Caregiver-mediated interventions to support self-regulation among infants and young children (0-5 years): a protocol for a realist review

INTRODUCTION

Self-regulation is a modifiable protective factor for lifespan mental and physical health outcomes. Early caregiver-mediated interventions to promote infant and child regulatory outcomes prevent long-term developmental, emotional and behavioural difficulties and improve outcomes such as school readiness, educational achievement and economic success. To harness the population health promise of these programmes, there is a need for more nuanced understanding of the impact of these interventions. The aim of this realist review is to understand how, why, under which circumstances and for whom, early caregiver-mediated interventions improve infant and child self-regulation. The research questions guiding this review were based on consultation with families and community organisations that provide early childhood and family services.

METHODS AND ANALYSIS

Realist reviews take a theory-driven and iterative approach to evidence synthesis, structured around continuous refinement of a programme theory. Programme theories specify context-mechanism-outcome configurations to explain what works, for whom, under which circumstances and how. Our initial programme theory is based on prior work in this field and will be refined through the review process. A working group, comprising service users, community organisation representatives, representatives from specific populations, clinicians and review team members will guide the evidence synthesis and interpretation, as well as the development and dissemination of recommendations based on the findings of the review. The review will involve searching: (i) electronic databases, (ii) connected papers, articles and citations and (iii) grey literature. Decisions to include evidence will be guided by judgements about their contribution to the programme theory and will be made by the research team, with input from the working group. Evidence synthesis will be reported using the Realist and MEta-narrative Evidence Synthesis: Evolving Standards guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is a review. Findings will be disseminated to our working group and through peer-reviewed publications and conference presentations.

REVIEW REGISTRATION NUMBER

The protocol is registered with Open Science Framework https://osf.io/5ce2z/registrations.

CRISPR-Cas9 Gene Editing in Yeast: A Molecular Biology and Bioinformatics Laboratory Module for Undergraduate and High School Students

CRISPR-Cas9 genome editing technology is widely used in scientific research and biotechnology. As this technology becomes a staple tool in life sciences research, it is increasingly important to incorporate it into biology curricula to train future scientists. To demonstrate the molecular underpinnings and some limitations of CRISPR-based gene editing, we designed a laboratory module to accompany a discussion-based course on genome editing for college and advanced high school biology students. The laboratory module uses CRISPR-Cas9 to target and inactivate the ADE2 gene in Saccharomyces cerevisiae so as to give red colonies, employing an inexpensive yeast model system with a phenotypic readout that is easily detectable without specialized equipment. Students begin by accessing the yeast ADE2 sequence in a genome database, applying their understanding of Cas9 activity to design guide RNA (gRNA) sequences, using a CRISPR analysis tool to compare predicted on- and off-target effects of various gRNAs, and presenting and explaining their choice of an optimal gRNA to disrupt the ADE2 gene. They then conduct yeast transformations using Cas9 and preselected gRNA plasmids with or without donor templates to explore the importance of DNA repair pathways in genome editing. Lastly, they analyze the observed editing rates across different gRNAs targeting ADE2, leading to a discussion of editing efficiency. This module engages students in experimental design, provides hands-on experience with CRISPR-Cas9 gene editing and collaborative data analysis, and stimulates discussion on the uses and limitations of CRISPR-based gene editing technology.

The chaperone-binding activity of the mitochondrial surface receptor Tom70 protects the cytosol against mitoprotein-induced stress

Most mitochondrial proteins are synthesized as precursors in the cytosol and post-translationally transported into mitochondria. The mitochondrial surface protein Tom70 acts at the interface of the cytosol and mitochondria. In vitro import experiments identified Tom70 as targeting receptor, particularly for hydrophobic carriers. Using in vivo methods and high-content screens, we revisit the question of Tom70 function and considerably expand the set of Tom70-dependent mitochondrial proteins. We demonstrate that the crucial activity of Tom70 is its ability to recruit cytosolic chaperones to the outer membrane. Indeed, tethering an unrelated chaperone-binding domain onto the mitochondrial surface complements most of the defects caused by Tom70 deletion. Tom70-mediated chaperone recruitment reduces the proteotoxicity of mitochondrial precursor proteins, particularly of hydrophobic inner membrane proteins. Thus, our work suggests that the predominant function of Tom70 is to tether cytosolic chaperones to the outer mitochondrial membrane, rather than to serve as a mitochondrion-specifying targeting receptor.

