Interventions in organizational and community context: a framework for building evidence on dissemination and implementation in health services research

Sexual Assault Response Team Goals and Motivations for Development

Sexual Assault Response Teams (SARTs) are community-based, multidisciplinary interventions that strive to coordinate the response to sexual assault. SARTs consist of sexual assault responders (e.g., rape crisis advocates, police, forensic examiners/Sexual Assault Nurse Examiners, and prosecutors) and seek to increase responder collaboration to improve survivors' help-seeking experiences. There is a lack of empirical research examining factors underlying SARTs' goals and what leads communities to form SARTs. Therefore, this study sought to examine the goals and motivations present in SART development using a multiple-methods approach with a national random sample of n = 172 SARTs. Exploratory factor analysis (EFA) was used to examine factors underlying SART goals, and qualitative thematic analysis was used to explore what motivators drove SART formation. Both qualitative and quantitative analyses underscored the importance of improving the accessibility and quality of services, improving the treatment of survivors, and increasing responder collaboration. The qualitative findings offered additional insight into the importance of community education and various community contextual factors (e.g., funding and policy requirements) that influence SARTs. Findings inform future research and practice on SART goals and functioning, such as how SART goals may relate to team structure, effectiveness, and capacity-building opportunities.

Bridging the gap of Inequity in Implementation Science: Adaptations of Group EBPs for those with Serious Mental Illness in the Public Sector

There are many group EBPs that are now listed as effective treatments for those with serious mental illness (SMI). Despite this, there are few of these group EBPs that are being delivered consistently in the public sector, causing disparity. This article reviews the challenges that relate to implementation science and those with SMI receiving group EBPs to help them live a life of meaning as they define. The article discusses the need for adaptations of EBPs as individuals with complex concerns need different approaches to implementation science. Next, the article conveys what core constructs of group EBPs have to be maintained as they are and what elements of EBPs need adapting to empower those with SMI in engagement. This article provides knowledge of practical application of implementation science approaches while providing dialectical behavior group therapy and cognitive behavior group therapy for psychosis adaptations for those with SMI in a public sector inpatient setting.

Stakeholder perceptions of factors contributing to effective implementation of exercise cardiac telerehabilitation in clinical practice

AIMS

Cardiac exercise telerehabilitation is effective and can be cost-effective for managing ischaemic heart disease, but implementation of evidence-based interventions in clinical practice remains a challenge. We aimed to identify factors that cardiac rehabilitation stakeholders perceived could influence the effectiveness of implementing an evidence-based, real-time remotely monitored cardiac exercise telerehabilitation intervention (REMOTE-CR).

METHODS AND RESULTS

Online interviews and focus groups were conducted with cardiac rehabilitation consumers (n = 16, 5 female, 61.1 ± 10.0 years), practitioners (n = 20, 14 female; 36.6 ± 11.8 years), and health service managers (n = 11, 7 female; 46.2 ± 9.2 years) recruited from one metropolitan and three inner-regional healthcare services in Western Victoria, Australia. Discussions were guided by two theoretical frameworks (Non-adoption, Abandonment, Scale-up, Spread, and Sustainability; Consolidated Framework for Implementation Research), and analysed thematically. Factors perceived to influence effective implementation of REMOTE-CR spanned all domains of the theoretical frameworks, related to six major themes (resources, change management, stakeholder targeting, knowledge, intervention design, security) and were largely consistent across study sites; however, the relative importance of each factor may vary between sites.

CONCLUSION

Effective implementation of exercise telerehabilitation interventions like REMOTE-CR will require a coordinated context-specific approach that considers factors across all levels of the healthcare system and implementation science frameworks. Key requirements include prioritizing resources, managing change, selecting target stakeholders, developing digital health capabilities, and selecting fit-for-purpose technologies that enable programme delivery objectives.

