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Conteúdo (article):

Aplicações da teoria dos Caminhos de Impacto do Programa no campo da nutrição em saúde pública: uma revisão de escopo

Applications of the Program Impact Pathway theory in the field of public health nutrition: a scoping review

Aplicaciones de la teoría de las vías de impacto de los programas en el ámbito de la salud pública nutricional: una revisión del alcance


Daiane Sousa Melo, Departamento de Nutrição, Faculdade de Saúde Pública, Universidade de São Paulo. Av. Dr. Arnaldo, 715 - Cerqueira César, São Paulo - SP, 01246-904, Brasil. Tel.: +55 11 3061-8100 e-mail: dsousamelo@gmail.com; ORCID: https://orcid.org/0000-0002-0560-5645

Gabriela Buccini, Department of Social and Behavioral Health, School of Public Health, University of Nevada Las Vegas, 4700 S. Maryland Pkwy. Ste. 335, Las Vegas, NV 89119, USA. Tel.: +1 203-512-7665 e-mail: gabriela.buccini@unlv.edu; ORCID: https://orcid.org/0000-0001-6008-0987

Sonia Isoyama Venancio, Coordenação Geral de Atenção à Saúde das Crianças, Adolescentes e Jovens; Ministério da Saúde, SRTV 702, 5º andar, Brasília, DF 70058-900. Tel:+55 61 3315-9071 e-mail: sonia.venancio@saude.gov.br; ORCID: https://orcid.org/0000-0001-7147-3292

RESUMO

A teoria dos Caminhos de Impacto do Programa (CIPs) representa a arquitetura e mecanismos causais pelos quais um programa alcança os resultados pretendidos. Buscou-se identificar as principais aplicações dos CIPs no campo da nutrição em saúde pública. A revisão de escopo selecionou 24 estudos em março de 2024. Foram identificados quatro objetivos da aplicação dos CIPs: Conhecer os processos e identificar mediadores. Identificar pontos críticos de controle da qualidade. Guiar a coleta de dados e definir indicadores de avaliação dos programas. Analisar os processos, adaptações e a fidelidade da implementação. As análises utilizam cinco etapas metodológicas: I) elaborar o diagrama inicial dos CIPs; II) confirmar/revisar o diagrama dos CIPs; III) identificar indicadores de avaliação; IV) comparar o processo de implementação com o diagrama dos CIPs; e V) avaliar desfechos ou impacto tendo como base análises dos CIPs. Em conclusão, a análise dos CIPs tem amplas possibilidades de aplicações e a metodologia de análise interativa apoia os gestores dos programas no processo de implementação.

Palavras-chave: Nutrição em Saúde Pública, Ciência de Implementação, Caminhos de Impacto do Programa

ABSTRACT
The Program Impact Pathway (PIP) theory represents the architecture and causal mechanisms by which a program achieves its intended outcomes. We sought to identify and analyze the main applications of PIPs in the public health nutrition field. This scoping review selected 24 studies in March 2024. Four objectives for applying PIPs were identified: To ascertain the processes and identify mediators. To identify critical quality control points. To guide data collection and define program evaluation indicators. To analyze the processes, adaptations, and fidelity of implementation. The analyses use five methodological steps: I) construct the initial PIP diagram; II) confirm/revise the PIP diagram; III) identify evaluation indicators; IV) compare the implementation process with the PIP diagram; and V) evaluate outcomes or impact based on PIP analysis. In conclusion, PIP analysis offers immense possibilities for application, and the interactive analysis methodology supports program managers in the implementation process.

