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Saccaetal. Implementation Science (2022) 17:18
https://doi.org/10.1186/s13012-022-01190-y
SYSTEMATIC REVIEW
Barriers, frameworks, andmitigating
strategies inuencing thedissemination
andimplementation ofhealth promotion
interventions inindigenous communities:
ascoping review
Lea Sacca1* , Ross Shegog1, Belinda Hernandez2, Melissa Peskin1, Stephanie Craig Rushing3, Cornelia Jessen4,
Travis Lane5 and Christine Markham1
Abstract
Background: Many Indigenous communities across the USA and Canada experience a disproportionate burden of
health disparities. Effective programs and interventions are essential to build protective skills for different age groups
to improve health outcomes. Understanding the relevant barriers and facilitators to the successful dissemination,
implementation, and retention of evidence-based interventions and/or evidence-informed programs in Indigenous
communities can help guide their dissemination.
Purpose: To identify common barriers to dissemination and implementation (D&I) and effective mitigating frame-
works and strategies used to successfully disseminate and implement evidence-based interventions and/or evidence-
informed programs in American Indian/Alaska Native (AI/AN), Native Hawaiian/Pacific Islander (NH/PI), and Canadian
Indigenous communities.
Methods: A scoping review, informed by the York methodology, comprised five steps: (1) identification of the
research questions; (2) searching for relevant studies; (3) selection of studies relevant to the research questions; (4)
data charting; and (5) collation, summarization, and reporting of results. The established D&I SISTER strategy taxonomy
provided criteria for categorizing reported strategies.
Results: Candidate studies that met inclusion/exclusion criteria were extracted from PubMed (n = 19), Embase (n =
18), and Scopus (n = 1). Seventeen studies were excluded following full review resulting in 21 included studies. The
most frequently cited category of barriers was “Social Determinants of Health in Communities.” Forty-three percent of
barriers were categorized in this community/society-policy level of the SEM and most studies (n = 12, 57%) cited this
category. Sixteen studies (76%) used a D&I framework or model (mainly CBPR) to disseminate and implement health
promotion evidence-based programs in Indigenous communities. Most highly ranked strategies (80%) corresponded
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Open Access
*Correspondence: Lea.Sacca@uth.tmc.edu
1 Center for Health Promotion and Disease Prevention, University of Texas
Health Science Center at Houston School of Public Health, 7000 Fannin,
Houston, TX 77030, USA
Full list of author information is available at the end of the article
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Page 2 of 29
Saccaetal. Implementation Science (2022) 17:18
Contributions totheliterature
• Informs and guides future D&I initiatives aimed at
reducing health disparities in Indigenous communities
• Identifies common D&I barriers that appear salient for
Indigenous communities
• Identifies effective mitigating D&I models and strate-
gies to successfully disseminate and implement evi-
dence-based programs in American Indian/Alaska
Native (AI/AN), Native Hawaiian/Pacific Islander
(NH/PI), and Canadian Indigenous communities
• Informs the development of culturally tailored D&I
strategies to improve efforts to scale-up effective inter-
ventions among Indigenous communities
Background
Many Indigenous communities across the USA and
Canada experience a disproportionate burden of health
disparities [1–3]. ese disparities exist across popula-
tions, age ranges, public health domains, disease preven-
tion, and management contexts. For example, American
Indian/Alaska Native (AI/AN) and Native Hawaiian/
Pacific Islander (NH/PI) youth, in particular, have expe-
rienced higher prevalence of sexual and reproductive
health and chronic disease disparities [1–3]. In 2017, AI/
AN females (15-19 years) had the highest teen birth rate
(32.9 per 1000) compared to other racial/ethnic groups
(18.8 per 1000) nationally [3]. Further, compared to white
peers, AI/AN and NH/PI youth exhibit higher prevalence
of obesity (76.7% vs. 63.2%), diabetes (21.4% vs. 8%), and
mental health conditions (including a 3-fold greater sui-
cide rate) [4]. Similarly, prevalence of diabetes in Cana-
dian First Nations and Inuit communities is 2.5 to 5 times
greater than the general population [5], and First Nations
communities experience higher rates of cancer due to
limited access to preventive services [2, 6, 7]. In response,
Indigenous communities have partnered with research-
ers to design and evaluate culturally relevant health
programs. is work has increased the availability of a
number of evidence-based interventions (EBIs) suitable
for implementation in Indigenous communities [8–32].
Evidence-based interventions (EBI) refer to treatments
that have been evaluated for a degree of effectiveness in
changing target behavior through outcome evaluations
[33, 34]. ey are validated for a specific purpose when
applied to a specific population and thus are only useful
for a range of health and social problems that underly
its design [34]. Changing parts of the EBI will invalidate
it by impacting its integrity and effectiveness [34]. Vali-
dation of EBIs occurs through large group research or
a series of small group studies [33, 34]. However, there
might be cases where the intervention was not effective
when applied to a specific case [34]. e use of main-
stream “evidence-based practices” (EBP), in place of
culturally relevant programs, has been a subject of con-
cern in Indigenous communities—where the use of EBP
are mandated by Federal or State funding—conflicting
with tribal values or ways of knowing [35–39]. Evidence-
based public health practices involve the development,
implementation, and evaluation of effective programs
and policies in public health through the utilization of
principles of scientific reasoning to combine individual
clinical expertise with the most prominent scientific
evidence [40, 41]. It draws on principles of good prac-
tice and integrates sound professional judgments with
a systematic body of research [42]. Emergent practices,
including practice-based evidence and cultural adap-
tation can improve the compatibility of EBPs in AI/AN
communities [33]. Indigenous tribes and researchers
have advocated for the inclusion of traditional practices
in evidence-based programs [35, 36, 43], and Tribal Best
Practices (TBP) have bridged that divide, incorporating
both cultural-based evidence and testable outcomes [33].
e design of culturally relevant EBPs in Indigenous
communities ranges from surface to deeper level adap-
tations [37]. Few mainstream EBPs have been rigorously
evaluated with AI/AN populations, which in turn gener-
ates limited outcomes or impacts for this group [44–46].
Some EBPs may be better aligned with tribal usability
and acceptability than others [46]. ere exists a need to
with those previously identified as “important” and “feasible” for D&I The most commonly reported SISTER strategy was
“Build partnerships (i.e., coalitions) to support implementation” (86%).
Conclusion: D&I frameworks and strategies are increasingly cited as informing the adoption, implementation, and
sustainability of evidence-based programs within Indigenous communities. This study contributes towards identifying
barriers and effective D&I frameworks and strategies critical to improving reach and sustainability of evidence-based
programs in Indigenous communities.
Registration number: N/A (scoping review)
Keywords: Dissemination frameworks, Implementation barriers, Indigenous communities, SISTER strategies, Cultural
context
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Page 3 of 29
Saccaetal. Implementation Science (2022) 17:18
further explore EBIs, EBPs, and evidence-informed pro-
grams (EIPs) in the context of Indigenous populations
[33, 43, 46, 47]. Evidence-informed programs (EIPs), a
sub-category of EBIs, are of particular interest—as they
aim to integrate research evidence, alongside practitioner
expertise, as well as community members’ experience
with the practice—such as elders, adults, children, com-
munity-health workers, and tribal leaders [48–50].