Adapting to the shifting landscape: Implications of climate change for malaria control: A review

Malaria, a global public health challenge, continues to affect millions of lives, particularly in regions where its transmission is endemic. The interplay between climate change and malaria dynamics has emerged as a critical concern, reshaping the landscape of this vector-borne disease. This review publication, titled "Adapting to the shifting landscape: Implications of climate change for malaria control," explores the multifaceted relationship between climate change and the control of malaria. The paper begins by dissecting the influence of climate change on malaria dynamics, including alterations in temperature, precipitation, and other climatic factors that impact the habitat and life cycle of malaria vectors. It delves into the evolving ecology and behavior of malaria vectors in response to changing climatic conditions, emphasizing the importance of understanding these adaptations. As a response to this shifting landscape, the review discusses adaptive strategies for malaria control, ranging from vector control measures to the utilization of climate data in early warning systems. Community engagement and education are highlighted as essential components of these strategies, recognizing the vital role of local communities in effective malaria control efforts. The paper also identifies future directions and research needs, underscoring the importance of staying ahead of the evolving climate-malaria relationship. This review underscores the urgency of adapting to the changing landscape of malaria transmission driven by climate change. It emphasizes the significance of proactively addressing climate-related challenges to enhance malaria control and protect the health and well-being of vulnerable populations.

Adaptability, Scalability and Sustainability (ASaS) of complex health interventions: a systematic review of theories, models and frameworks

BACKGROUND

Complex health interventions (CHIs) are increasingly used in public health, clinical research and education to reduce the burden of disease worldwide. Numerous theories, models and frameworks (TMFs) have been developed to support implementation of CHIs. This systematic review aims to identify and critique theoretical frameworks concerned with three features of implementation; adaptability, scalability and sustainability (ASaS). By dismantling the constituent theories, analysing their component concepts and then exploring factors that influence each theory the review team hopes to offer an enhanced understanding of considerations when implementing CHIs.

METHODS

This review searched PubMed MEDLINE, CINAHL, Web of Science, and Google Scholar for research investigating the TMFs of complex health interventions. Narrative synthesis was employed to examine factors that may influence the adaptability, scalability and sustainability of complex health interventions.

RESULTS

A total of 9763 studies were retrieved from the five databases (PubMed, MEDLINE, CINAHL, Web of Science, and Google Scholar). Following removal of duplicates and application of the eligibility criteria, 35 papers were eligible for inclusion. Influencing factors can be grouped within outer context (socio-political context; leadership funding, inter-organisational networks), inner context; (client advocacy; organisational characteristics), intervention characteristics (supervision, monitoring and evaluation), and bridging factors (individual adopter or provider characteristics).

CONCLUSION

This review confirms that identified TMFS do not typically include the three components of adaptability, scalability, and sustainability. Current approaches focus on high income countries or generic "whole world" approaches with few frameworks specific to low- and middle-income countries. The review offers a starting point for further exploration of adaptability, scalability and sustainability, within a low- and middle-income context.

TRIAL REGISTRATION

Not registered.

Strengths, challenges, and strategies for implementing pragmatic multicenter randomized controlled trials (RCTs): example of the Personalized Citizen Assistance for Social Participation (APIC) trial

BACKGROUND

Randomized controlled trials (RCTs) are rigorous scientific research designs for evaluating intervention effectiveness. However, implementing RCTs in a real-world context is challenging. To develop strategies to improve its application, it is essential to understand the strengths and challenges of this design. This study thus aimed to explore the strengths, challenges, and strategies for improving the implementation of a pragmatic multicenter, prospective, two-arm RCT evaluating the effects of the Personalized Citizen Assistance for Social Participation (Accompagnement-citoyen Personnalisé d'Intégration Communautaire: APIC; weekly 3-h personalized stimulation sessions given by a trained volunteer over a 12-month period) on older adults' health, social participation, and life satisfaction.

METHODS

A multiple case study was conducted with 14 participants, comprising one research assistant, seven coordinators, and six managers of six community organizations serving older adults, who implemented the APIC in the context of a RCT. Between 2017 and 2023, qualitative data were extracted from 24 group meetings, seven semi-directed interviews, emails exchanged with the research team, and one follow-up document.

RESULTS

Aged between 30 and 60 (median ± SIQR: 44.0 ± 6.3), most participants were women from organizations already offering social participation interventions for older adults and working with the public sector. Reported strengths of this RCT were its relevance in assessing an innovative intervention to support healthy aging, and the sharing of common goals, expertise, and strategies with community organizations. Challenges included difficulties recruiting older adults, resistance to potential control group assignments, design complexity, and efforts to mobilize and engage volunteers. The COVID-19 pandemic lockdown and health measures exacerbated challenges related to recruiting older adults and mobilizing volunteers and complicated delivery of the intervention. The strategies that mostly overcame difficulties in recruiting older adults were reducing sample size, simplifying recruitment procedures, emphasizing the health follow-up, extending partnerships, and recognizing and supporting volunteers better. Because of the lockdown and physical distancing measures, the intervention was also adapted for remote delivery, including via telephone or videoconferencing.