Improving Payment for Collaborative Mental Health Care in Primary Care

BACKGROUND

There is strong evidence supporting implementation of the Collaborative Care Model within primary care. Fee-for-service payment codes, published by Current Procedural Terminology in 2018, have made collaborative care separately reimbursable for the first time. These codes (ie, 99492-99494) reimburse for time spent per month by any member of the care team engaged in Collaborative Care, including behavioral care managers, primary care providers, and consulting psychiatrists. Time-based billing for these codes presents challenges for providers delivering Collaborative Care services.

OBJECTIVES

Based on experience from multiple health care organizations, we reflect on these challenges and provide suggestions for implementation and future refinement of the codes.

CONCLUSIONS

Further refinements to the codes are encouraged, including moving from a calendar month to a 30-day reimbursement cycle. In addition, we recommend payers adopt the new code proposed by the Centers for Medicare and Medicaid Services to account for smaller increments of time.

Does coaching matter? Examining the impact of specific practice facilitation strategies on implementation of quality improvement interventions in the Healthy Hearts in the Heartland study

BACKGROUND

Practice facilitation is a multicomponent implementation strategy used to improve the capacity for practices to address care quality and implementation gaps. We sought to assess whether practice facilitators use of coaching strategies aimed at improving self-sufficiency were associated with improved implementation of quality improvement (QI) interventions in the Healthy Hearts in the Heartland Study.

METHODS

We mapped 27 practice facilitation activities to a framework that classifies practice facilitation strategies by the degree to which the practice develops its own process expertise (Doing Tasks, Project Management, Consulting, Teaching, and Coaching) and then used regression tree analysis to group practices by facilitation strategies experienced. Kruskal-Wallis tests were used to assess whether practice groups identified by regression tree analysis were associated with successful implementation of QI interventions and practice and study context variables.

RESULTS

There was no association between number of strategies performed by practice facilitators and number of QI interventions implemented. Regression tree analysis identified 4 distinct practice groups based on the number of Project Management and Coaching strategies performed. The median number of interventions increased across the groups. Practices receiving > 4 project management and > 6 coaching activities implemented a median of 17 of 35 interventions. Groups did not differ significantly by practice size, association with a healthcare network, or practice type. Statistically significant differences in practice location, number and duration of facilitator visits, and early study termination emerged among the groups, compared to the overall practice population.

CONCLUSIONS

Practices that engage in more coaching-based strategies with practice facilitators are more likely to implement more QI interventions, and practice receptivity to these strategies was not dependent on basic practice demographics.

Innovative applications of informatics for families, systems, and health: Introduction to the special issue

The articles included in this special issue of Families, Systems, & Health on informatics represent distinct elements of health informatics relevant to the implementation and provision of clinical services. Informatics is the collection, analysis, and application of data for direct care decisions in health care and an interdisciplinary field that brings medicine together with computer, cognitive, and social sciences. We frame the contributions of the included articles within the framework of the Quadruple Aim for health care: better outcomes, lower costs, improved patient satisfaction, and improved work life of health care providers. The examples provided aim to show how health informatics provides opportunities to improve care delivered to patients at individual and system levels while both identifying and closing gaps in research addressing the management and use of information generated in the course of delivering health care. The articles in this special issue reflect the cutting edge of health care, research and technology, where there is as much risk as there is promise of delivering stability to our dynamic health care system. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Virtual Reality Job Interview Training in Transition Services: Results of a Single-Arm, Noncontrolled Effectiveness-Implementation Hybrid Trial

This study reports the results of a single-arm non-controlled, Type 3 hybrid effectiveness-implementation trial evaluating virtual reality job-interview training (VR-JIT) delivered in five pre-employment transition programs comprising 15 schools, 10 administrators, 23 teachers, and 279 youth ages 16-21 years receiving special education pre-employment transition services. Fidelity, expected implementation feasibility, and teacher and student acceptance of VR-JIT were high. Youth completed virtual interviews over six to eight weeks (M = 10.8, SD = 7.4). At the six-month follow-up, teachers reported that youth using VR-JIT had employment rates higher than current national employment rates for youth with disabilities. A multinomial logistic regression revealed VR-JIT engagement was associated with greater employment rates by six-month follow-up (OR=1.63, p=0.002). This study provides promising evidence that VR-JIT may be feasibly implemented with high fidelity in special education pre-employment transition services and can potentially enhance employment outcomes among transition-age youth receiving special education services.