e emergence of EBPs, cultural adaptations, and their
associated evidence base increases the importance of
understanding the most salient barriers and facilitators
to the successful adoption, implementation, dissemina-
tion, and sustainability of EBIs in Indigenous communi-
ties. Several contextual factors can assist or hinder this
process and may be further confounded by the geo-
graphic, cultural, and political diversity of Indigenous
communities [9]. ese factors can occur at each level
of the socio-ecological model (SEM) [8–32]. Individual
(intrapersonal) factors include characteristics, attitudes,
and skills of program staff to implement and evaluate
programs. Interpersonal factors include influencing roles
of family members, peers, and mentors and their training
skills. Organizational factors include administrative sup-
port, cultural components, and management of resources
within Indigenous organizations (e.g., staff turnover and
training, participant recruitment and retention, technol-
ogy availability and use, program funding). Community
factors are embedded within the physical and social envi-
ronment (e.g., integration with cultural values, transpor-
tation). Public policy factors include social and cultural
norms supporting certain behavioral outcomes, along
with health, educational, economic, and social policies
that exacerbate social inequalities between subgroups
in Indigenous communities [11]. e requirements and
demands of implementing EBIs are often mismatched
with the capacities of the Indigenous communities that
need them, undermining broad EBI scale-up and dis-
semination [51]. Increased reach and implementation of
EBIs can be facilitated by the use of guiding dissemina-
tion and implementation (D&I) frameworks, theories,
and models, referred hereto as models [52, 53] and by the
application of empirically validated strategies [54, 55]; yet
few studies have examined their application in guiding
the implementation of EBIs within Indigenous communi-
ties [8, 10]
Dissemination andimplementation models
e formalization of research in D&I is growing and
numerous models exist to guide this process [52, 53].
Research-to-practice models are most frequently
applied and are intended for use by diverse stakehold-
ers (e.g., researchers, community-based practitioners,
and funders) to systematically guide and critically assess
prevention efforts [56, 57]. ey also help to inform on
specific D&I steps, such as community needs assess-
ment, to identify important barriers and facilitators, and
inclusion of community members’ expert knowledge in
implementation planning, and assessment of community
capacity [56]. e “Dissemination and Implementation
Models in Health Research and Practice Webtool,” a col-
laboratively developed decision support tool, provides an
updated database of D&I frameworks to assist research-
ers and practitioners to generate research questions,
select, adapt, and combine D&I models for particular
study contexts, and implement and evaluate D&I models
[53]. Despite the utility of D&I models and availability of
decision tools, their application to guide program imple-
mentation has been the exception rather than the rule [8,
9, 58, 59].
Implementation strategies
ese are practical tasks (often associated with D&I
models) recommended to aid the successful D&I of
research findings into clinical and community prac-
tice [60]. Taxonomies of strategies to successfully facili-
tate the adoption, use, and maintenance of EBIs include
the ERIC (Expert Recommendations for Implementing
Change) and SISTER (School Implementation Strate-
gies, Translating ERIC Resources) taxonomies [54, 55].
e ERIC taxonomy comprises 73 strategies devoted to
implementation of EBIs in healthcare settings [54, 60].
e SISTER strategies are an adaptation from those in
ERIC but focused on, and more compatible with, school
and community-based contexts [61]. e SISTER tax-
onomy comprises nine domains: (1) use evaluative and
iterative strategies; (2) provide interactive assistance; (3)
adapt and tailor to context; (4) develop stakeholder inter-
relationships; (5) train and educate stakeholders; (6) sup-
port educators; (7) engage consumers; (8) use financial
strategies; and (9) change infrastructure [59, 60]. Within
the nine domains are 75 strategies focused on training,
local technical assistance, adoption, high fidelity imple-
mentation of EBIs, and program replication in school-
based settings [62, 63]. Additional previously identified
strategies, seminal to use in Indigenous communities,
include integration of EBIs within the cultural context
[64, 65], involvement of Indigenous leaders, and ensuring
sufficient resources (i.e., economic, health, and political)
[9, 64, 65].
e purpose of this scoping review was to identify
common barriers and effective mitigating D&I models
and strategies to successfully disseminate and implement
evidence-based programs in American Indian/Alaska
Native (AI/AN), Native Hawaiian/Pacific Islander (NH/
PI), and Canadian Indigenous communities. is review
builds on a published multi-case study by Jernigan etal.
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Page 4 of 29
Saccaetal. Implementation Science (2022) 17:18
(2020) to develop culturally tailored D&I strategies to
enhance the ability of researchers to scale up effective
interventions among Indigenous communities [8]. is
scoping review may further contribute to informing and
guiding future D&I initiatives aimed at reducing health
disparities in this population.
Methods
e review team comprised researchers with expertise
in D&I and in the development and implementation of
EBIs for Indigenous communities in the US and Canada.
e PRISMA-ScR (Preferred Reporting Items for System-
atic reviews and Meta-Analyses extension for Scoping
Reviews) was used as a reference checklist in the devel-
opment of the study sections [66]. Arksey and O’Malley’s
(2005) York methodology guided the review [67]. is
framework methodology comprises five steps to (1) iden-
tify research questions; (2) search for relevant studies; (3)
select studies relevant to the research questions; (4) chart
the data; and (5) collate, summarize, and report results.
e method ensures transparency, enables replication of
the search strategy, and increases the reliability of study
findings [67].
Step 1. Identify research questions
ree guiding research questions for the scoping review
were: (1) What are the main barriers encountered in the
D&I of programs and EBIs in Indigenous communities?;
(2) Which research-to-practice models have been used to
promote the D&I of health promotion EBIs in Indigenous
communities?; (3) What implementation strategies have
been used in Indigenous communities for program and
EBI adoption, implementation and/or maintenance?
Step 2. Search forrelevant studies
Keywords and mesh terms were developed in corrobora-
tion with a research librarian experienced with scoping
review protocols. Search terms focused on AI/AN and
NH/PI communities, Native communities, Indigenous
tribes, tribal groups, dissemination models, dissemina-
tion frameworks, implementation frameworks, EBIs,
and US and Canadian territories (Table1). Educational
subject headings and Boolean operators were adopted
as search tools to narrow, widen, and combine literature
searches. e Rayyan platform was used to condense all
studies generated from our search [68]. ree electronic
databases (PubMed, EMBASE, and Medline (Ovid)),
selected for their breadth and focus on psychosocial
and behavioral science, were searched to identify peer-
reviewed literature from primary data sources, secondary
data sources, and case reports. e review of the litera-
ture databases was completed over a period of 2 months,
ending in June 2020. Articles were screened for eligibility
by reviewer pairs (CM and BH; RS and MP) over a period
of 3 months, ending in September 2020.
Inclusion criteria
Included were peer-reviewed studies, published in Eng-
lish between 2000 and 2020 that (1) described the use of
D&I models and frameworks to increase the dissemina-
tion, implementation, or maintenance of evidence-based
or evidence-informed programs among Indigenous com-
munities, and (2) were conducted among AI/AN, NH/PI,
and Indigenous populations of any age range located in
the USA or Canada. ‘Dissemination’ and ‘Implementa-
tion’ were defined in accordance with the 2016 National
Institute of Health definitions [69]. Indigenous popula-
tions of interest included individuals identifying as AI/
AN, NH/PI, or Indigenous in the USA and Canada.
EBIs were defined as any evidence-based or evidence-
informed intervention or program disseminated or
implemented in AI/AN, NH/PI, and/or Canadian Indig-
enous communities to improve health and behavioral
outcomes. e rigor of evidence supporting the dissemi-
nation, implementation, or maintenance of these pro-
grams was not a criterion by which articles were included
Table 1 Key search terms
a Dissemination is the distribution of intervention information and material to a specic public community or clinical practice audience (dened by the National
Institute of Health) [58]
b Implementation is the utilization of strategies to adopt and integrate evidence-based health interventions within specic settings (dened by the National Institute
of Health) [58]
Keywords Mesh terms
DisseminationaInformation dissemination; dissemination; diffusion of innovation; health information exchange; health informa-
tion management; Public health surveillance; informatics; information management
ImplementationbImplementation; health plan implementation; implementation science; regional health planning; social planning
Assessment Process assessment; process measures
AI/AN; NH/PI communities Tribes; natives; native-born; American Indian; Alaska Native; Native Hawaiian; Pacific Islander; Indigenous popula-
tions; Indigenous communities; Canadian aboriginals
Interventions Interventions; preventive health services; programs; health promotion programs
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Page 5 of 29
Saccaetal. Implementation Science (2022) 17:18
or excluded. Articles that describe the D&I of either
evidence-based or evidence-informed programs were
included.
