufficient practitioner training, limited resources, organizational resistance, and failure to adapt interventions to the local context [16, 17]. These factors contribute to a significant evidence-practice gap, with research suggesting it can take an average of 17 years for evidence-based interventions to become standard practice [18]. Implementation gaps contribute to the limited availability of evidence-based interventions, depriving children who could benefit from them [19] Therefore, an opportunity exists to promote equity for children with disabilities by improving the translation and implementation of evidence-based practices in rehabilitation services [20].

Implementation strategies are methods that help individuals, teams, and organizations enhance the adoption, utilization, and sustainability of evidence-based interventions, initiatives, or innovations [21]. The Expert Recommendations for Implementing Change (ERIC) initiative presented a taxonomy of 73 discrete implementation strategies used to optimize evidence utilization in routine care [22]. These strategies were then synthesized into nine clusters [23, 24] Implementation outcomes are the consequences of using implementation strategies to increase the use of evidence-based or evidence-informed practices [25] The Implementation Outcomes Framework proposed eight outcomes that implementation research should contain: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability [26] These criteria can be used to describe available evidence and understand the landscape of implementation of evidence-based interventions in a specified field [21, 27]. To our knowledge, there is no study summarizing implementation strategies in the field of pediatric rehabilitation.

The purpose of this scoping review was to summarize the characteristics of implementation studies conducted in pediatric rehabilitation, as well as to define the implementation strategies and outcomes reported. Secondarily, we aimed to evaluate the breadth of current implementation research in pediatric rehabilitation research. The findings from this study will expand our knowledge of what implementation strategies have been used and what opportunities exist to improve implementation and support best practices for ensuring that effective interventions are implemented equitably for all children. As we strive to improve access and equity in healthcare, we anticipate that this work will lay a foundation for understanding better ways to implement effective interventions and increase implementation strategy testing in pediatric rehabilitation.

Methods

A scoping review methodology was used to (1) synthesize the characteristics of studies related to implementation science in pediatric rehabilitation and (2) identify gaps in the literature about pediatric rehabilitation implementation strategies and outcomes. The methodology followed Joanna Briggs Institute guidelines and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews [28, 29]. The protocol was registered with Open Science Framework on 7/1/2023 and is available on the website [30].

Eligibility criteria

Peer-reviewed studies were included if they focused on a pediatric rehabilitation intervention and named an implementation strategy [31]. We chose the closest strategy aligned with the ERIC taxonomy for intervention studies that labeled a strategy not mentioned within the ERIC strategy [22] For example, one study labeled a strategy as a “workshop to train therapists,” which was translated to “conduct an educational meeting.” All study designs were included, but non-peer-reviewed studies were excluded. All inclusion and exclusion criteria are outlined in Table 1.

Table 1 Inclusion and exclusion criteria
Full size table

Search strategy and information sources

A structured literature search was implemented in PubMed/MEDLINE (1946-), Elsevier EMBASE (1947-), CINAHL (Cumulative Index of Nursing and Allied Health Literature, 1937-), SCOPUS (1823-), and Clarivate Web of Science Core Collection (WOS, 1900-) from the inception of each database through December 2, 2022. The search was executed using the standardized indexing terms keywords and the wildcard for occupational therapist*, occupational therapy, physical therapists, therap*, Physical Therapy Modalities, Allied Health Personnel, physiotherapists, Speech Therapy, Speech-Language Pathology, Physical and Rehabilitation Medicine, Rehabilitat*, Rehabilitation, Implementation Science, OR "implement*, goal*, knowledge brokers, translational science biomedical, and knowledge translation. All results were exported to EndNote X9™ (Philadelphia, PA, USA). Fully reproducible search strategies for each database can be found in the supplemental materials.

Source of evidence selection

All citations identified in the search were uploaded into the web-based scoping–systematic review program Covidence (Veritas Health Innovation, Melbourne, Australia). Two reviewers independently screened the titles and abstracts between January and September 2023 (KT, TH, CRH, SG, NAB, AL, SL). Two reviewers (SG, CRH, AL) then independently screened full texts, and reasons for exclusion were recorded. Disagreements were adjudicated by a third member of the research team (CRH, AL, KH) in alignment with published implementation strategies and guidance [26].

Data items

The 73 implementation strategies extracted from studies were categorized into nine clusters following previously published methodology [23]. The nine clusters included: (1) engage consumers, (2) use evaluative and iterative strategies, (3) change infrastructure, (4) adapt and tailor to the context, (5) develop key informant interrelationship, [32]Footnote 1 (6) utilize financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) train and educate key informant. Studies might have mentioned one or more strategies. Any descriptions provided by authors of the implementation strategies used in studies were documented following published definitions as the actor, the action, action target, temporality, dosage, implementation outcome affected, or justification [26].