Under‐recognition of pediatric hypertension diagnosis: Examination of 1 year of visits to community health centers

Pediatric hypertension is associated with significant target organ damage in children and cardiovascular morbidity in adulthood. Appropriate diagnosis and management per guideline recommendations are inconsistent. In this study, we determined the proportion of missed diagnosis of hypertension and prehypertension and appropriate follow‐up in pediatric patients, stratified by sex, age, race/ethnicity, and weight status. Based on the electronic health record (EHR) data from eight federally qualified health centers, among 62,982 children aged 3 to 18 years, 6233 (10%) had at least one abnormal blood pressure (BP) measurement over twelve months. Among those children whose recorded BPs met the criteria for prehypertension (N = 6178), 14.6% had a diagnosis in the EHR. These children were more likely to be White and have obesity compared with children who met the criteria but were not diagnosed with prehypertension. Among those who met the criteria for hypertension (N = 55), 41.8% had a diagnosis of hypertension in the EHR. Being diagnosed with hypertension was not associated with any examined patient characteristics. Over eleven months, 2837 children had BP ≥ 95th percentile on ≥ 1 visit. Only 13% had guideline‐adherent follow‐up within 1 month and were more likely to be older, female, and of Hispanic ethnicity or “other” race. Over six months, 2902 children had BP ≥ 90th percentile on one visit. 41% had guideline‐adherent follow‐up within 6 months and were more likely to be older, of either White, Hispanic, Asian race, or Hispanic ethnicity. In a community‐based setting, pediatric hypertension and prehypertension were persistently underdiagnosed with low adherence to recommended follow‐up.

Network interventions for managing the COVID-19 pandemic and sustaining economy

Sustaining economic activities while curbing the number of new coronavirus disease 2019 (COVID-19) cases until effective vaccines or treatments become available is a major public health and policy challenge. In this paper, we use agent-based simulations of a network-based susceptible-exposed-infectious-recovered (SEIR) model to investigate two network intervention strategies for mitigating the spread of transmission while maintaining economic activities. In the simulations, we assume that people engage in group activities in multiple sectors (e.g., going to work, going to a local grocery store), where they interact with others in the same group and potentially become infected. In the first strategy, each group is divided into two subgroups (e.g., a group of customers can only go to the grocery store in the morning, while another separate group of customers can only go in the afternoon). In the second strategy, we balance the number of group members across different groups within the same sector (e.g., every grocery store has the same number of customers). The simulation results show that the dividing groups strategy substantially reduces transmission, and the joint implementation of the two strategies could effectively bring the spread of transmission under control (i.e., effective reproduction number ≈ 1.0).

Implementation strategies for digital mental health interventions in health care settings

U.S. health care systems are tasked with alleviating the burden of mental health, but are frequently underprepared and lack workforce and resource capacity to deliver services to all in need. Digital mental health interventions (DMHIs) can increase access to evidence-based mental health care. However, DMHIs commonly do not fit into the day-to-day activities of the people who engage with them, resulting in a research-to-practice gap for DMHI implementation. For health care settings, differences between digital and traditional mental health services make alignment and integration challenging. Specialized attention is needed to improve the implementation of DMHIs in health care settings so that these services yield high uptake, engagement, and sustainment. The purpose of this article is to enhance efforts to integrate DMHIs in health care settings by proposing implementation strategies, selected and operationalized based on the discrete strategies established in the Expert Recommendations for Implementing Change project, that align to DMHI-specific barriers in these settings. Guidance is offered in how these strategies can be applied to DMHI implementation across four phases commonly distinguished in implementation science using the Exploration, Preparation, Implementation, Sustainment Framework. Next steps to advance research in this area and improve the research-to-practice gap for implementing DMHIs are recommended. Applying implementation strategies to DMHI implementation will enable psychologists to systematically evaluate this process, which can yield an enhanced understanding of the factors that facilitate implementation success and improve the translation of DMHIs from controlled trials to real-world settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