Exclusion criteria
Excluded were studies that addressed populations dis-
tinct from Indigenous communities or targeted samples
that did not exclusively identify as Indigenous communi-
ties located in the USA or Canada, studies focusing solely
on improved behavioral or health outcomes with no ref-
erence to the D&I field, and studies that only reported
general recruitment strategies, follow-up studies after
the implementation of a program, or that focused solely
on ethical issues related to the implementation of these
programs. Initial screening and Rayyan page construc-
tion were performed by the lead author (LS). Reviewer
pairs (CM and BH; RS and MP) conducted secondary
screening of the titles and abstracts. Disagreements were
resolved by reaching consensus through discussions that
involved the initial reviewer (LS) (Fig.1).
Step 3. Selection ofstudies relevant totheresearch
questions
e lead author (LS) extracted and summarized the
data from relevant studies. Reviewer pairs (CM and BH;
RS and MP) reviewed the data extraction and summary
tables for accuracy. Conflicting opinions were resolved by
consensus discussion. Summary tables included an evi-
dence table describing each study’s parameters including
guiding D&I models, identified barriers, and mitigating
strategies. D&I models were identified using the ‘Dissem-
ination and Implementation Models in Health Research
and Practice Webtool’ previously described [53]. Bar-
riers, contextual factors that hinder implementation at
each level of the socio-ecological model (SEM) [11], were
classified by the 5 levels of the (SEM) and by barrier cat-
egories based on major themes within the broader SEM
framework. e SEM framework acts as a comprehen-
sive external reference to the D&I models and strategies;
therefore, it aids in the assessment of such models and
strategies when applied to multiple and interacting deter-
minants of health behaviors [11].
D&I strategies were categorized and coded according
to the SISTER framework (previously described). e
SISTER taxonomy was used as the referent due to its util-
ity for school and community-based contexts [61]. Initial
categorization and coding by the lead author (LS) was
compared to independent categorization with reviewer
pairs for inter-rater reliability in a subsample of 38% (n
= 8) studies. Inter-rater reliability was conducted in
two rounds with discrepancies resolved by consensus
discussion. Resulting inter-rater reliability was 90% for
strategy-level matching and 70% for domain-level match-
ing (Supplemental Tables1 & 2).
Steps 4 and5. Data charting andcollation, summarization,
andreporting ofresults
Study characteristics were tabulated for primary author,
country, study type, sample size, target population, study
topic area, and D&I model (Table2). Identified barriers
were tabulated by SEM level and classified to one of nine
barrier categories (Personnel Challenges & High Turno-
ver; Distrust; Funding; Lack of Integration with Cultural
Values; Social Determinants of Health in Communities
(physical, mental, health, social, and financial challenges);
Insufficient Evaluation Skills; Technology Barriers; Lim-
ited Retention and High Attrition; Climate Conditions)
(Table 3). e specific strategies were rank ordered
within the SISTER domains, as well as based on impor-
tance and feasibility (Table4).
Results
e initial study extraction resulted in 79,585 studies
from PubMed (n = 87), EMBASE (n = 79,485), and Med-
line Ovid (n = 13) (Fig.1). Studies were excluded due to
targeting non-Native communities (n = 89), implement-
ing medical protocols and treatments (n = 79,398), tak-
ing place outside the USA or Canada (n = 17), or failing
to address dissemination or implementation processes
(strategies, theories, or frameworks) related to evidence-
based or evidence-informed programs among Indigenous
communities (n = 21). Duplicate studies were deleted (n
= 16). irty-eight studies met inclusion criteria from
PubMed (n = 19), EMBASE (n = 18), and Medline (n =
1). An additional 17 studies were excluded following a
full study review due to failure to 1) report D&I strategies
(n = 2), 2) correspond to definitions of D&I (n = 8), or 3)
focus on D&I (n = 7). A total of 21 eligible studies were
retained for analysis.
e 21 retained studies were published between 2004
and 2020 (Table2). Most studies (14/21, 66%) were pub-
lished in 2015 or later (n = 14), and most were conducted
in the USA (14/21, 66%). Study designs included qualita-
tive studies (n = 3); case studies (n = 7); randomized con-
trolled trials (n = 3); pilot studies (n = 2); cross-sectional
studies (n = 2); quasi-experimental studies (n = 3); and
systematic review (n = 1) Study implementation duration
varied from 5-hour trainings to projects of 13 months
duration. For quasi-experimental studies and randomized
controlled trials, study follow-up periods ranged from 0
months (assessment directly after program completion)
to 3 years. e evidence-based programs described in the
studies were community-based programs carried out in
diverse tribal settings.
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Saccaetal. Implementation Science (2022) 17:18
Priority populations andkey stakeholders
Priority populations who were actively involved (or
targeted) in implementation activities were adults
(81%, n = 17) and/or children/youth (43%, n = 9)
(Table2). Adult participants included tribal members
and elders (AI/AN, n = 4; NH, n = 1; First Nation, n =
1), community health workers (n = 1), women (AI/AN,
n = 1; Choctaw, n = 1), mothers and caregivers (AI/
AN, n = 1; First Nation, n = 1, Choctaw, n = 1); and
those with chronic disease and health challenges (AI/
AN with Alzheimer’s, n = 1; adults enrolled in fetal
alcohol spectrum disorder services, n = 1; Indigenous
victims of car accidents, n = 1; NH with cardiovascu-
lar disease and hypertension, n = 2). Key stakeholders
who were crucial to planning program implementation
Fig. 1 Flow chart of the study selection process
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Saccaetal. Implementation Science (2022) 17:18
Table 2 Study characteristics
# Author/country Study design Sample (size) Priority population Stakeholders Intervention/program
topic area D&I theory/framework
1 Barlow (2018) [16] (USA) Case study Choctaw (n = 220,000),
Apache (n = 17,000),
Kodiak (n = 226), & Native
American Health Center
(n = 7,200)
AI/AN mothers and infant
caregivers Indigenous home visitors;
Staff from Urban Indian
Center
Evaluation of the Tribal
Maternal and Early
Childhood Home Visiting
(MIECHV) legislation
supporting the delivery
of home-visiting interven-
tions in low-income AI/
AN communities
None
2 Black (2018) [17] (USA) Randomized controlled
trial AI/AN youth from
program delivery sites
in tribal communities (n
= 16)
AI/AN youth Tribal partners (funding
agencies, academic insti-
tutions); Chief program
officers; Program staff;
Community advisory
group
Implementation of a
sexual health intervention
for AI/AN youth.