Data charting and critical appraisal of evidence

The team met to review methods and pilot the extraction process at each phase to ensure consistency. With consensus at each stage, two authors completed data extraction independently between October 2023 and January 2024 (CRH, AL, SG, KH). The following data were extracted from each full text: country in which the study took place, study aims, rehabilitation field included, intervention focus, the target population’s age and diagnosis, inclusion and exclusion criteria, study design, implementation strategies used, and their specification, and any reported implementation outcomes. Two team members met to compare all extracted data and reach a consensus for each data point (SG, CH). Disagreements were resolved by a third member of the research team (CRH, AL, KH).

Synthesis of results

The data from each included study were exported and summarized using descriptive statistics. The frequency with which each strategy was used was calculated and categorized into nine implementation categories [22, 23].

Results

Selection of sources of evidence

A comprehensive search by a medical librarian [33] yielded a total of 17,335 results. After removing duplicate records, 11,740 distinct studies remained for further analysis. The distribution across various databases included 5,001 from PubMed, 1,159 from CINAHL, 4,103 from EMBASE, 1,076 from SCOPUS, and 401 from Web of Science. The full text of 557 papers was reviewed, and 44 studies were included (Fig. 1) [29].

Fig. 1
figure 1

PRISMA-ScR Diagram

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Characteristics of studies

This scoping review identified 44 studies published between 1998 and 2022 that included implementation strategies and outcomes in pediatric rehabilitation. More than half of the studies were conducted in the United States (n = 15, 34%) [31, 34,35,36,37,38,39,40,41,42,43,44,45,46,47] or Canada (n = 10, 23%) [48,49,50,51,52,53,54,55,56,57] and used both quantitative and qualitative approaches. The majority of included studies involved occupational or physical therapy, which is consistent with the finding that a substantial portion of the interventions targeted motor skill development. Similarly, children with cerebral palsy and autism spectrum disorder were the most common participants. A summary of all included studies is available in the supplementary Table 1 (Table S1).

Results of individual sources of evidence

Most studies used mixed methods (n = 13, 30%), followed by cohort (n = 7, 16%), as their study design. Almost half of the interventions were related to motor skills (n = 19, 43%). Most of the studies were conducted in outpatient settings (n = 14, 32%) or at home (n = 11, 25%).

Almost half of the interventions were focused on developing motor skills (n = 18, 41%). Several interventions focused on infant–toddler development (n = 6, 14%), communication (n = 5, 11%), caregivers (n = 2, 5%), [57, 58] or other types of intervention (n = 8, 18%). Occupational therapy appeared in 26 (59%) of the studies, followed by physical therapy in 24 studies (57%). Speech and language pathologists were included in 11 studies (25%).

Children participating in the interventions were described as having a range of conditions, including cerebral palsy (n = 10, 23%), autism spectrum disorder (n = 4, 9%), developmental coordination disorders (n = 2, 5%), and acquired brain injury (n = 2, 5%). One study represented each of the following: movement disorders, cleft palate, congenital Zika syndrome, anxiety, prematurity, speech sound disorders, sensory processing disorder, concussion, and hemophilia. The remaining studies did not specify the diagnoses served.

Thematic categories of implementation strategies

Each study reported at least one implementation strategy. Each strategy identified was categorized into one of the nine categories as previously published [23]. The most commonly reported category was “train and educate key informant” (n = 21, 48%), followed by the “use evaluative/iterative strategies” category (n = 19, 43%). The third most common category was “engage consumers” (n = 12, 27%), followed by the “adapt and tailor to context” category (n = 11, 25%). The categories “develop key informant interrelationships” (n = 3, 7%), [45, 59, 60] “use financial strategies” (n = 2, 5%), [55, 61] and “change infrastructure” (n = 1, 2%) [62] were reported infrequently. Finally, no studies reported strategies within the “provide interactive assistance” and “support clinicians” categories. See Table 2 for the most used implementation strategies, clusters, and outcomes with citations. The supplementary Table 2 (Table S2) summarizes how the implementation strategies were organized in terms of thematic categories. Figure 2 shows a bar chart comparing the number of times each category was used in the literature.