An effectiveness-implementation hybrid trial for informatics-based cancer symptom management

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Background: Oncology outpatients can facesignificant cancer- and treatment-related symptoms that compromise health related quality of life and quality health care. Although the burden of symptoms on patients’ lives are well-known, most health care systems are not ideally set up to relieve them. Patients are not typically drawn into meaningful engagement with the health care team in ways that enable symptom self-management. As a result, opportunities for early identification and treatment are lost, causing avoidable human suffering and cost. The Northwestern University IMPACT (NU IMPACT) project aims to evaluate the effectiveness and implementation of an informatics-driven symptom monitoring and web-based self-management intervention. The project uses PROMIS measures, integrated into the EHR, to trigger response and intervention. This presentation describes the effectiveness-implementation hybrid trial design and measurement of implementation. Methods: NU IMPACT will test the effectiveness and implementation of a system-wide symptom management intervention, across six adult hematology/oncology and gynecologic oncology outpatient clinics at Northwestern Memorial HealthCare, using a cluster randomized pragmatic roll-out implementation trial with an embedded individual-level randomized clinical trial. This unique design allows for a fully-powered randomized trial to establish the efficacy of the intervention, as well as a randomized test of implementation. We are enrolling approximately 6,000 patients in pre-implementation and 6,000 in post-implementation, with half of the latter group randomly assigned to enhanced symptom management, and the other half to usual care. Results: Implementation process is guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) model with evaluation following the RE-AIM framework. Particular focus is paid to adoption at the clinic and provider levels, the extent to which the intervention achieves meaningful reach to cancer patients, and the potential for sustainment. Additionally, we are testing and validating a newly developed method for tracking and reporting dynamic changes to implementation strategies. Conclusions: Achieving the aims of the NU IMPACT project is a critical step in the advancement of informatics-driven symptom management interventions for cancer patients. The innovative implementation trial design and measurement approach will aid in the rapid translation of findings to other healthcare systems. Clinical trial information: NCT03988543 .

Parenting and social-ecological correlates with children's health behaviours: A latent profile analysis

BACKGROUND

Paediatric obesity poses dangers to children's short and long-term health. Multi-level ecological models posit how children's health behaviours are influenced by interpersonal relationships.

OBJECTIVES

To identify profiles of individual and interpersonal health behaviours and parenting skills among caregivers and their children with elevated BMI.

METHODS

Participants were 240 children (63.7% Latino) ages 5 to 12 years with body mass index ≥85th percentile and their caregivers in a paediatric weight management intervention trial. A latent profile analysis was used to identify profiles among caregiver report of parenting skills; child physical activity, eating behaviours, and food and beverage choices; family mealtime, media and sleep routines; and parent health behaviours, and associations with food and housing insecurity.

RESULTS

A three-class model was chosen based on conceptual interpretation and model fit. Profiles were differentiated by parenting skills, child food choices, child physical activity habits, family mealtime, media, and sleep routines, and parent health behaviours. Food and housing insecurity were associated with class membership while child and caregiver anthropometrics were not.

CONCLUSIONS

Distinct profiles existed among this low-income, racially/ethnically diverse sample of children with elevated BMI. Such findings emphasize the importance of assessing individual and interpersonal influences and contextual factors on childhood obesity.

The Implementation Research Logic Model: a method for planning, executing, reporting, and synthesizing implementation projects

BACKGROUND

Numerous models, frameworks, and theories exist for specific aspects of implementation research, including for determinants, strategies, and outcomes. However, implementation research projects often fail to provide a coherent rationale or justification for how these aspects are selected and tested in relation to one another. Despite this need to better specify the conceptual linkages between the core elements involved in projects, few tools or methods have been developed to aid in this task. The Implementation Research Logic Model (IRLM) was created for this purpose and to enhance the rigor and transparency of describing the often-complex processes of improving the adoption of evidence-based interventions in healthcare delivery systems.

METHODS

The IRLM structure and guiding principles were developed through a series of preliminary activities with multiple investigators representing diverse implementation research projects in terms of contexts, research designs, and implementation strategies being evaluated. The utility of the IRLM was evaluated in the course of a 2-day training to over 130 implementation researchers and healthcare delivery system partners.