Keywords: Public Health Nutrition, Implementation Science, Program Impact Pathways

RESUMEN

La teoría de las Vías de Impacto de los Programas (VIPs) representa la arquitectura y los mecanismos causales mediante los cuales un programa alcanza los resultados previstos. Se buscó identificar las principales aplicaciones de las VIPs en el campo de la nutrición en salud pública. La revisión de alcance seleccionó 24 estudios en marzo de 2024. Se identificaron cuatro objetivos para la aplicación de las VIPs: Conocer los procesos e identificar mediadores. Identificar puntos críticos de control de calidad. Orientar la recogida de datos y definir los indicadores de evaluación del programa. Analizar los procesos, las adaptaciones y la fidelidad de la aplicación. Los análisis utilizan cinco pasos metodológicos: I) elaborar el diagrama inicial de las VIPs; II) confirmar/revisar el diagrama de las VIPs; III) identificar los indicadores de evaluación; IV) comparar el proceso de implementación con el diagrama de las VIPs; y V) evaluar los resultados o el impacto basándose en los análisis de las VIPs. En conclusión, el análisis de las VIPs tiene amplias posibilidades de aplicación y la metodología de análisis interactivo ayuda a los gestores de programas en el proceso de implementación.

Palabras clave: Nutrición en Salud Pública, Ciencia de la Implementación, Vías de Impacto de Programas


INTRODUCTION

Dissemination and implementation research uses theories and frameworks to guide the analysis and evaluation of programs and public policies 1,2, helping improve the cycle of these policies, from conception to adoption and evaluation 3. More than 60 theories, models, and frameworks are described in the literature to guide the studies. These instruments have different assumptions, objectives, and other characteristics. Despite the lack of unanimity on how to select an approach or how to combine them, Per Nilsen proposed three overarching objectives for these approaches: (1) describe and/or guide the process of translating research into practice (ex. procedural models), (2) understanding and/or explaining what influences implementation outcomes (e.g., determinant framework, classical, or implementation theories), and (3) evaluating implementation (e.g., evaluation frameworks) 1. One of these procedural theories is the “Program Impact Pathway” (PIP) theory, the focus of this study. The objective of this study was to identify the objectives of the application of the PIP theory 4.
The PIP theory was initially applied in 2011 to analyze programs that promote the nutrition and development of children in Peru. PIP diagrams were developed with the intention of going beyond static input and output models, representing the program architecture and focusing on causal mechanisms 4,5. Thus, the diagram describes the path of an intervention (of a program or policy), from the initial activities – called inputs – through the scheduled delivery, at the community, household, or individual level, to the desired impacts 4.
In 2014, experts on the subject synthesized the necessary steps of applying PIPs in public health and nutrition programs 5. The guidelines focused on conducting interviews and interactive workshops to develop the diagrams. These interactions included researchers who were experts in implementation research and key program stakeholders, such as policy managers, program managers, frontline workers, and program beneficiaries. This process aimed to identify influences along the implementation paths and contexts, as well as to define evaluation indicators of programs 5.
Some studies published between 2013 and 2019 indicate that the development of the PIP theory was a breakthrough to analyze maternal and child nutrition and health programs, increasing understanding about what is needed to improve community counseling practices and reduce child mortality in low- and middle-income countries 5-10. Despite the positive results, the diagrams elaborated in the studies and analysis methods displayed notable differences and adaptations. This could be because an update of the recommendations describing a standardization in the methodology was published only by 2022. In addition, no publications in Portuguese have been identified to date that guide the use of this theory, which may limit its application in Latin American countries, a region that significantly needs to improve the food and nutritional security of the population 11.
Hence, synthesizing more recent evidence from the applications of PIP theory to support future implementation studies in the field of public health nutrition, and, consequently, the effective implementation of evidence-based interventions is relevant 3,5,12. To identify and analyze the main applications of PIPs, the specific objectives investigated are: (1) identify the objectives of the use of PIPs in the area of in public health nutrition, (2) group the main methodological steps adopted to analyze PIPs, and (3) map the utilities and limitations of the use of PIPs.

METHODS
A scoping review was conducted following the methodological framework of the Joanna Briggs Institute - JBI 13. A study protocol was developed defining the objectives, methods, and proposal for presenting the results. This study was part of a doctoral research, so the protocol was not published due to the schedule of the project. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used to organize and report the manuscript (Annex A) 14.

Research question

The acronym PCC (population, concept, and context) was used to guide the research question and inclusion criteria.
Research question: “How has the Program Impact Pathway theory been applied in implementation studies that analyzed health and nutrition programs?”
Population: Program beneficiaries and stakeholders (frontline professionals, implementers, managers of health departments, among others involved in implementation).
Concept: Studies that analyzed programs (including interventions, actions, projects, strategies, policies) for the promotion and protection of health and nutrition, in their different determinants, using the PIP theory in implementation research.
Context: Studies conducted in any country, with programs analyzed in different scenarios (communities, health services, education services, among others).