Table 2 Most used implementation strategies, clusters, and outcomes with citations
Full size table
Fig. 2
figure 2

Implementation Strategy Categories

Full size image

Implementation strategies

Overall, the studies included in this review used 28 of the 73 discrete strategies drawn from the ERIC taxonomy [22]. Studies varied from 1 to 9 (Median = 3) strategies described, with the three most common being “conduct educational meetings” (n = 20, 46%), followed by “develop educational materials” (n = 15,34%) and “distribute educational materials” (n = 15, 34%). Other discrete implementation strategies frequently used included: “obtain and use patients/consumers and family feedback” (n = 9, 21%), “assess for readiness and identify barriers and facilitators” (n = 8, 18%), “involve patients/consumers and family members” (n = 8, 18%), “tailor strategies” (n = 8, 18%), “audit and provide feedback” (n = 7, 16%), and “promote adaptability” (n = 6, 14%). Figures for each category with individual strategy use are available in the supplemental materials (Figures S1 to S7).

Implementation Outcomes

Feasibility (n = 19, 43%) and acceptability (n = 16, 36%) were targeted most frequently, followed by uptake (n = 11, 25%), fidelity (n = 10, 23%), appropriateness (n = 6, 14%), and sustainability (n = 6, 14%). Penetration (n = 1, 3%) [35] and cost (n = 1, 3%) [68] were the least reported implementation outcomes.

Synthesis of Results

Regarding implementation strategies, the included studies reported using 28 out of the 73 strategies from the ERIC taxonomy in total, with training and educating key informants being the most frequently used implementation strategy category. For implementation outcomes, we reported the terms “acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability” if the authors mentioned them. However, these terms could have been defined in various ways. For example, while 19 studies measured feasibility as an implementation outcome, the definitions and evaluations of feasibility varied. Some studies used surveys completed by parents or therapists involved in the intervention, [34, 51, 61] qualitative interviews, [31, 74] retention rates, accrual, dropout rates, or adherence to the protocol [36, 50, 57, 60, 67] Several studies employed a combination of these methods to assess feasibility [41,42,43, 58, 71]; some did not specify their assessment process [35, 37,38,39, 47]. While feasibility and acceptability were more common outcomes, increasing the uptake of evidence-based practice in pediatric rehabilitation will require considering other outcomes like adoption, appropriateness, cost, fidelity, penetration, and sustainability.

Discussion

The purpose of this review was to characterize the types of implementation studies being conducted in pediatric rehabilitation, the implementation strategies deployed, and outcomes measured. The most important finding from this study was that reporting related to intervention implementation in pediatric rehabilitation is limited. There was high variability in strategies deployed, with a concentration on developing and sharing educational materials. Many strategies were not mentioned at all—such as those designed to support clinicians or provide interactive assistance—which emphasizes the need for a more systematic approach to implementation in the future. Administrative and systems-level interventions were absent in most studies.

The essence of implementation science can be divided into two main aspects: (1) determine the barriers and facilitators of uptake of evidence-based clinical innovations at multiple levels, including individuals in treatment, providers, organizations, and other key informant groups and (2) develop and test strategies that address these obstacles and enhance the factors that promote adoption to increase uptake [77]. The findings from this review identified that many studies in rehabilitation are in the pre-implementation phase and likely are focused on identifying barriers and facilitators, with fewer moving toward testing implementation strategies to increase uptake or penetration of the innovation (intervention), which should be the ultimate goal of any evidence-based intervention.

Not surprisingly, a pervasive challenge was the lack of a common language used in studies to describe implementation strategies. Although the ERIC taxonomy language was first introduced in 2012 and updated in 2015, [22] most studies in our review did not apply this terminology to describe implementation strategies. Similarly, many studies did not explicitly state an implementation outcome based on the Implementation Outcomes Framework [25]. Going forward, we recommend investigators consistently use language from these two frameworks to describe their implementation strategies and outcomes to advance the field’s understanding of effective implementation strategies in the context of pediatric rehabilitation. While most studies touched upon training and educational strategies, cost outcomes were inadequately addressed. The lack of cost-effectiveness in many studies is a notable gap in pediatric rehabilitation literature and is an opportunity for future rehabilitation implementation research.

Included studies frequently focused on training and education of rehabilitation providers and family members, aligning with other recent findings [78]. While potentially valuable, more details about the implementation of these strategies are needed to understand the components of training and education that have been successful [26] Further, educational strategies alone may not be sufficient to change practice and may benefit from the addition of other strategies [78]. While educational interventions are effective in increasing knowledge, changes in knowledge alone often do not lead to behavior change due to different barriers, such as organizational constraints, lack of resources, and insufficient motivation among practitioners [79, 80]. Therefore, combining educational strategies with other approaches, such as audit and feedback, promoting adaptability, or organizational change efforts, can enhance their effectiveness in achieving sustained practice change [81, 82]. Without clear descriptions, consistent language, and identification of causal mechanisms of change, it remains challenging for implementors to translate findings to new settings [33, 83].