RESULTS

Preliminary work with the IRLM produced a core structure and multiple variations for common implementation research designs and situations, as well as guiding principles and suggestions for use. Results of the survey indicated a high utility of the IRLM for multiple purposes, such as improving rigor and reproducibility of projects; serving as a "roadmap" for how the project is to be carried out; clearly reporting and specifying how the project is to be conducted; and understanding the connections between determinants, strategies, mechanisms, and outcomes for their project.

CONCLUSIONS

The IRLM is a semi-structured, principle-guided tool designed to improve the specification, rigor, reproducibility, and testable causal pathways involved in implementation research projects. The IRLM can also aid implementation researchers and implementation partners in the planning and execution of practice change initiatives. Adaptation and refinement of the IRLM are ongoing, as is the development of resources for use and applications to diverse projects, to address the challenges of this complex scientific field.

Optimizing Health Information Technologies for Symptom Management in Cancer Patients and Survivors: Usability Evaluation

Background

Unmanaged cancer symptoms and treatment-related side effects can compromise long-term clinical outcomes and health-related quality of life. Health information technologies such as web-based platforms offer the possibility to supplement existing care and optimize symptom management.

Objective

This paper describes the development and usability of a web-based symptom management platform for cancer patients and survivors that will be implemented within a large health system.

Methods

A web-based symptom management platform was designed and evaluated via one-on-one usability testing sessions. The System Usability Scale (SUS), After Scenario Questionnaire (ASQ), and qualitative analysis of semistructured interviews were used to assess program usability.

Results

Ten cancer survivors and five cancer center staff members participated in usability testing sessions. The mean score on the SUS was 86.6 (SD 14.0), indicating above average usability. The mean score on the ASQ was 2.5 (SD 2.1), indicating relatively high satisfaction with the usability of the program. Qualitative analyses identified valued features of the program and recommendations for further improvements.

Conclusions

Cancer survivors and oncology care providers reported high levels of acceptability and usability in the initial development of a web-based symptom management platform for cancer survivors. Future work will test the effectiveness of this web-based platform.

The Family Check-Up 4 Health: Study protocol of a randomized type II hybrid effectiveness-implementation trial in integrated primary care (the healthy communities 4 healthy students study)

BACKGROUND

Parenting interventions like the Family Check-Up have demonstrated effects on child physical and behavioral health outcomes. However, access to these programs is limited, particularly for populations experiencing health disparities. Primary care settings have become recognized as a potential delivery system in which these programs may be implemented at scale. The purpose of this trial is to test the effectiveness of the Family Check-Up 4 Health (FCU4Health) program, an adaptation of the FCU for primary care, and assess program implementation in an integrated primary care setting.

METHODS

We will conduct a hybrid type 2 effectiveness-implementation trial in partnership with a primary care clinic in a low-income, majority Latino community. Families with 2- to 5-year-old children will be eligible to participate. Families will be randomized to receive the intervention (n = 130) or services as usual (n = 70) and will be assessed annually over three years. Outcomes are informed by the RE-AIM framework (i.e., reach, effectiveness, adoption, implementation, and maintenance). Effectiveness outcomes include child health behaviors (e.g., Dietary Screener Questionnaire), behavioral health (e.g., Strengths and Difficulties Questionnaire), and parenting (e.g., Proactive Parenting). Early stage implementation outcomes are also included (e.g., cost, acceptability, appropriateness, and feasibility). Effectiveness outcomes will be assessed via intent-to-treat (ITT) analyses. Implementation outcomes will be primarily descriptive with comparisons to prior trials of FCU4Health and the original FCU.

PROJECTED OUTCOMES

This trial will provide evidence related to the potential of integrated primary care settings to deliver evidence-based preventive interventions with a dual focus on behavioral and physical health.

Costs of preparing to implement a virtual reality job interview training programme in a community mental health agency: A budget impact analysis

RATIONAL, AIMS AND OBJECTIVES

Individual Placement and Support (IPS) is an evidence based strategy for facilitating employment among adults with severe mental illness (SMI) where staff may lead mock job interviews to prepare clients for real-world interviews (a method with limited scalability and cost effectiveness). A virtual reality job interview training program (VR-JIT)-delivered via the internet-has demonstrated efficacy for increasing employment among adults with SMI. Now, VR-JIT is being implemented with a community mental health agency (CMHA) and evaluated for its effectiveness within IPS. This study is a budget impact analysis, evaluating the costs of preparing a CMHA to implement VR-JIT.