CONCLUSION

Knowledge of the strengths and challenges of pragmatic RCTs can contribute to the development of strategies to facilitate implementation studies and better evaluate health and social participation interventions delivered under real-life conditions.

TRIAL REGISTRATION

NCT03161860; Pre-results. Registered on May 22, 2017.

Implementation Science and Practice-Oriented Research: Convergence and Complementarity

Implementation science is the scientific study of methods to promote the uptake of research findings and other evidence-based practices in routine care, with the goal of improving the quality and effectiveness of health services (Bauer et al., 2015). In addition to this common goal, practice-oriented psychotherapy research (and researchers) and implementation science (and scientists) share a common focus on the people and the places where treatment happens. Thus, there exists strong potential for combining these two approaches. In this article, we provide a primer on implementation science for psychotherapy researchers and highlight important areas and examples of convergence and complementarity between implementation science and practice-oriented psychotherapy research. Specifically, we (a) define and describe the core features of implementation science; (b) discuss similarities and areas of complementarity between implementation science and practice-oriented psychotherapy research; (c) discuss a case example that exemplifies the integration of implementation science and practice-oriented research; and (d) propose directions for future research and collaborations that leverage both implementation science and practice-oriented research.

"Early intervention isn't an option, it's a necessity": learning from implementation facilitators and challenges from the rapid scaling of an early intervention eating disorders programme in England

Introduction

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has shown promising outcomes for young people with an eating disorder, leading to national scaling and implementation across England. Between 2020 and 2023, the national implementation of FREED was supported by the Academic Health Science Networks (AHSNs), which are publicly funded organisations with the mission to spread innovations at scale and pace. This study aimed to investigate the views and experiences of AHSN programme leads on the national roll-out of FREED and the perceived sustainability of the model.

Methods and results

Semi-structured interviews were conducted with 13 programme leads across the AHSNs with direct experience supporting the national implementation of FREED. Thematic analysis was adopted using a critical realist approach. Initial sub-themes were inductively generated and then organised under seven larger themes representing the domains of the Non-adoption, Abandonment, and Challenges to Scale-Up, Spread and Sustainability (NASSS) framework. Each sub-theme was classified as a facilitator and/or barrier and then each larger theme/domain was assessed for its complexity (simple, complicated, complex). Data analysis revealed 28 sub-themes, 10 identified as facilitators, 13 as barriers, and five as both. Two domains were classed as simple, three as complicated, and two as complex. Sub-themes ranged from illness-related complexities to organisational pressures. Key facilitators included a high-value proposition for FREED and a supportive network. Key barriers included staffing issues and illness-related factors that challenge early intervention.

Discussion

Participants described broad support for FREED but desired sustained investment for continued provision and improving implementation fidelity. Future development areas raised by participants included enlarging the evidence base for early intervention, increasing associated training opportunities, and widening the reach of FREED. Results offer learning for early intervention in eating disorders and the scaling of new health initiatives.

Addressing COVID-19 vaccine hesitancy in rural community pharmacies: a protocol for a stepped wedge randomized clinical trial

BACKGROUND

Uptake of COVID-19 vaccines remains problematically low in the USA, especially in rural areas. COVID-19 vaccine hesitancy is associated with lower uptake, which translates to higher susceptibility to SARS-CoV-2 variants in communities where vaccination coverage is low. Because community pharmacists are among the most accessible and trusted health professionals in rural areas, this randomized clinical trial will examine implementation strategies to support rural pharmacists in delivering an adapted evidence-based intervention to reduce COVID-19 vaccine hesitancy.

