Opening the Black Box: A Causal Pathway Methodology for Precise Implementation Strategy Design

Abstract Background Despite the growing use of implementation frameworks, there is still limited understanding of how implementation strategies influence contextual determinants in order to produce desired outcomes. Closing this knowledge gap is essential for developing effective, theory-informed, and tailored implementation strategies. Methods This study presents a seven-step approach that links implementation determinants with adapted strategies using the Consolidated Framework for Implementation Research, the Implementation Outcomes Framework, the Behavior Change Techniques Taxonomy, and the Expert Recommendations for Implementing Change (ERIC). Causal pathway diagrams guided the process of articulating the hypothesized causal mechanisms. This methodology was applied during the pre-implementation phase of a study that aimed to integrate a computerized decision support system for preventing hospital-acquired pressure injuries in a Swiss university hospital. Results The process identified context-specific barriers and facilitators, prioritized determinants, and mapped them to implementation antecedents and mechanisms of action. Adapted and prioritized implementation strategies were co-designed with stakeholders. The result was a strategy bundle tailored to local context, validated through iterative stakeholder engagement. Conclusions This methodology provides a transparent, rigorous, and participatory approach to strategy development that can enhance implementation precision and contribute to theory building in implementation science. The integration of numerous frameworks and the incorporation of stakeholder input provides a replicable model for the design of context-sensitive implementation strategies.