METHOD

Implementation preparation occurred over 7 months from October 1, 2016 to April 30, 2017. CMHA staff (n = 15) and external research partners (n = 3) tracked their hours completing implementation preparation activities. Salaries plus a 28% fringe benefit rate were used to derive a per-hour salary amount for each individual and applied to each activity. Non-labor equipment costs were obtained from purchase receipts. A budget impact analysis evaluated the expenditures associated with preparing the CMHA to implement VRJIT.

RESULTS

The total implementation preparation costs equaled $25,482. Labor costs equaled $22,882 and non-labor costs equaled $2,600. In total, 655 person-hours were spent preparing for VR-JIT implementation (e.g., preparing lab space, training, and supervising operations).

CONCLUSIONS

This study presents an initial evaluation of the budget impact of preparing to implement VR-JIT in a CMHA. Cost considerations for future implementation preparation will be discussed. Given that the cost to prepare to implement an intervention can hinder its adoption, results provide an important analysis for decision-makers that may enhance uptake. Future work will determine the cost-effectiveness of VR-JIT implemented within IPS. This study is registered at http://clinicaltrials.gov, NCT = 03049813, "Virtual Reality Job Interview Training: An Enhancement to Supported Employment in Severe Mental Illness."

Enhancing vocational training in corrections: A type 1 hybrid randomized controlled trial protocol for evaluating virtual reality job interview training among returning citizens preparing for community re-entry

The Michigan Department of Corrections operates the Vocational Villages, which are skilled trades training programs set within prisons that include an immersive educational community using virtual reality, robotics, and other technologies to develop employable trades. An enhancement to the Vocational Villages could be an evidence-based job interview training component. Recently, we conducted a series of randomized controlled trials funded by the National Institute of Mental Health to evaluate the efficacy of virtual reality job interview training (VR-JIT). The results suggested that the use of VR-JIT was associated with improved job interview skills and a greater likelihood of receiving job offers within 6 months. The primary goal of this study is to report on the protocol we developed to evaluate the effectiveness of VR-JIT at improving interview skills, increasing job offers, and reducing recidivism when delivered within two Vocational Villages via a randomized controlled trial and process evaluation. Our aims are to: (1) evaluate whether services-as-usual in combination with VR-JIT, compared to services-as-usual alone, enhances employment outcomes and reduces recidivism among returning citizens enrolled in the Vocational Villages; (2) evaluate mechanisms of employment outcomes and explore mechanisms of recidivism; and (3) conduct a multilevel, mixed-method process evaluation of VR-JIT implementation to assess the adoptability, acceptability, scalability, feasibility, and implementation costs of VR-JIT.

Parenting Interventions in Pediatric Primary Care: A Systematic Review

CONTEXT

More than 4 decades of research indicate that parenting interventions are effective at preventing and treating mental, emotional, and behavioral disorders in children and adolescents. Pediatric primary care is a viable setting for delivery of these interventions.

OBJECTIVE

Previous meta-analyses have shown that behavioral interventions in primary care can improve clinical outcomes, but few reviews have been focused specifically on the implementation of parenting interventions in primary care. We aimed to fill this gap.

DATA SOURCES

We reviewed 6532 unique peer-reviewed articles published in PubMed, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo.

STUDY SELECTION

Articles were included if at least part of the intervention was delivered in or through primary care; parenting was targeted; and child-specific mental, emotional, and behavioral health outcomes were reported.

DATA EXTRACTION

Articles were reviewed in Covidence by 2 trained coders, with a third coder arbitrating discrepancies.

RESULTS

In our review of 40 studies, most studies were coded as a primary. Few researchers collected implementation outcomes, particularly those at the service delivery system level.

LIMITATIONS

Including only published articles could have resulted in underrepresentation of implementation-related data.

CONCLUSIONS

Parenting interventions delivered and implemented with fidelity in pediatric primary care could result in positive and equitable impacts on mental, emotional, and behavioral health outcomes for both parents and their children. Future research on the implementation strategies that can support adoption and sustained delivery of parenting interventions in primary care is needed if the field is to achieve population-level impact.