METHODS

We will use an incomplete stepped wedge trial design in which we will randomize 30 rural pharmacies (unit of analysis) to determine the effectiveness and incremental cost-effectiveness of a standard implementation approach (consisting of online training that describes the vaccine hesitancy intervention, live webinar, and resource website) compared to adding on a virtual facilitation approach (provided by a trained facilitator in support of the delivery of the vaccine hesitancy counseling intervention by pharmacists). The intervention (ASORT) has been adapted from an evidence-based vaccine communication intervention for HPV vaccines through a partnership with rural pharmacies in a practice-based research network in seven southern US states. ASORT teaches pharmacists how to identify persons eligible for COVID-19 vaccination (including a booster), solicit and address vaccine concerns in a non-confrontational way, recommend the vaccine, and repeat the steps later if needed. The primary trial outcome is fidelity to the ASORT intervention, which will be determined through ratings of recordings of pharmacists delivering the intervention. The secondary outcome is the effectiveness of the intervention, determined by rates of patients who agree to be vaccinated after receiving the intervention. Other secondary outcomes include feasibility, acceptability, adoption, reach, and cost. Cost-effectiveness and budget impact analyses will be conducted to maximize the potential for future dissemination and sustainability. Mixed methods will provide triangulation, expansion, and explanation of quantitative findings.

DISCUSSION

This trial contributes to a growing evidence base on vaccine hesitancy interventions and virtual-only facilitation of evidenced-based practices in community health settings. The trial will provide the first estimate of the relative value of different implementation strategies in pharmacy settings.

TRIAL REGISTRATION

NCT05926544 (clinicaltrials.gov); 07/03/2023.

Using audit and feedback to guide tailored implementations of measurement-based care in community mental health: a multiple case study

BACKGROUND

Audit and feedback (A&F) is an implementation strategy that can facilitate implementation tailoring by identifying gaps between desired and actual clinical care. While there are several theory-based propositions on which A&F components lead to better implementation outcomes, many have not been empirically investigated, and there is limited guidance for stakeholders when applying A&F in practice. The current study aims to illustrate A&F procedures in six community mental health clinics, with an emphasis on reporting A&F components that are relevant to theories of how feedback elicits behavior change.

METHODS

Six clinics from a larger trial using a tailored approach to implement measurement-based care (MBC) were analyzed for feedback content, delivery mechanisms, barriers to feedback, and outcomes of feedback using archival data. Pattern analysis was conducted to examine relations between A&F components and changes in MBC use.

RESULTS

Several sites utilized both aggregate and individualized data summaries, and data accuracy concerns were common. Feedback cycles featuring individual-level clinician data, data relevant to MBC barriers, and information requested by data recipients were related to patterns of increased MBC use.

CONCLUSIONS

These findings support extant theory, such as Feedback Intervention Theory. Mental health professionals wishing to apply A&F should consider establishing reciprocal feedback mechanisms on the quality and amount of data being received and adopting specific roles communicating and addressing data quality concerns.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02266134.

Using a person-centered approach in clinical care for patients with complex chronic conditions: Perspectives from healthcare professionals caring for Veterans with COPD in the U.S. Veterans Health Administration's Whole Health System of Care

BACKGROUND

The largest nationally integrated health system in the United States, the Veterans Health Administration (VHA), has been undergoing a transformation toward a Whole Health (WH) System of Care. WH Clinical Care, a component of this system, includes holistically assessing the Veteran's life context, identifying what really matters to the Veteran, collaboratively setting and monitoring personal health and well-being goals, and equipping the Veteran with access to conventional and complementary and integrative health resources. Implementation of WH Clinical Care has been challenging. Understanding healthcare professionals' perspectives on the value of and barriers and facilitators to practicing WH Clinical Care holds relevance for not only VHA's efforts but also other health systems, in the U.S. and internationally, that are engaged in person-centered care implementation.

OBJECTIVES

We sought to understand perspectives of healthcare professionals at VHA on providing WH Clinical Care to Veterans with COPD, as a lens to understand the broader issue of WH Clinical Care for Veterans living with complex chronic conditions.

DESIGN

We interviewed 25 healthcare professionals across disciplines and services at a VA Medical Center in 2020-2021, including primary care providers, pulmonologists, palliative care providers, and chaplains. Interview transcripts were analyzed using qualitative content analysis.

KEY RESULTS

Each element of WH Clinical Care raised complex questions and/or concerns, including: (1) the appropriate depth/breadth of inquiry in person-centered assessment; (2) the rationale for elicitation of what really matters; (3) the feasibility and appropriate division of labor in personal health goal setting and planning; and (4) challenges related to referring Veterans to a broad spectrum of supportive services.

CONCLUSIONS

Efforts to promote person-centered care must account for healthcare professionals' existing comfort with its elements, advocate for a team-based approach, and continue to grapple with the conflicting structural conditions and organizational imperatives.