CBPR
3 Jernigan (2020) [20] (USA) Case study series Community-based
organization on major
Hawaiian Islands (n =
30) (KaHOLO Project);
indigenous adolescents
(n = 200) across 10 urban
communities across Cali-
fornia (MICUNAY); 1,640
shoppers from Chickasaw
Nation and Choctaw
Nation of Oklahoma
(THRIVE Study)
Native Hawaiians at risk
of CVD and HT (KaHOLO
Project); Urban Native
American Youth (Moti-
vational Interviewing
and Culture for Urban
Native American Youth-
MICUNAY); shoppers from
Chickasaw Nation and
Choctaw Nation of OK
(THRIVE Study)
Hula community; Native
Hawaiian Health Task
Force; Community
members; Health care
providers; Tribal govern-
ment; Commerce; Health
sectors
Assessment of three
D&I case studies of
NIH-funded interven-
tion research to improve
Native American Health
(IRINAH)
CBPR (KaHOLO Project &
MICUNAY); Reach, Efficacy,
Adoption, Implementation,
& Maintenance (RE-AIM)
Framework (THRIVE study)
4 Counil (2012) [13]
(Canada) Qualitative 5 participants (Inuk
leader; Inuk student;
southern student;
southern nutritionist; and
southern researcher)
Inuit communities in
Greenland & Northern
Canada
Inuk leader; Inuk student;
southern student;
southern nutritionist; and
southern researcher
Implementation of a
reduction of the trans-fat
content of food sold in
Nunavik
None
5 Craig Rushing [12] (2018)
(USA) Pilot 50 states and 73 countries AI/AN youth Representatives from
community-based organi-
zations; Tribal health
educators; advocates;
teachers; school counse-
lors; university partners
Assessing the reach and
usability of the Healthy
Native Youth website
including culturally
acceptable sexual health
curricula
None
6 Douglas (2013) [18]
(Canada) Pilot First Nation children with
asthma and their caregiv-
ers (n = 13)
First Nation children with
asthma in Canada National advisory group;
instructors; health
professionals; academics
with expertise in asthma
education
Adaptation of the “Roar-
ing Adventures of Puff
Program” for First Nation
Children with asthma
Knowledge-to-Action
Framework
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Saccaetal. Implementation Science (2022) 17:18
Table 2 (continued)
# Author/country Study design Sample (size) Priority population Stakeholders Intervention/program
topic area D&I theory/framework
7 Gates (2013) [19]
(Canada) Case study First Nations youth
attending one school in
Kashechewan, Ontario
(sample size not speci-
fied)
First Nations youth School administrators;
university researchers;
community key stake-
holders
Lessons learned following
the implementation of a
school-based snack pro-
gram for Native Youth
CBPR
8 Jernigan (2016) [20] (USA) Cross-sectional Key stakeholders in
Oklahoma (n = 100) and
California (n = 75)
AI stakeholders in two
reservations (California
and Oklahoma)
Community advisory
board; university research
center
Assessing obesity
through policy and envi-
ronmental approaches in
two AI communities
CBPR
9 Jiang (2013) [21] (USA) Quasi-experimental Participants from AI/AN
communities (n = 2,553) 80 AI/AN tribes served by
36 healthcare programs IHS-contracted health
programs; IHS hospitals/
clinics; lifestyle coaches
Evaluation of the special
diabetes program for
Indians Diabetes Preven-
tion
CBPR
10 Kaufman (2018) [22]
(USA) Cross-sectional Stakeholders involved
with sexual health and
well-being of AI/AN youth
(n = 142)
AI/AN youth Expert task force (local
technicians, CDC, IHS
personnel, experts in HIV/
STD)
Identification and assess-
ment of the parameters
facilitating the uptake of
a sexual risk reduction EBI
(RESPECT)
Diffusion of Innovation
11 Markham (2016) [10]
(USA) Randomized controlled
trial AI/AN youth (12-14 yrs.)
from 13 urban (n = 13) &
rural/tribal (n = 12) set-
tings in AK, AZ, OR, ID, WA.
AI/AN youth Regional staff; site
coordinators (teachers,
counselors, nurses, well-
ness coordinators, and
college students)
Assessing the impact of
the internet in the deliv-
ery of evidence-based
health programs
None
12 Martindale-Adams (2017)
[23] (USA) Randomized controlled
trial Caregiving dyads from
a federal or Tribal health
care program serving one
of the 546 federally rec-
ognized Tribes, an Urban
Indian Health program,
or awardees of the ACL/
AOA Native American Car-
egiver Support Program
(NACSP)
AI/AN with Alzheimer’s
disease or early dementia Staff from tribal health-
care programs; public
health nurses; community
health representatives;
university research center
Implementation of
REACH (Resources for
Enhancing Alzheimer’s
Caregivers Health) for an
EBI Alzheimer’s EBI
Implementation Process
Model
13 Mokuau (2008) [24] (USA) Qualitative Native Hawaiian elders
seeking health services
at the National Resource
Center established at the
University of Hawaii
Native Hawaiian elders University of Hawaii
research center; congres-
sional leaders; national
leaders in Native elder
health; leaders at the
University of Hawaii;
gerontologists; Native
Hawaiian leaders in the
community
Development of a
National Resource Center
for Hawaiian elders to
decrease disparities in
accessing health services
CBPR
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Page 9 of 29
Saccaetal. Implementation Science (2022) 17:18
Table 2 (continued)
# Author/country Study design Sample (size) Priority population Stakeholders Intervention/program
topic area D&I theory/framework
14 Moleta (2017) [25] (USA) Quasi-experimental Community Health Work-
ers (CHWs) (n = 46) Community Health Work-
ers in Native communities Ulu network members;
Center for Native and
Pacific Health Disparities
Research
Development, Implemen-
tation, and Evaluation of
“Heart 101”, a cardiovas-
cular disease training
program in Hawaii
CBPR/Adult Learning
Theory
15 Nadin (2018) [26]
(Canada) Quasi-experimental 7 client and family
members; 22 healthcare
providers
First Nation elderly
people Community care program
staff; federal and provin-
cial government; funding
agencies; external
resources; healthcare pro-
viders; elders; members
of the Band council and
administration
Process evaluation of a
pilot implementation
of a community-based
palliative care program
(Wiisokotaatiwin)
CBPR
16 Orians (2004) [15] (USA) Multisite case study
design 141 interviews with key
informants and 16 focus
groups (132 AI/AN eligi-
ble women)
AI/AN eligible women Program site staff; tribal
members; health educa-
tors; outreach workers
Assessment of the tribal
programs’ implemen-
tation of the public
education and outreach
component of CDC’s
National Breast and Cervi-
cal Cancer Early Detection
Program
CBPR
17 Pei (2019) [28] (USA) Qualitative 35 participants in the
Parent-Child Assistance
Program for fetal alcohol
spectrum disorder
First nation communities
enrolled in fetal alcohol
spectrum disorder
services
First Nation community;
leaders; program staff;
university research
members
Assessment of men-
tors’ perceptions of the
impacts and suitability
of a relational, trauma-
informed, and commu-
nity-based approach to
service delivery in First
Nation communities
CBPR
18 Rasmus (2019) [29] (USA) Case Study Alaska Native communi-
ties suffering from the
burden of suicide and
alcohol misuse (sample
size not specified)
AN communities Indigenous researchers;
Zuni tribal members and
teachers; local commu-
nity advisory; advisory
committee; tribal/univer-
sity collaboration; elders
Development of an
Indigenous knowledge
theory-driven interven-
tion to guide researchers
in indigenous communi-
ties who seek to create
Indigenously informed
and locally sustain-
able strategies for the
promotion of health and
well-being
Theory of Change frame-
work/Indigenous Knowl-
edge and Cultural Logic
Model of Contexts
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Page 10 of 29
Saccaetal. Implementation Science (2022) 17:18
Table 2 (continued)
# Author/country Study design Sample (size) Priority population Stakeholders Intervention/program
topic area D&I theory/framework
19 Short (2014) [30] (Canada
& USA) Systematic review 10 Indigenous communi-
ties suffering from motor
vehicle crashes (MVC)
Indigenous communities Child restraint techni-
cians; police officers;
prenatal and child safety
seat clinic staff; Head Start
staff
Successful dissemina-
tion and implementa-
tion strategies used in
the development and
implementation of MVC
interventions
None
20 Walters (2020) [31] (USA) Case study series Yappalli Choctaw Study:
Choctaw women (sample
size not specified); the
Qungasvik (Toolbox)
Prevention Approach: AN
youth 12–18 years old
(sample size not speci-
fied); KaHOLO Project:
Native Hawaiian adults
at risk of cardiovascular
disease and hyperten-
sion (sample size not
specified)
Native communities Choctaw health leaders;
non-Native support staff;
Native allies; Choctaw
community members;
community and cultural
leaders; Choctaw elders;
research team; elders;
hula members; teachers;
community-based organi-
zations; investigations
from the University of
Hawaii and Washington
state; health providers;
housing representatives;
environmental depart-
ments; cultural leaders;
knowledge keepers;
youth; parents