Optimizing the implementation of a population panel management intervention in safety-net clinics for pediatric hypertension (The OpTIMISe-Pediatric Hypertension Study)

BACKGROUND

Though clinical practice guidelines are available, the diagnosis of pediatric hypertension (HTN) is often missed. Management may not follow guidelines due to the measurement challenges in children, complexity of interpreting youth blood pressure standards that are dependent on height, age, and sex, familiarity with diagnostic criteria, and variable comfort with management of pediatric HTN among providers. Evidence suggests that wide adoption and adherence to pediatric HTN guidelines would result in lower cardiovascular disease and kidney damage in adulthood. The proposed project will develop an implementation strategy package to increase adherence to clinical practice guidelines for pediatric HTN within safety-net community health centers (CHCs). The centerpiece of which is a provider-facing population panel management (PPM) tool and point-of-care clinical decision support (CDS). Prior research indicates that multiple discrete implementation strategies (e.g., stakeholder involvement, readiness planning, training, ongoing audit and feedback) are needed to institute practice- and provider-level adoption of such tools.

METHODS

Using participatory research methods involving stakeholders from a practice-based research network of CHCs, with input from scientific advisors, the project aims to (1) employ user-centered design methods to tailor an existing CDS tool for use at the point of care and optimize cohort management with a PPM tool to support adherence to the latest pediatric HTN guidelines, and (2) use a stakeholder-driven method for selecting implementation strategies that support tool adoption and increase guideline-adherent physician behaviors. Multilevel process evaluation using surveys and key informant interview data will assess the acceptability, adoption, appropriateness, cost, and feasibility of the PPM tool and its multicomponent implementation strategy package. Usability testing will be conducted with the PPM tool to iteratively refine features and ensure proper functionality.

DISCUSSION

The proposed research has the potential to improve identification, diagnosis, and management of HTN in primary care settings for high-risk youth by assisting healthcare providers in implementing the American Academy of Pediatrics' 2017 guidelines using an EHR-integrated PPM tool with CDS. Should the strategy package for PPM tool adoption be successful for pediatric HTN, findings will be translatable to other settings and PPM of other chronic cardiovascular conditions affecting overall population health.

Redesigning Implementation Measurement for Monitoring and Quality Improvement in Community Delivery Settings

The field of prevention has established the potential to promote child adjustment across a wide array of outcomes. However, when evidence-based prevention programs have been delivered at scale in community settings, declines in implementation and outcomes have resulted. Maintaining high quality implementation is a critical challenge for the field. We describe steps towards the development of a practical system to monitor and support the high-quality implementation of evidence-based prevention programs in community settings. Research on the implementation of an evidence-based parenting program for divorcing families called the "New Beginnings Program" serves as an illustration of the promise of such a system. As a first step, we describe a multidimensional theoretical model of implementation that links aspects of program delivery with improvements in participant outcomes. We then describe research on the measurement of each of these implementation dimensions and test their relations to intended program outcomes. As a third step, we develop approaches to the assessment of these implementation constructs that are feasible to use in community settings and to establish their reliability and validity. We focus on the application of machine learning algorithms and web-based data collection systems to assess implementation and provide support for high quality delivery and positive outcomes. Examples are presented to demonstrate that valid and reliable measures can be collected using these methods. Finally, we envision how these measures can be used to develop an unobtrusive system to monitor implementation and provide feedback and support in real time to maintain high quality implementation and program outcomes.

Prevention and Management of Childhood Obesity and Its Psychological and Health Comorbidities

Childhood obesity has become a global pandemic in developed countries, leading to a host of medical conditions that contribute to increased morbidity and premature death. The causes of obesity in childhood and adolescence are complex and multifaceted, presenting researchers and clinicians with myriad challenges in preventing and managing the problem. This article reviews the state of the science for understanding the etiology of childhood obesity, the preventive interventions and treatment options for overweight and obesity, and the medical complications and co-occurring psychological conditions that result from excess adiposity, such as hypertension, nonalcoholic fatty liver disease, and depression. Interventions across the developmental span, varying risk levels, and service contexts (e.g.,community, school, home, health care systems) are reviewed. Future directions for research are offered with an emphasis on translational issues for taking evidence-based interventions to scale in a manner that will reduce the public health burden of the childhood obesity pandemic.