Eligibility criteria

Reports published in any year, in Portuguese and English, were included, as these are the authors’ languages. Review studies, study protocols, and studies that addressed topics unrelated to the use of PIPs in public health nutrition were excluded. Studies with qualitative approaches to implementation research were included. Primary studies of different designs, such as case, cross-sectional, and longitudinal studies, as well as dissertations and technical reports from the gray literature that described the implementation analyses performed, were considered eligible.

Data source

Searches were carried out in MEDLINE/PubMed, Virtual Health Library (VHL), and Embase databases. The database search was conducted in January 2022 and updated in March 2024, using the keywords “program impact pathway” or “program impact pathways” and “implementation” and “health”. The terms used in the three databases and the number of references retrieved are presented in Supplementary Material 1. In the reports selected for full reading, a manual search was performed in the list of references to identify additional studies.

Process of selection and extraction of evidence

In the step of identifying the records, the first author (D.S.M.) used the free web tool Rayyan to exclude duplicate records. Then, that author screened to select by titles and abstracts. In a second screening step, the selected records were evaluated for eligibility through full reading of the texts. In the selected reports, a manual search was performed in their bibliographic references to identify additional records. For the additional records located, the first author (D.S.M.) read the abstracts and the full text to assess eligibility. The selection results were discussed with a second researcher (S.I.V.) experienced in conducting systematic reviews. There was no need to contact the authors of the primary studies for further information.
One author (D.S.M.) followed planned steps in the protocol to extract information from the included reports (Figure 1). A spreadsheet was used that pre-determined the relevant items for data extraction. The spreadsheet was perfected during the extraction of the first three articles. The extracted data were organized into general characteristics of the selected studies (Year of publication, Journal, Country of the study, Country income, Conflict of interest, Funding), characteristics of the programs/ interventions (Intervention/Program name, Implementation level, Implementation area, Beneficiary population), description of the objectives and methods of the studies, and description of the discussions and conclusions about the PIPs. Additionally, the figures of the PIP diagrams of the studies were saved to identify similarities between them and propose a model to synthesize the main structural elements of a PIP diagram.
[insert Figure 1 here]
Data synthesis

The descriptive data extracted about the objectives and methods of the studies, and discussions and conclusions about the PIPs were organized by the first author (D.S.M.) to group similarities through a qualitative analysis 15. First, codes were opened to define the objectives of applying PIP theory in the studies and identify the steps for implementation analysis using PIP theory. After opening the codes, a new reading of the data was made by three authors (D.S.M., S.I.V., and G.B.) to confirm the defined categories. Second, a narrative synthesis of the data extracted from the discussion and conclusion of the studies was written to point out the utilities and limitations of the PIP theory for the implementation analysis. This synthesis was made taking care not to make premature conclusions. For this, three authors (D.S.M., S.I.V., and G.B.) checked the extracted data and reviewed the established generalizations. In the end, the synthesis was organized according to the objectives of the applied PIPs. According to the PRISMA-ScR, the evaluation of the methodological quality of primary studies gathered by a standardized instrument is not required in scoping reviews 14. Therefore, as this study focused on mapping the applications of PIPs, no evaluation of the methodological quality of the included studies was performed. Finally, tables were prepared to present the descriptive results and figures to synthesize the categories identified in the analyses.

RESULTS

Selection of the studies

The flowchart in Figure 2 shows how the reports were selected. We found 720 records in the databases, of which 24 duplicates were excluded, and the remainder were screened by title and abstract. After screening, the 664 records that did not meet the inclusion criteria were excluded. Thus, 32 reports were evaluated for eligibility, of which 15 were selected. The reference list of the 32 reports was checked, and 34 new reports were identified. After screening by abstracts and rapid reading of the texts, 13 were assessed for eligibility, of which 9 were selected. The list of the 21 reports evaluated for eligibility, but excluded, and the justifications for exclusion are described in Supplementary Material 2. Finally, the information extracted from 24 reports (21 articles, two technical reports, and a master’s thesis) was included in the synthesis of the results.