Implementation strate-
gies, indigenous world-
views, and protocols
derived from five diverse
community-based Native
health intervention
studies
Culturally grounded mod-
els of health promotion:
original instructions; rela-
tional restoration; narrative-
embodied transformation;
and indigenous CBPR
21 Young (2017) [32]
(Canada) Case Study 15 Canadian Aboriginal
communities 50 Canadian Aboriginal
communities Aboriginal children Planning discussions
on challenges and best
practices to implement
a children’s well-being
assessment tool
None
*Ind, individual; Inter, interpersonal; Org, organizational; Comm, community; Soc/Pol, society/policy
**Level of SEM per Barrier Category: Social determinants of health in communities = Community/Society-Policy; Personnel Challenges & High Turnover = Organizational; Funding = Organizational; Lack of Integration
with Cultural Values = Organizational/Community; Limited Retention and High Attrition = Intrapersonal/Organizational; Distrust = Intrapersonal/Interpersonal/Organizational; Technology Barriers = Organizational;
Insucient Evaluation Skills = Intrapersonal/Organizational; Climate Conditions = Intrapersonal/Organizational/Community/Society-Policy
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Page 11 of 29
Saccaetal. Implementation Science (2022) 17:18
Table 3 Barriers classified based on the socio-ecological model (SEM) and barrier category themes
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Barlow (2018)
[16]Socio-
economic,
geographic,
and structural
challenges
X X X X X X
Poverty,
economic,
and human
resource
challenges
that strain
home-visiting
implementa-
tion
X X X X X X X
Lack of reli-
able vehicles
to drive to
homes and
implement
intervention
X X
Complex
issues of
historical
oppression
and trauma
that burden
families
X X X X
Homelessness
as a serious
challenge for
clients and
their “home
visitors”
X X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Black (2018)
[17]Insufficient
broadband X X
Poorly
maintained
computers
X X
Financial
Instability X X
Loss of inter-
est in the
program and
attrition
X X
Jernigan
(2020) [8]None
Jernigan
(2016) [20]Inability to
compare
readiness
scores across
different
stakeholder
groups
X X X
Community
members
identifying
themselves
as members
of multiple
stakeholder
groups
X X
Changes
in program
leadership
X X
Changes in
funding sup-
port
X X
Limited
resources
influencing
readiness
levels
X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Counil (2012)
[13]Isolation from
food produc-
tion and
distribution
centers
X X X
Communities
isolated from
each other
X X
Extreme cli-
mate weather
conditions
X X
Cost of trans-
portation X X X X X
High price
of imported
goods
X X X X
High costs of
healthcare
professionals
and health
promotion
campaigns
X X X
High turnover
of healthcare
professionals,
store manag-
ers, and
volunteers
X X
Risk of food
insecurity in
community
X X X
Clash of
dietary cul-
tures
X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Lack of
language-
sensitive and
culturally sen-
sitive dietary
recommenda-
tions
X X
Sedentary
settlement
due to school,
trading posts,
and other
governmental
incentives
X X X X
Structural
violence X X
Craig Rushing
(2018) [12]Infrastructure
shortcom-
ings (internet
connection;
mobile broad-
band use)
X X X
Low fund-
ing for the
network of
technical
assistance
X X
Lack of fund-
ing to host
kick-off events
to build
community
awareness
X X X
Lack of fund-
ing to secure
approval from
local tribal
communities
X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Douglas
(2013) [18]Contextual
barriers to
knowledge
use including
individual
health
(comorbidi-
ties)
X X
Lack of proper
diagnosis
within the
healthcare
system
X X
Low funding
levels at the
level of the
health system
X X X X X
Competing
healthcare
staff demands
X X
Strain of acute
care on health
system
X X X X
Access to care
in remote
areas
X X X
Childcare
when in need
of healthcare
services
X X X
Negative
healthcare
experiences
X X X
Capacity of
family to
respond to
healthcare
stressors
X X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Capacity of
schools to
respond to
stress, variety
of caregivers,
and socioeco-
nomic factors
X X X X X
Capacity of
community
to respond to
stress, variety
of caregivers,
and socioeco-
nomic factors
X X X X X
Lack of
asthma
awareness
and low read-
ing levels
X X X
Gates (2013)
[19]Challenges
to improved
dietary intakes
and sustain-
ability in the
first year
X X X
Jiang (2013)
[21]Skepticism of
grantee staff
about the
importance
and success
of evaluation
X X X
Staff had no
experience
in evaluating
other rigorous
programs
X X X
Challenge of
participant
retention
X X
Scheduling
difficulties X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Participants
moving away X X
Compromised
attendance of
participants
due to stress-
ful lifestyles
X X X
Challenge
to sustain
intervention
effects for
long periods
of time
X X X X X X
Kaufman
(2018) [22]Integration of
new routines
into settings
often imbued
with particu-
lar cultural
expectations
of care and
service
X X X X
Limited
financial
and material
resources
X X X X
Markham
(2016) [10]Frozen
screens (4/6
programs)
X X X
Long loading
time of activi-
ties
X X
Trouble
navigating
programs
X X
Technical and
connectivity
issues at sites
X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Martindale-
Adams (2017)
[23]
Staff concern
about iden-
tification of
caregivers in
cases of loss
of memory
X X X X
Lack of aware-
ness of public
health nurses
about patient
memory
concerns
X X
Family
members not
identifying
themselves as
caregivers
X X
Mokuau
(2008) [24]None
Moleta (2017)
[25]Short dura-
tion of staff
training for
the amount
of material
covered
X X
Limited
information
on alterna-
tive and
traditional
medicine
practices
X X
Limited strate-
gies to help
uninsured
clients
X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Nadin (2018)
[26]Limited fund-
ing for pallia-
tive care and
community
care services
X X X
Lack of service
delivery funds X X
Lack of
housing infra-
structure and
overcrowding
X X
Difficulty in
assessing
system-level
outcomes
X X
Orians (2004)
[15]Limited
experiences
of tribes in
providing and
participating
in federally
funded health
promotion
and disease
prevention
programs
X X X X X
Limited
resources
for chronic
disease care
X X X X X X
Inadequate
mammogra-
phy services
X X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Pei (2019) [28] Lack of com-
munity aware-
ness about
fetal alcohol
spectrum
disorder
X X
Stigma
around the
disease
X X X
Reluctance
of women to
admit using
substances
X X
Complex
needs of cli-
ents served by
Parent-Child
Assistance
Program
X X X
Rasmus (2019)
[29]None
Short (2014)
[30]Lack of
integration
of specific
cultural and
contextual
variables of a
given com-
munity
X X
Timing of the
intervention X X X X
Lack of
integration of
local customs
and cultural
values into
program
activities
X X X
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Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Having no
tribal police
department
and a second-
ary enforce-
ment law
X X X X
Shortage of
police officers X X X
High turnover
in police chief
positions
X X X X
Large
geographic
distance
between the
community
and the evalu-
ation team
X X X
Limitations
in evaluating
community
outcomes
X X
Conflicts in
scheduling
community
meetings
X X
Walters (2020)
[31]None
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Page 22 of 29
Saccaetal. Implementation Science (2022) 17:18
Table 3 (continued)
Study (year) Barriers (n =
100) Socio-ecological model (SEM)
level* Barrier category**
Ind Inter Org Comm Soc/Pol Social
determinants
of health in
communities
Personnel
challenges
and high
turnover
Funding Lack of
integration
with cultural
values
Limited
retention
and high
attrition
Technology
barriers Distrust Insucient
evaluation
skills
Climate
conditions
Young (2017)
[32]Communica-
tion differ-
ences
X X X X
Capacity/
turn-over X X
Building trust
over distance X X
Negative
historical
experiences
with research
X X X X
Local com-
plexities X X X
Multiple ser-
vice providers X X X
Timeline
uncertainties X X
Total 22 6 49 41 26 38 29 18 11 9 7 6 3 2
*Ind, individual; Inter, interpersonal; Org, organizational; Comm, community; Soc/Pol, society/policy
**Level of SEM per Barrier Category: Social determinants of health in communities = Community/Society-Policy; Personnel Challenges & High Turnover = Organizational; Funding = Organizational; Lack of Integration
with Cultural Values = Organizational/Community; Limited Retention and High Attrition = Intrapersonal/Organizational; Distrust = Intrapersonal/Interpersonal/Organizational; Technology Barriers = Organizational;
Insucient Evaluation Skills = Intrapersonal/Organizational; Climate Conditions = Intrapersonal/Organizational/Community/Society-Policy
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Saccaetal. Implementation Science (2022) 17:18
included decision makers in healthcare, school, com-
munity, organizations, academics, and government
(Table2).