Translating evidence-based parenting programs for primary care: Stakeholder recommendations for sustainable implementation

AIMS

To translate evidence-based programs (EBP) for a new setting, attention must be given to the characteristics of the intervention and the local setting, as well as evidence that is compelling to decision-makers. This paper describes the history of a partnership and stakeholder recommendations to inform the adaptation of an EBP for primary care.

METHODS

We established a community advisory board (CAB) consisting of stakeholders with expertize in primary care delivery. A thematic analysis was conducted with fieldnotes and transcriptions from CAB meetings and regular meetings with participating clinics.

RESULTS

We found that (a) parenting programs with a focus on behavioral and physical health are appropriate for this setting, (b) variability in the structure of primary care means implementation must be tailorable, and (c) financial and organizational outcomes are compelling for decision-makers.

CONCLUSION

Factors related to the content and structure of evidence-based programs are uniquely related to distinct implementation outcomes of interest to key stakeholders.

Pragmatic adaptation of implementation research measures for a novel context and multiple professional roles: a factor analysis study

BACKGROUND

Although some advances have been made in recent years, the lack of measures remains a major challenge in the field of implementation research. This results in frequent adaptation of implementation measures for different contexts-including different types of respondents or professional roles-than those for which they were originally developed and validated. The psychometric properties of these adapted measures are often not rigorously evaluated or reported. In this study, we examined the internal consistency, factor structure, and structural invariance of four well-validated measures of inner setting factors across four groups of respondents. The items in these measures were adapted as part of an evaluation of a large-scale organizational change in a rehabilitation hospital, which involved transitioning to a new building and a new model of patient care, facilitated by a significant redesign of patient care and research spaces.

METHODS

Items were tailored for the context and perspective of different respondent groups and shortened for pragmatism. Confirmatory factor analysis was then used to test study hypotheses related to fit, internal consistency, and invariance across groups.

RESULTS

The survey was administered to approximately 1208 employees; 785 responded (65% response rate) across the roles of clinician, researcher, leader, support staff, or dual clinician and researcher. For each of the four scales, confirmatory factor analysis demonstrated adequate fit that largely replicated the original measure. However, a few items loaded poorly and were removed from the final models. Internal consistencies of the final scales were acceptable. For scales that were administered to multiple professional roles, factor structures were not statistically different across groups, indicating structural invariance.

CONCLUSIONS

The four inner setting measures were robust for use in this new context and across the multiple stakeholder groups surveyed. Shortening these measures did not significantly impair their measurement properties; however, as this study was cross sectional, future studies are required to evaluate the predictive validity and test-retest reliability of these measures. The successful use of adapted measures across contexts, across and between respondent groups, and with fewer items is encouraging, given the current emphasis on designing pragmatic implementation measures.

Designs and methods for implementation research: Advancing the mission of the CTSA program

INTRODUCTION

The US National Institutes of Health (NIH) established the Clinical and Translational Science Award (CTSA) program in response to the challenges of translating biomedical and behavioral interventions from discovery to real-world use. To address the challenge of translating evidence-based interventions (EBIs) into practice, the field of implementation science has emerged as a distinct discipline. With the distinction between EBI effectiveness research and implementation research comes differences in study design and methodology, shifting focus from clinical outcomes to the systems that support adoption and delivery of EBIs with fidelity.

METHODS

Implementation research designs share many of the foundational elements and assumptions of efficacy/effectiveness research. Designs and methods that are currently applied in implementation research include experimental, quasi-experimental, observational, hybrid effectiveness-implementation, simulation modeling, and configurational comparative methods.

RESULTS

Examples of specific research designs and methods illustrate their use in implementation science. We propose that the CTSA program takes advantage of the momentum of the field's capacity building in three ways: 1) integrate state-of-the-science implementation methods and designs into its existing body of research; 2) position itself at the forefront of advancing the science of implementation science by collaborating with other NIH institutes that share the goal of advancing implementation science; and 3) provide adequate training in implementation science.

CONCLUSIONS

As implementation methodologies mature, both implementation science and the CTSA program would greatly benefit from cross-fertilizing expertise and shared infrastructures that aim to advance healthcare in the USA and around the world.