There is strong direct evidence that the pressure to adopt an innovation, independent of perceptions of whether recipients need it or in response to a perceived problem, influences adoption and implementation, particularly in settings with strong external connections (see Outer Setting: Partnerships and Connections) (T. Greenhalgh, Robert, et al. 2004). External pressure may emanate from multiple entities in the Outer Setting (Dy et al. 2015), including the subconstructs below.