[insert Figure 2 here]

Characteristics of studies

Table 1 shows some characteristics and objectives of the selected reports 4-8,10,16-33. The reports were published between 2011 and 2022 in health-related journals, with the “Food and Nutrition Bulletin” being the most frequent (n=6; 25.0%). Most studies were carried out in lower-middle-income (n=8; 33.3%) and low-income (n=6; 25.0%) countries, according to World Bank data for 2022 34. Most reports (n=22; 91.6%) cited the absence of conflicts of interest and funding received to carry out the research (20; n=83.3%). Most analyzed programs or interventions were implemented at the district (n=8; 33.3%) or national scope (n=7; 29.2%). Urban, rural, or semi-urban communities were the focal location of the implementation of the intervention or program for the majority of the studies (n=13; 54.2%). The beneficiary populations of the programs were children under five years of age and their families (n=20; 83.3%), pregnant women (n=11; 45.8%), or children and adolescents attending schools (n=3, 12.5%).

[insert Table 1 here]

Summary of results

1. Objectives for applying the PIP theory: Four categories of study objectives were identified: I) Know the processes and identify mediators (n=11; 45.8%). II) Identify critical quality control points (n=6; 25.0%). III) Guide data collection and define program evaluation indicators (n=16; 66.6%). IV) Analyze the implementation processes, adaptations, and fidelity (n=6; 25.0%). Several studies had more than one of the objectives.

2. Steps for implementation analysis: Five main methodological steps were synthesized to conduct the implementation analysis of programs or interventions using PIPs (Figure 3): I) prepare the initial PIP diagram; II) confirm/revise the PIP diagram; III) identify evaluation indicators of the interventions; IV) compare the implementation process with the PIP diagram; and V) evaluate outcomes or impact based on PIP analyses. The five stages took place in an interactive process with the participation of several key implementation actors. For this, the authors used multiple data production instruments, described below:
[insert Figure 3 here]

2.1 Prepare the initial diagram of PIPs. Most studies conducted documentary analysis of reports, guidelines, or program manuals to describe the hypothetical paths for the impact of the program 4,6,8,10,18,19,25-32. Many researchers used interviews and/or conversations in workshops, groups, and implementation stakeholder meetings to understand how programs worked 4-6,8,10,16,17,19-21,25-29. In two studies, direct observation of community actions was made 4,8. In five studies, a narrative of the Logical Models of the programs was constructed, which later guided the development of the PIP theory 5,20,21,25,33. The main participants were political actors (government and health department representatives), implementation team (national, regional, local managers, and frontline workers), study authors, and implementation science experts 4-6,8,10,16,17,19-21,25-29. The information collected by the contact with key actors allowed the development of the PIP diagram with more details about the implementation at different levels, i.e., national, regional, and local.
2.2. Confirm/revise the PIP diagram. This step was based on the dialogue between researchers and key implementation actors, in addition to the support of experts, in some cases. Through interviews, workshops, and meetings, the authors identified the participants\' impressions and improved the diagram to represent with greater reliability the real scenario of implementation of the programs 5,8,10,16,21,24,25,27,29-33. Participation of experts from the areas of health, nutrition, and implementation science in a workshop to refine the diagram was cited in seven studies 5,18,20,21,24,25,29. Field observation 20 and documentary analysis 10,18,25 were also used. In one study, the PIP diagram was revised after evaluating the impact of the program to represent a version of the program with proven effectiveness for large-scale implementation 7. The iterative review of the PIPs allowed identification of critical points for quality control of the programs, bottlenecks in the implementation, and mediating or facilitating aspects.
As a result of steps I and II, the authors produced figures containing the PIP diagram of the programs. Figure 4 summarizes a model of the structural elements of the identified diagrams. The diagrams of most of the studies published between 2011 and 2019 (n=17; 70.8%) described detailed program activities, connected by arrows. Boxes in different prominent forms presented the mediators of the implementation, the activities, and the evaluation scope of the study in question 8,16,29. The diagrams of the six most recent publications (2019 to 2022) include columns that organize the structure into: Inputs, Process, Outputs, Outcomes, and Impacts. These elements clarify the relationship between program activities and implementation stages 10,27,29,31-33. Other details were presented to describe better the paths or obstacles to the impact of the program, such as the level of governance and implementation phases 27,31,33. The main implementation mediators described in the diagrams were “barriers”, “facilitators”, “contextual factors”, “assumptions”, and “critical control points” 4,9,18,20,21,31,33. A study included indicators in the diagram for evaluating the program implementation fidelity 23. Detailed definitions of these elements are described in Figure 4.
[insert Figure 4 here]