Content domains
e evidence-based programs targeted a variety of
health domains, including chronic disease and injury,
substance misuse, wellness and illness prevention, and
historical trauma (Table2). Chronic disease and injury
topics included hypertension and cardiovascular dis-
ease (n = 3), obesity (n = 1), asthma (n = 1), diabetes
(n = 1), hearing loss (n = 1), Alzheimer’s (n = 1), pal-
liative care (n = 1), and motor vehicle crashes (n = 1).
Substance misuse included misuse of alcohol and other
drugs (n = 5) and tobacco use (n = 1). Wellness and
illness prevention topics included maternal and child
health (n = 1), sexual health (n = 4), nutrition (n = 4),
physical activity (n = 1), improved access to healthcare
services (n = 2), breast and cervical cancer screening (n
= 1), overall children’s well-being (n = 1), and reduction
of environmental contaminants exposures (n = 1). One
study focused on a historical approach to health through
walking the Trail of Tears and 2 studies reported pro-
grams addressing multiple health topics [8, 10, 31].
Tribal communities andsettings
Diverse tribal communities were represented in this
review, including AI/AN (n = 13), Inuit (n = 2), and First
Table 4 SISTER-Strategies by domain, rank, and percentage of citation
a SISTER category number based on Cook etal., 2019 [38]. A total of 26 strategies are documented in the table. The rationale behind the cut-o is that the strategy has
been included in at least four out of the twenty-three studies
b Ranked as highly important by Lyon etal., 2019 [33]
c Ranked as highly feasible by Lyon etal., 2019 [33]
d All 9 SISTER domains were cited (Cook etal, 2019 [38]). They numbered (from highest to lowest) based on the 26 (out of 60) highly ranked SISTER strategies (≥ 4
studies) cited within seven of these domains: Develop stakeholder interrelationships (31%); Train and educate stakeholders (23%); Provide interactive assistance
(15%); Use evaluative and iterative strategies (12%); Adapt and tailor to contex t (8%); Engage consumers (8%); and Change infrastructure (4%). The remaining two
domains (“Support educators” and “Use nancial strategies”) included strategies cited in less than four studies and were thus not included in the table
#aStrategy DomaindRank Strat. (%) Imp.bFeas.c
21 Build partnerships (i.e., coalitions) to support implementation Develop stakeholder interrelationships 1 86
22 Capture and share local knowledge Develop stakeholder interrelationships 2 81 x
17 Tailor strategies Adapt and tailor to context 3 71
23 Conduct local consensus discussions Develop stakeholder interrelationships 4 52
37 Conduct educational meetings Train and educate stakeholders 5 38
9 Monitor the progress of the implementation effort Use evaluative and iterative strategies 5 38 x
57 Involve students, family members, and other staff Engage consumers 5 38
39 Conduct ongoing training Train and educate stakeholders 5 38 x
35 Use advisory boards and workgroups Develop stakeholder interrelationships 6 33
43 Make training dynamic Train and educate stakeholders 6 33 x x
28 Inform local opinion leaders Develop stakeholder interrelationships 7 29
24 Develop academic partnerships Develop stakeholder interrelationships 7 29
42 Distribute educational materials Train and educate stakeholders 7 29 x
40 Create a professional learning collaborative Train and educate stakeholders 8 24
58 Prepare families and students to be active participants Engage consumers 8 24
13 Peer-assisted learning Provide interactive assistance 8 24
14 Provide practice-specific supervision Provide interactive assistance 8 24
12 Facilitation/problem-solving Provide interactive assistance 9 19 x
15 Provide local technical assistance Provide interactive assistance 9 19
16 Promote adaptability Adapt and tailor to context 9 19
29 Involve governing organizations Develop stakeholder interrelationships 9 19
44 Provide ongoing consultation/coaching Train and educate stakeholders 9 19 x
1 Assess for readiness and identify barriers and facilitators Use evaluative and iterative strategies 9 19
7 Develop instruments to monitor and evaluate core compo-
nents of the innovation/new practice Use evaluative and iterative strategies 9 19
34 Recruit, designate, train for leadership Develop stakeholder interrelationships 9 19
68 Change/alter environment Change infrastructure 9 19
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Page 24 of 29
Saccaetal. Implementation Science (2022) 17:18
Nation/Indigenous (n = 7), and Native Hawaiian (n =
2) communities (Table2). AI/AN communities included
tribes in Oklahoma, California, Alaska, Arizona, and the
Pacific Northwest (Oregon, Idaho, and Washington).
Inuit communities included tribes in Greenland and
Northern Canada. First Nation/Indigenous and Native
Hawaiian communities had representation from multiple
regions in Canada and Hawaii respectively. Settings com-
prised Native nations, reservations and reserves, tribal
agencies and associations, health agencies, academic
affiliates, and schools (Table2).
D&I barriers
Eighty-nine barriers to implementation were reported
in 17 studies (81%), representing the five levels of the
socio-ecological model (SEM): Individual (n = 22), inter-
personal (n = 6), organizational (n = 49), community
(n = 41), and society/policy (n = 26) (Table3). Barriers
were also sorted into nine categories (Table3) based on
major themes that were established through similarity of
barriers highlighted across studies at the different levels
of SEM. Some barriers fit into the SEM levels, and thus
generated more than one theme. For instance, Barlow
et al. (2018) highlighted “socioeconomic, geographic,
and structural challenges” as a barrier, affecting the indi-
vidual, community, and society/policy levels of the SEM.
e barrier category themes emerging from this barrier
and its subsequent SEM classification included “fund-
ing,” “social determinants of health in communities,” and
“climate conditions.” Most cited barriers (n = 38) sorted
into the Community/Society-Policy category of “Social
determinants of health in communities.” A majority of
studies also cited “Personnel challenges and high turno-
ver” (n = 29), “Funding” (n = 18); “Lack of integration
with cultural values (n = 11), and “Limited retention and
high attrition” (n = 9) Other barrier categories included
Technology barriers (n = 7); Distrust (n = 6); Insufficient
evaluation skills (n = 3); and Climate conditions (n = 2).
D&I models
Sixteen studies (76%) used a specific D&I model to pro-
mote the adoption and implementation of health pro-
motion EBIs in Indigenous communities (Table2). Eight
different unique models were cited. Community-Based
Participatory Research (CBPR) was most commonly
reported (n = 11). Four studies used models that focused
on dissemination and/or implementation (Knowledge-
to-Action Framework, Diffusion of Innovation eory,
and RE-AIM), andragogy (Adult Learning eory), or
inductive and culturally responsive processes (Cultur-
ally Grounded Models of Health Promotion). Remaining
models focused on the broader implementation process
inclusive of dissemination. Ten studies used a D&I model
for the purpose of identifying barriers and/or facilitators
to the dissemination process; seven studies highlighted
the main barriers and/or facilitators that were encoun-
tered during the implementation process.
