Sustainability, spread, and scale in trials using audit and feedback: a theory-informed, secondary analysis of a systematic review

Celia Laur, Zeenat Ladak, Alix Hall, Nathan M. Solbak, Nicole Nathan, Shewit Buzuayne, Janet A. Curran, Rachel C. Shelton, Noah Ivers

Research output: Contribution to journalArticlepeer-review


Background: Audit and feedback (A&F) is a widely used implementation strategy to influence health professionals’ behavior that is often tested in implementation trials. This study examines how A&F trials describe sustainability, spread, and scale. Methods: This is a theory-informed, descriptive, secondary analysis of an update of the Cochrane systematic review of A&F trials, including all trials published since 2011. Keyword searches related to sustainability, spread, and scale were conducted. Trials with at least one keyword, and those identified from a forward citation search, were extracted to examine how they described sustainability, spread, and scale. Results were qualitatively analyzed using the Integrated Sustainability Framework (ISF) and the Framework for Going to Full Scale (FGFS). Results: From the larger review, n = 161 studies met eligibility criteria. Seventy-eight percent (n = 126) of trials included at least one keyword on sustainability, and 49% (n = 62) of those studies (39% overall) frequently mentioned sustainability based on inclusion of relevant text in multiple sections of the paper. For spread/scale, 62% (n = 100) of trials included at least one relevant keyword and 51% (n = 51) of those studies (31% overall) frequently mentioned spread/scale. A total of n = 38 studies from the forward citation search were included in the qualitative analysis. Although many studies mentioned the need to consider sustainability, there was limited detail on how this was planned, implemented, or assessed. The most frequent sustainability period duration was 12 months. Qualitative results mapped to the ISF, but not all determinants were represented. Strong alignment was found with the FGFS for phases of scale-up and support systems (infrastructure), but not for adoption mechanisms. New spread/scale themes included (1) aligning affordability and scalability; (2) balancing fidelity and scalability; and (3) balancing effect size and scalability. Conclusion: A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the benefits can continue. A deeper empirical understanding of the factors impacting A&F sustainability is needed. Scalability planning should go beyond cost and infrastructure to consider other adoption mechanisms, such as leadership, policy, and communication, that may support further scalability. Trial registration: Registered with Prospero in May 2022. CRD42022332606.

Original languageEnglish
Article number54
JournalImplementation Science
Issue number1
StatePublished - Dec 2023
Externally publishedYes


  • Audit and feedback
  • Implementation
  • Scale
  • Spread
  • Sustainability
  • Systematic review


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