2.3. Identify program evaluation indicators. The PIP diagram was the basis for identifying evaluation indicators in fifteen studies 5,6,8,10,16,17,20,21,23,24,27,28,31. One of the most used ways to define indicators was the discussion between the studies’ co-authors and professionals involved in implementing the programs (national, regional, and local managers and frontline workers). Four studies used the SMART acronym approach (Specific, Measurable, Achievable, Achievable, Relevant, Timely) and expert support in a workshop to identify three to five indicators used in the program and to assess their impact. This decision was informed by the analysis of the PIPs, and in the end, a project was proposed to evaluate the programs 5,20,21,25. This approach was useful for selecting impact indicators, such as healthy lifestyle indicators (percentage of intervention participants who increased vegetable and fruit consumption) and qualitative outcome indicators (percentage of participants who engaged and felt satisfied with the nutrition education intervention) 5,19.
2.4. Compare the implementation process with the PIP diagram. The main data production instruments used in this stage were interviews with frontline workers and beneficiaries, along with field observations, as reported in seven studies 6,8,10,16,19,22,23,26,27. Meetings and/or interviews with management-level stakeholders were also conducted in three studies 7,8,31. One study conducted a focus group to gain deeper insights into stakeholders’ views 16. In summary, the researchers sought to identify: 1) the impressions of managers (national, regional, and local) and frontline workers (health professionals, community consultants, volunteers) on the delivery of the program, as well as the barriers and facilitators for its execution; 2) the impressions of the beneficiaries (mothers, families, community members) about the usefulness of the program; 3) the factors that influence the use of the practices promoted by the program; and 4) the fidelity of the program delivery compared to the guiding documents.
2.5. Evaluate outcomes and impact based on the PIP analysis. In several studies, the PIP analysis was incorporated into broader evaluation/efficacy studies, which included collecting monitoring information and evaluating the programs’ impact. The main instruments for data production were interviews, household surveys with beneficiaries, and field observations 4,6-8,17,19,22,24,25,27,28,31. Some studies analyzed reports from frontline workers 7,24 and data from surveillance systems 17. Five studies conducted a randomized efficacy trial 19,24,27,28,31. In general, the studies employed mixed research methods to advance program evaluation.