Implementation strategies
All SISTER domains were represented, and all extracted
D&I strategies were matched to relevant SISTER strate-
gies However, not all SISTER strategies were represented
in the included studies. One hundred and eighty-four
D&I strategies (n = 184) were identified, correspond-
ing to 60 (80%) of the SISTER strategies. A range of
three through nineteen strategies were reported in any
one study. e most commonly reported SISTER strat-
egy (identified in 86% of studies) was: “Build partner-
ships (i.e., coalitions) to support implementation” (#21)
(Table4). Four SISTER strategies, previously recognized
as being highly important for D&I success were repre-
sented in the top 10 strategies [33]. ese were “Conduct
ongoing training” (#39), “Monitor the progress of the
implementation effort” (#9), “Provide ongoing consulta-
tion/coaching” (#44), and “Make training dynamic” (#43).
ese strategies occur in the domains of “Train and edu-
cate stakeholders” and “Use evaluative and iterative strat-
egies.” Four SISTER strategies previously described as
most feasible for successful D&I were also represented in
the top 10. ese were: “Make training dynamic” (#43),
“Distribute educational materials” (#42), “Facilitation/
Problem solving” (#12), and “Capture and share local
knowledge” (#22) (Table4).
Discussion
e purpose of this scoping review was to identify barri-
ers and mitigating D&I processes related to the adoption
and implementation of EBIs in Indigenous communities.
Analysis of the 23 included studies (conducted between
2004 and 2020) may contribute to our understanding of
common barriers and mitigating D&I models and strate-
gies used to successfully disseminate and implement EBIs
in Indigenous communities in the United States, Hawaii,
Pacific Islands, and Canada [8, 10, 12–32].
D&I models
e majority of the studies (76%) used a D&I model to
guide the dissemination and/or implementation of an
EBI. Such studies have increased in recent years with
66% of the included studies published since 2015. is
reflects the recognition of D&I to address existing and
emerging health disparities and is consistent with a
broader increase in D&I research. e most frequently
reported model was Community-Based Participatory
Research (CBPR) (n = 11), which encompasses an array
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 25 of 29
Saccaetal. Implementation Science (2022) 17:18
of principles consistent with partnering with Indigenous
minorities [70]. A recent systematic review by Julian
McFarlane etal. (2021) [71] highlighted the large increase
in the number of CBPR-related studies targeting a broad
racial and ethnic representation in research. More than
85% of these studies saw statistically positive outcomes
when applying CBPR methods, particularly community
partner participation in study advisory committees, data
collection, the development of interventions, and partici-
pant recruitment [65].
CBPR aims to (1) recognize the Indigenous commu-
nity as a unit of identity, (2) build on the community’s
strengths and resources, (3) facilitate collaborative part-
nerships in all phases of the research, (4) integrate local
knowledge and actions that benefit all partners, (5)
empower community members to address social ine-
qualities, (6) involve a cyclical and iterative process, (7)
address health from both positive and ecological per-
spectives, and (8) disseminate findings and knowledge
gained to all partners [72]. ese principles represent an
important foundation to guide ethical D&I studies and
are complementary with common reported strategies
(described below). Yet CBPR is not without limitations
and may not account for the specific array of facilita-
tion strategies and prescriptive steps associated with
many D&I models [70]. e frequency of application of
D&I models other than CBPR was relatively low (n = 5).
Greater research on D&I models in Indigenous commu-
nities may enhance the quality of implementation plan-
ning and evaluation in those settings, building empirical
evidence for the utility of such models using traditional
CBPR approaches [73, 74]. Encouraging these systematic
approaches can also expand our knowledge-base on the
most salient D&I models and strategies for Indigenous
communities [73, 74].
Barriers andmitigating D&I strategies
is study reinforced the critical need to identify and
implement D&I strategies at all levels of the socio-eco-
logical model to address common barriers that impede
implementation efforts. e social milieu in which pro-
grams are deployed in Indigenous communities can be
complex and challenging. Principal among these chal-
lenges are consideration of social determinants of health,
perceptions of community trust, community skill sets,
and financial challenges. Social determinants of health
are important considerations when attempting to reach
underserved populations as they address issues related
to the complex mental, health, social, physical, and soci-
oeconomic issues of communities. ey can represent
major barriers to program implementation. Cited fac-
tors that can compromise program implementation in
Indigenous communities include poverty, homelessness
or residential instability, geographic remoteness with
accompanying challenges of access to healthcare service,
and greater transportation expenses. Across the litera-
ture, intentional information gathering and community
involvement were critical to program success. ese
included “assessing for readiness and identifying barri-
ers and facilitators,” “involving governing organizations,”
“informing local opinion leaders,” and “involving stu-
dents, family members, and other staff” [13–18, 23, 24,
26–31]. More broadly, the strategy of “changing or alter-
ing the environment” was employed where feasible, again
in consort with community stakeholders.
Complicating the challenge of social determinants is
the perception of trust between community members
and healthcare providers, or between program partici-
pants and the entity delivering the program (i.e. organi-
zation, academic institution, governmental agency).
ese relate to the barrier categories of “distrust” and
“lack of integration with cultural values.” Building part-
nerships to support implementation was the most com-
monly cited SISTER strategy across the included studies
(86%). However, despite the importance of building part-
nerships in the community and sharing its local knowl-
edge, additional strategies are indicated. Most studies
(55%) reported organizational barriers related to involv-
ing the views and experiences of elders, community
health workers, families, and youth as part of the imple-
mentation process [13, 15, 20–22, 28, 30, 32]. Hearing the
community voice and attending to community needs can
further engender trust. e expertise of Indigenous com-
munity members, elders, and health planners, many of
whom have unique skills, particularly in the fields of cul-
tural adaptation, tailoring interventions, and appropriate
implementation is highly valued and can help to allevi-
ate community concerns [75] as well as smooth logis-
tics involved with navigating the complex tribal internal
review and research review boards necessary for collabo-
ration with external academic and research partners [8].
e studies mentioned other D&I strategies that can
promote cohesion around program implementation
at the organizational level. ese included recruiting
and retaining families through trust-building; ensuring
convenience of program offerings, forming local advi-
sory boards and task forces, creating cultural activi-
ties, and using mass media tools (newspaper, written
materials, and radio programs) to promote programs.
Organizational administration included attention to data
management; capacity-building efforts, prioritization
of strategies, and collaboration with academic research-
ers and regional stakeholders [8, 10, 12–32]. Frequently
cited was the need to elicit community support through
engagement of the community and Native stakehold-
ers in the planning and implementation process [13,
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 26 of 29
Saccaetal. Implementation Science (2022) 17:18
15, 20–22, 27, 28, 30, 32]. is is vital to aid in cultural
learning, integration of cultural values, and inclusion of
indigenous role models to optimize cultural compatibility
and the potential for sustained implementation. Native
stakeholders should be engaged in the planning phase to
ensure that their needs and desires are fulfilled [13, 15,
20–22, 28, 30, 32].
Staff training, personalized technical assistance, staff
commitment to engage youth, and continuous evaluation
of staff performance [8, 10, 12, 17, 23–25, 29, 30] are nec-
essary for sustained implementation of programs within
Indigenous communities. ese strategies can mitigate
the “Personnel Challenges and High Turnover” that was
cited in 65% of the studies [13–16, 18, 20–23, 25, 32].
High turnover rates can undermine personnel skills train-
ing due to the continuous loss of acquired talent and the
need to accustom new personnel to the community and
program material [13–16, 18, 20–23, 25, 32]. Insufficient
skills needed to deliver the program material were cited
as a common barrier. SISTER strategies included under
the two domains—“training and educating stakeholders”
and “developing stakeholder interrelationships”—could
help address those common barriers.
