Search results

Database searches yielded 26,011 studies, of which 107 full texts were reviewed. During the full-text review, 99 articles were excluded: 41 studies did not mention a model or framework for assessing the implementation of the CPG, 31 studies evaluated only implementation strategies (isolated actions) rather than the implementation process itself, and 27 articles were not related to the implementation assessment. Therefore, eight studies were included in the data analysis. The updated search did not reveal additional relevant studies. The main reason for study exclusion was that they did not use models or frameworks to assess CPG implementation. Additionally, four methodological guidelines were included from the manual search (Fig. 1).

Fig. 1

PRISMA diagram. Acronyms: ADH—Australian Department of Health, CINAHL—Cumulative Index to Nursing and Allied Health Literature, CDC—Centers for Disease Control and Prevention, CRD—Centre for Reviews and Dissemination, GIN—Guidelines International Networks, HSE—Health Systems Evidence, IOM—Institute of Medicine, JBI—The Joanna Briggs Institute, MHB—Ministry of Health of Brazil, NICE—National Institute for Health and Care Excellence, NHMRC—National Health and Medical Research Council, MSPS – Ministerio de Sanidad Y Política Social (Spain), SIGN—Scottish Intercollegiate Guidelines Network, VHL – Virtual Health Library, WHO—World Health Organization. Legend: Reason A –The study evaluated only implementation strategies (isolated actions) rather than the implementation process itself. Reason B – The study did not mention a model or framework for assessing the implementation of the intervention. Reason C – The study was not related to the implementation assessment. Adapted from Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71. For more information, visit:

Risk of bias assessment of studies

According to the JBI’s critical appraisal tools, the overall assessment of the studies indicates their acceptance for the systematic review.

The cross-sectional studies lacked clear information regarding "confounding factors" or "strategies to address confounding factors". This was understandable given the nature of the study, where such details are not typically included. However, the reviewers did not find this lack of information to be critical, allowing the studies to be included in the review. The results of this methodological quality assessment can be found in an additional file (see Additional file 5).

In the qualitative studies, there was some ambiguity regarding the questions: "Is there a statement locating the researcher culturally or theoretically?" and "Is the influence of the researcher on the research, and vice versa, addressed?". However, the reviewers decided to include the studies and deemed the methodological quality sufficient for the analysis in this article, based on the other information analyzed. The results of this methodological quality assessment can be found in an additional file (see Additional file 6).

Documents characteristics (Table 1)Table 1 Document characteristics and usage context of the models

The documents were directed to several continents: Australia/Oceania (4/12) [31, 33, 36, 37], North America (4/12 [30, 32, 38, 39], Europe (2/12 [29, 35] and Asia (2/12) [34, 40]. The types of documents were classified as cross-sectional studies (4/12) [29, 32, 34, 38], methodological guidelines (4/12) [33, 35,36,37], mixed methods studies (3/12) [30, 31, 39] or noncomparative studies (1/12) [40]. In terms of the instrument of evaluation, most of the documents used a survey/questionnaire (6/12) [29,30,31,32, 34, 38], while three (3/12) used qualitative instruments (interviews, group discussions) [30, 31, 39], one used a checklist [37], one used an audit [33] and three (3/12) did not define a specific instrument to measure [35, 36, 40].

Considering the clinical areas covered, most studies evaluated the implementation of nonspecific (general) clinical areas [29, 33, 35,36,37, 40]. However, some studies focused on specific clinical contexts, such as mental health [32, 38], oncology [39], fall prevention [31], spinal cord injury [30], and sexually transmitted infections [34].

Usage context of the models (Table 1)Specific objectives

All the studies highlighted the purpose of guiding the process of evaluating the implementation of CPGs, even if they evaluated CPGs from generic or different clinical areas.

Levels of use

The most common level of use of the models/frameworks identified to assess the implementation of CPGs was policy (6/12) [33, 35,36,37, 39, 40]. In this level, the model is used in a systematic way to evaluate all the processes involved in CPGs implementation and is primarily related to methodological guidelines. This was followed by the organizational level of use (5/12) [30,31,32, 38, 39], where the model is used to evaluate the implementation of CPGs in a specific institution, considering its specific environment. Finally, the clinical level of use (2/12) [29, 34] focuses on individual practice and the factors that can influence the implementation of CPGs by professionals.

Type of health service

Institutional services were predominant (5/12) [33, 35,36,37, 40] and included methodological guidelines and a study of model development and validation. Hospitals were the second most common type of health service (4/12) [29,30,31, 34], followed by ambulatorial (2/12) [32, 34] and community health services (1/12) [32]. Two studies did not specify which type of health service the assessment addressed [38, 39].

Target group

The focus of the target group was professionals directly involved in clinical practice (6/12) [29, 31, 32, 34, 38, 40], namely, health professionals and clinicians. Other less related stakeholders included guideline developers (2/12) [39, 40], health policy decision makers (1/12) [39], and healthcare organizations (1/12) [39]. The target group was not defined in the methodological guidelines, although all the mentioned stakeholders could be related to these documents.

Model and framework characteristicsModels and frameworks for assessing the implementation of CPGs

The Consolidated Framework for Implementation Research (CFIR) [31, 38] and the Promoting Action