3. Utilities and limitations of PIP theory for implementation analysis: This section summarizes the discussions and conclusions of the studies about the utilities and limitations of PIPs, organized into the four application objectives of the PIPs.
3.1 Understand the processes and identify mediators. The diagram was a useful theoretical framework to explain the pathways followed to reach the results 16,29,25. The participation of program implementers and other key stakeholders ensured that the key components of the program were identified, as well as the processes and assumptions that must be in place 16,30-32. The analysis assessed the critical links between the implementation and use of the program 6,8,33. For example, in a study conducted in Peru, the PIP diagram provided a deeper insight into the mechanisms by which three nongovernmental programs promoted nutrition, food security, and child development. However, the authors clarified that the PIP analysis is an extensive work that requires a specific evaluation process 4. Other authors stated that the paths of program implementation may differ depending on the contextual factors and mediating phenomena that occur during large-scale implementation. Therefore, they concluded that components of the PIP diagram may require adaptations depending on the context and assumptions for implementation in different countries, regions, municipalities, or communities 10,32.
3.2 Identify critical quality control points. The researchers concluded that PIP analyses were fundamental to systematically identifying the strengths and weaknesses of each country’s program, which helped indicate the critical points that should be monitored 5,21,30,32. For example, in a study conducted in Brazil, the PIP analysis identified six critical monitoring points of a national strategy to promote breastfeeding and complementary feeding of children under two years old 32. Similarly, Buccini et al. (2019) 10 identified through the PIP analysis eight critical points that can mitigate or promote the impact of breastfeeding promotion programs in Mexico and Ghana. According to the authors, the perceptions of the participants interviewed were fundamental to providing evidence and confirming the critical points for the implementation, replication, and expansion of the programs 10,18,30,32. However, the authors argue that, when analyzing a large-scale program, the generalization of PIP analysis is limited. Therefore, they recommend continuing research with implementers from different regions and levels of implementation to understand the extent to which components and critical points are empirically associated with the success of the program or intervention 10,30,32.
3.3 Guide data collection and define program evaluation indicators. Several studies concluded that the use of PIP theory was successful in addressing research questions and methods, as well as supporting data analysis and interpretation 6,18,20,23,31. Some studies used PIPs to develop the interview script with key informants of the program 10,32,33 and to identify quantitative and qualitative indicators 7,16,20,21,27–29,31. As an example, a study analyzed the Health in Action program in Brazilian schools and proposed a way to optimize the evaluation indicators 21. The program has four main objectives for promoting education about healthy lifestyles and increasing students’ access to healthy food. The authors concluded that while the program had previously measured several important indicators of its impact, the PIP analysis provided insight into how to improve the measurement of these indicators and which impact indicators could be added. Thus, indicators of changes in students’ daily physical activity were introduced to the program model, considered a critical component to achieve the program’s overall goal of improving children’s health and nutritional status 21.
3.4 Analyze the processes, adaptations, and fidelity of the implementation. Some authors have argued that, although the PIP analysis does not point to a causal inference, it helps to identify and test assumptions about the fidelity and use of a program 33. Therefore, they concluded that the PIP analysis is useful to observe gaps in the adequacy of a program in relation to the planned one and to signal the need for adaptations to the specific contextual factor, which influences the acceptance and use of the program 26. For example, researchers found through the PIP analysis evidenced strong fidelity in the training and delivery of a community-based counseling intervention for infant feeding in Ethiopia 22. Two studies pointed out that the PIP diagram could help managers to continuously track and evaluate actions 17,22. However, other researchers stressed the need to update the diagram throughout the program to meet the objective of continuous evaluation, requiring investment in human resources for evaluations 31.