Funding is a continuous challenge affecting sustained
implementation. Funding issues were frequently reported
by Native stakeholders during interviews and focus
group sessions and emerged as a main theme in quali-
tative studies [13–15]. is included a lack of sustained
funding at the organizational level to increase research
outputs [12–18, 20, 22, 26]. is in turn led to a limited
availability of resources and thus the inability to maintain
programs outcomes for longer periods of time. Specific
financial barriers included high cost of salaries, housing,
transportation, and other mission fees needed to hire
social workers, program adopters and implementers, and
healthcare workers [13, 14, 20–23, 25, 32]. Accessing new
funding sources was a leading D&I strategy employed in
Native communities. Continuous delivery of program
resources and material is predicated on sustained finan-
cial support without which D&I efforts are hobbled [55].
Studies describing intervention implementation at the
policy level cited the importance of creating and imple-
menting new public health policies to overcome societal
and economic barriers. ese crosscut other socioeco-
logical levels and included the high costs of imported
goods and healthy foods, inadequate funding allocations
to healthcare systems, limited assistance for uninsured
clients, limited resources for chronic diseases, improper
management of historical oppression and trauma, infra-
structure shortcomings, and high levels of poverty [13,
15, 16, 18, 25]. All nine domains encompassing multiple
SISTER strategies were mentioned in the studies. Studies
on the effectiveness of D&I strategies in this domain are
limited [54, 61]. Future work could focus on the multi-
level policies that shape social determinants of health and
their impact on D&I outcomes in Indigenous settings.
Holistic approaches with culturally tailored strategies are
essential to overcome potential barriers.
Strengths & limitations
ese studies correspond highly to reported SISTER
strategies previously categorized as important and fea-
sible in non-indigenous contexts [61]. Four of five strat-
egies rated as most important were among the top ten
reported in this review. ese strategies included (1)
“Monitor the progress of the implementation effort” (#9);
(2) “Conduct ongoing training” (#39); (3) “Make training
dynamic” (#43); and (4) “Provide ongoing consultation/
coaching” (#44). e 5th strategy, “Improve implement-
ers’ buy-in” (#51), was not represented. Four of five
strategies rated as most feasible were among the top ten
reported in this review. ese included (1) “Capture and
share local knowledge” (#22), (2) Distribute educational
materials” (#42); (3) “Make training dynamic” (#43); and
(4) “Facilitation/Problem solving” (#12). e 5th strategy,
“Remind school personnel” (#53), was not represented
in any of the studies. Financial strategies categorized
under the domain “Use financial strategies” received a
low feasibility rating in Lyon etal. (2019) and were only
reported in a few of our studies [61]. is may reflect the
lack of funding that was identified as a barrier in 50% of
the studies [61].
Findings need to be interpreted in the context of
study limitations. First, despite a comprehensive search
of the most relevant psychosocial databases, this review
did not include tracing of reference lists in included
studies, hand-searches of journals, or grey literature.
Broader reviews are recommended that account for
these sources. Second, the D&I field is growing rap-
idly, so it is possible that some relevant studies were
not found due to inadvertent omission of search terms.
e mesh terms included as many technical D&I key-
words as possible and the collaboration of a research
librarian who imposed rigor in the protocols likely mit-
igated this concern. Future reviews are recommended
to include emerging terms from this rapidly evolving
field. ird, the scope of the current review was lim-
ited. Formal assessment of the quality of the included
studies was beyond scope and the inter-rater reliabil-
ity, though acceptable with domain and strategy corre-
spondence of 70% and 90% respectively, was based on
assessment of only eight (38%) of the included studies.
Fourth, matching the identified D&I strategies to the
SISTER strategies was challenging due to the diversity
of terms used to describe any given strategy. Consist-
ency of terminology represents a challenge for any
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 27 of 29
Saccaetal. Implementation Science (2022) 17:18
emerging field. Standardizing the nomenclature will be
important to enable clear research and practice guide-
lines for EBI implementation. Fifth, the use of SEM to
categorize barriers and contextual factors limits com-
parison to other D&I frameworks such as CFIR (Con-
solidated Framework for Implementation Research) or
EPIS (Exploration, Preparation, Implementation, Sus-
tainment). However, SEM categorization will inform
the selection of multilevel implementation strategies to
facilitate EBI uptake in Indigenous communities [52]. It
also provides an objective assessment agnostic of any
particular D&I framework [52]. Finally, the SISTER
strategies were originally developed based on studies
in non-Indigenous settings. Although the taxonomy is
comprehensive and provides a useful comparison for
non-indigenous settings, it may also miss cultural influ-
ences or D&I processes that are unique to Indigenous
communities. e similarity with findings from Lyon
etal. (2019) indicates some validity across cultural set-
tings [61]. Future studies are recommended to provide
guidance on which strategies to use to promote behav-
ior and health changes in Indigenous settings. e use
of existing accepted taxonomies in this study may pro-
vide guidance for future work.
Conclusion
is scoping review describes D&I efforts to translate
research and change practice in Indigenous communi-
ties across the USA and Canada. Results may contrib-
ute to a broader perspective of barriers and mitigating
strategies to inform and guide future D&I initiatives in
Indigenous communities, with a goal to reduce health
disparities in these populations. is study emphasized
ranks of barriers and related D&I strategies (matched to
the adapted SISTER strategies) that appear salient for
Indigenous communities including focusing on cultur-
ally relevant partnerships, trainings, evaluations, and
adaptation. e existing diversity in culture, beliefs, val-
ues, and resources across tribes and borders is a major
consideration for future D&I initiatives. Efforts to apply
D&I models and strategies are increasing within Native
communities as they are in non-indigenous communi-
ties. is study can guide researchers and community
partners using D&I models and strategies to improve
the reach and sustainability of evidence-based pro-
grams in Indigenous communities.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s13012- 022- 01190-y.
Additional le1.
Acknowledgements
The authors do not have any acknowledgments to declare.
Authors’ contributions
LS was the primary reviewer who carried out the preliminary search, set up
the Rayyan platform, extracted the data, and developed the draft of the man-
uscript. RS and CM were the secondary reviewers who helped out with data
collection, analysis, tabulation of information, and manuscript development.
MP and BH helped with data analysis and manuscript development. SCR, CJ,
and TL provided critical review of drafts of the manuscript. The author(s) read
and approved the final manuscript.
Funding
NIH/NIMHD 1R21MD013960-01A1
Native iCHAMPS: An Innovative Online Decision Support System for Increasing
Implementation of Effective Sexual Health Education in Tribal Communities.
PIs: Markham, Shegog, Peskin
Availability of data and materials
All data generated or analyzed during this study are included in this published
article [and its supplementary information files].
Declarations
Ethics approval and consent to participate
Not Applicable
Consent for publication
Not Applicable
Competing interests
The authors declare that they have no competing interests.
Author details
1 Center for Health Promotion and Disease Prevention, University of Texas
Health Science Center at Houston School of Public Health, 7000 Fannin,
Houston, TX 77030, USA. 2 Center for Health Promotion and Disease Preven-
tion, University of Texas Health Science Center School of Public Health in San
Antonio, 7411 John Smith Drive, Suite 1100, San Antonio, T X 78229, USA.
3 Northwest Portland Area Indian Health Board, 2121 SW Broadway Suite
300, Portland, OR 97201, USA. 4 Alaska Native Tribal Health Consortium, 4000
Ambassador Drive, Anchorage, AK 99508, USA. 5 Inter Tribal Council of Arizona,
Inc., 2214 North Central Avenue, Phoenix, AZ 85004, USA.
Received: 21 July 2021 Accepted: 18 January 2022
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