We used a scoping review methodology to describe the current literature on implementation strategies in pediatric rehabilitation. While helpful, there are notable limitations to this approach. Importantly, the inconsistency in language used in studies made the selection process difficult and lengthy. We provided training to all team members at every stage to promote consistent application of the inclusion criteria and required a minimum of two reviewers at each stage. Additionally, studies in other languages may have been left out of our search. A research librarian facilitated the search process to minimize this potential for bias. Unlike systematic reviews, scoping reviews do not conduct a formal quality assessment of included studies; however, this review focused solely on implementation strategies and not the effect of the intervention itself. Finally, despite the 18-month interval since our literature review, we believe our findings remain valid due to the well-established nature of implementation strategies and outcomes in pediatric rehabilitation. Methodological advancements in this field typically require longer periods to produce significant shifts, ensuring the relevance of our results [84]

Several theories, models, and frameworks in dissemination and implementation science can be applied to describe implementation studies [85]. Given the focus of this study on implementation strategies and outcomes, we utilized the ERIC implementation strategies and Proctor's model of implementation outcomes.

Conclusion

In conclusion, implementation strategies can play an essential role in bridging the gap between research and practice, ensuring the effective integration of evidence-based interventions as rapidly as possible. However, our study reveals a lack of consistency in reporting implementation strategies and outcomes across studies, hindering the ability to draw meaningful comparisons. The findings from this scoping review highlight the critical need for standardized documentation of implementation strategies and outcomes in studies focused on pediatric interventions in rehabilitation. Additionally, future pediatric rehabilitation intervention research should plan for implementation from the beginning of the intervention ideation, exploring implementation outcomes such as providing interactive assistance, supporting clinicians, and financial strategies. Early identification of determinants that will influence future implementation through hybrid trials can help ensure faster uptake of effective interventions into clinical environments [86].

Data availability

Not applicable.

Change history

Notes

  1. To align with the current recommendation of the CDC we have adjusted the language of the ERIC clusters and strategies that have used the term “stakeholder” to “key informant”.

Abbreviations

ERIC:

Expert Recommendations for Implementing Change

PRISMA-ScR:

Preferred Reporting Items for Systematic Review and Meta-Analyses, Extension for Scoping Reviews

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Acknowledgements

We would like to thank Kaitlyn Thornton and Tara Han for their contributions to screening titles and abstracts. We would also like to thank Byron Powell for his feedback on the research concept, and Megan Devine for her support with editing and formatting.

Funding

This study was supported by the Center for Dissemination and Implementation at Washington University in St. Louis award CDI_2023-01-CAM (CH) and the National Heart, Lung and Blood Institute award K23HL161328-01A1 (CH).

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Authors and Affiliations

  1. Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA

    Sahar Ghahramani

  2. Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA

    Sophia C. Larson, Kelly M. Harris & Catherine R. Hoyt

  3. School of Medicine, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA

    Allison J. L’Hotta

  4. Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA

    Kelly M. Harris

  5. Department of Education, Washington University in St. Louis, St. Louis, MO, USA

    Kelly M. Harris

  6. Washington University School of Medicine, Becker Medical Library, St. Louis, MO, USA

    Kim Lipsey

  7. Department of Medicine, Division of Infectious Disease, Washington University School of Medicine, St. Louis, MO, USA

    Elvin H. Geng

  8. School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA

    Lisa A. Juckett

  9. Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA

    Catherine R. Hoyt

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  8. Catherine R. Hoyt
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Contributions

SG: writing, data extraction, analysis, reviewing/editing. SL: making the tables. AL: study design, data extraction, reviewing/editing. KH: study design, reviewing/editing. KL: The librarian of the team, search strategy. EG: Search, study design, reviewing/editing. LJ: Search, study design, reviewing/editing. CH: Search, study design, reviewing/editing, data extraction, writing.

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Correspondence to Sahar Ghahramani.

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The authors declare that they have no competing interests. Elvin Geng, one of the authors of this paper, is an associate editor for Implementation Science Communications Journal.

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Ghahramani, S., Larson, S.C., L’Hotta, A.J. et al. Education strategies are the most commonly used in pediatric rehabilitation implementation research: a scoping review. Implement Sci Commun 6, 5 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s43058-024-00690-w

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Implementation Science Communications

ISSN: 2662-2211