DISCUSSION

The scoping review mapped the applications of PIP theory in the analysis of program implementation processes in public health nutrition. This comprehensive approach stood out because it can be used with different objectives, such as identifying mediators, critical control points, indicators, or adaptations and evaluating the fidelity of the program. The analysis systematized five methodological steps that can guide the utilization, rigor, and replicability of PIP theory in evaluating program and policy implementation. The model diagram and the synthesis of the utilities and limitations produced in this study may promote the use of PIP theory in future implementation studies.
The PIP theory was identified as a participatory methodology that facilitates the engagement of implementers. Several studies have highlighted that the interactive and evaluative nature of PIPs can help identify processes and mediators of the implementation process and facilitate the consensus among stakeholders about how different program activities work in practice 4-6,8,10,16,17,19-21,25-29. The participatory process during evaluation in health care, including the field of nutrition in public health, benefits the proposal of implementation strategies to improve the quality of implementation and delivery of programs, as well as contributing to effectiveness and sustainability 39,40.
Among the identified application objectives, the use of PIPs to identify critical points and determine evaluation indicators is important. Thus, managers’ understanding of the processes of the program helps advance to the evaluation of effectiveness based on the PIP analysis 5,20. The combination with other implementation models and frameworks can provide greater specificity to this step. For example, recent studies have shown that the analysis of program theory combined with the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) may be adequate to guide dimensions of program implementation outcomes 41 and determine monitoring and evaluation indicators 42. The combination with the ERIC (Expert Recommendations for Implementation Change) taxonomy may be suitable for proposing implementation strategies to improve the quality of programs 43. The combining PIPs with the SMART approach (Specific, Measurable, Achievable, Achievable, Relevant, Timely) proved advantageous to clarify objectives and define goals for evaluation and monitoring 5,18,21,41 a program. Future studies could demonstrate whether combining the analysis and evaluation of programs based on PIP theory with other approaches to implementation research may be beneficial 12.
Few studies have demonstrated applications of PIPs to assess program fidelity. The PIP diagram is indicated as a model to increase the potential impact of programs 7,22. In fact, PIP theory has the potential to help researchers and managers identify the core functions (also called core elements or core components) of programs, i.e., those that cannot be changed to maintain program fidelity 44. Simultaneously, PIPs can guide identification of adaptations that are occurring, which program components are being adapted, or whether adaptations are necessary due to contextual factors 36,38,44. The documentation of adaptations in the implementation, in turn, is essential to achieve the fidelity and effectiveness of programs 45.
The mapping of the methodological steps of the PIPs elucidated that the diagram is not a simple flowchart of the program. There are advantages in using PIPs instead of traditional logical models, because logical models are generally limited to the linear cause-effect path of the program and do not include perceptions of the implementers in the design. Although some authors describe the PIP approach as requiring extensive work, the five methodological steps synthesized in this review contribute to its systematization and dissemination 5,20,21,25,33.
The synthesis of the utilities and limitations produced in this review demonstrated the important role of PIPs in explaining how programs are implemented in the real world, highlighting which activities work well and which require improving 8,10,16-21,24,25,27,29-33. The dissemination of studies using PIPs can help other researchers and implementers choose, replicate, and adapt interventions 37. Although the results identified in this study are limited to the applications of PIPs in public health nutrition programs, these results may be useful for studies that seek to analyze community-based interventions in other sectors, such as education and social assistance 37.
The important characteristics of the studies include the use of PIPs in 19 countries and the financial support received. According to the literature, most research approaches to implementation lack validation in low- and middle-income countries, which limits their reliability and usefulness 35. The increasing use of PIPs supports the recommendation for its use. Investment in the development and use of innovative approaches in implementation research promotes cooperation between academia and program leaders to replicate effective interventions 36,45. Therefore, the findings of the present review corroborate expanding the analysis of the implementation of public health nutrition programs in low- and middle-income countries, where food and nutritional security of families with young children is a priority for the survival and development of the population 11.
Although this scoping review has innovated and advanced in the systematization of important concepts in the field of implementation science, the results should be interpreted considering some methodological limitations. First, a specific search strategy was used, in Portuguese and English, in three databases, which may have restricted the number of studies identified. However, manual selection in the bibliographic reference lists of the included publications facilitated the inclusion of studies that were not identified in the original database search. Thus, the objectives of using PIPs and methodological steps systematized in this study are limited to the scope of evidence identified by our search. Second, the selection and extraction of study data were conducted by only one researcher. This may have added bias or limited data extraction; however, to minimize this bias, two experienced authors performed a critical analysis of the synthesized data, provided support in organizing the categories, and validated the final version of the results presented in the tables and figures. Third, the a priori of the scoping review protocol was not published despite the guidelines for conducting this type of study. However, the research team detailed the rigorous process for designing the research question, searching for evidence, and the selection process, which aimed to ensure transparent and reproducible methods. Fourth, the research and search questions were restricted to the field of nutrition in public health. Despite the limited scope, future studies could help identify the applicability of PIP analysis in other fields and sectors.
In conclusion, this study mapped four objectives for the use of PIP and five methodological steps for conducting the analysis. PIPs have been used to identify mediators and critical points, to determine goals and indicators, and to analyze adaptations and fidelity of the program. Among the methodological steps, a diagram model must be created in a participatory manner and is a critical step for further analysis. The PIP analysis theory has the limitation of being an extensive work; however, it helps the interaction between program managers and is adaptable to the context. Therefore, the PIP has the utility of supporting the application of strategies to overcome barriers to implementation and helping the optimization of results. Finally, future studies may indicate other advantages of applying PIPs to the analysis of multifaceted and multilevel programs, as well as deepen the discussion about their use in fidelity analysis and other forms of combination with models and frameworks that expand their analysis potential.

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