A landscape assessment of the activities and capacities of evidence-to-policy intermediaries (EPI) in behavioral health

BACKGROUND

A significant gap exists between the production of research evidence and its use in behavioral health policymaking. Organizations providing consulting and support activities for improving policy represent a promising source for strengthening the infrastructure to address this gap. Understanding the characteristics and activities of these evidence-to-policy intermediary (EPI) organizations can inform the development of capacity-building activities, leading to strengthened evidence-to-policy infrastructure and more widespread evidence-based policymaking.

METHODS

Online surveys were sent to 51 organizations from English-speaking countries involved in evidence-to-policy activities in behavioral health. The survey was grounded in a rapid evidence review of the academic literature regarding strategies used to influence research use in policymaking. The review identified 17 strategies, which were classified into four activity categories. We administered the surveys via Qualtrics and calculated the descriptive statistics, scales, and internal consistency statistics using R.

RESULTS

A total of 31 individuals completed the surveys from 27 organizations (53% response rate) in four English-speaking countries. EPIs were evenly split between university (49%) and non-university (51%) settings. Nearly all EPIs conducted direct program support (mean = 4.19/5 [sd = 1.25]) and knowledge-building (4.03 [1.17]) activities. However, engagement with traditionally marginalized and non-traditional partners (2.84 [1.39]) and development of evidence reviews using formal critical appraisal methods (2.81 [1.70]) were uncommon. EPIs tend to be specialized, focusing on a group of highly related strategies rather than incorporating multiple evidence-to-policy strategies in their portfolios. Inter-item consistency was moderate to high, with scale α's ranging from 0.67 to 0.85. Ratings of respondents' willingness to pay for training in one of three evidence dissemination strategies revealed high interest in program and policy design.

CONCLUSIONS

Our results suggest that evidence-to-policy strategies are frequently used by existing EPIs; however, organizations tend to specialize rather than engage in a breadth of strategies. Furthermore, few organizations reported consistently engaging with non-traditional or community partners. Focusing on building capacity for a network of new and existing EPIs could be a promising strategy for growing the infrastructure needed for evidence-informed behavioral health policymaking.

A scoping review of outer context constructs in dissemination and implementation science theories, models, and frameworks

Many studies have explored organizational factors that facilitate implementation. However, there is still a limited understanding of determinants external to the implementing organization and their effects on evidence-based intervention (EBI) adoption, implementation, and outcomes. The purpose of this scoping review was to assess definitions of context and identify salient determinants of outer context found in dissemination and implementation theories, models, and frameworks. We employed a compilation of dissemination and implementation frameworks from two reviews as the data source. We abstracted the following information: type of article, outcomes of the framework, presence of a context definition, presence of any outer setting definition and the definition, number and domains of outer setting mentioned, definitions of outer context constructs, and any quantitative measures of outer setting. We identified 19 definitions of outer context. Forty-seven (49%) frameworks reported one or more specific constructs of the outer setting. While the outer context domains described in the frameworks varied, the most common domains were policy (n = 24), community (n = 20), partnerships (n = 13), and communications (n = 12). Based on our review of the frameworks, more conceptualization and measurement development for outer context domains are needed. Few measures were found and definitions of domains varied across frameworks. Expanding outer context construct definitions would advance measure development for important factors external to the organizations related to EBI implementation.

Taking a Magnifying Glass to Measurement-Based Care Consultation Sessions: with What Issues Do Mental Health Clinicians Struggle?

PURPOSE

Ongoing consultation following initial training is one of the most commonly deployed implementation strategies to facilitate uptake of evidence-based practices, such as measurement-based care (MBC). Group consultation provides an interactive experience with an expert and colleagues to get feedback on actual issues faced, yet there is little research that unpacks the questions raised in consultation and what types of issues are important to address.

METHODS

The current study characterized the questions and concerns raised by community mental health clinicians (N = 38 across six clinics) during group consultation sessions completed as part of an MBC implementation trial. We conducted a qualitative content analysis of consultation forms completed by clinicians before each MBC consultation session.

RESULTS

Clinicians sought MBC consultation for clients across a range of ages and levels of depression severity. Qualitative results revealed five main questions and concerns in consultation sessions: (1) how to administer the PHQ-9, (2) how to review PHQ-9 scores, (3) how to respond to PHQ-9 score, (4) the types of clients for whom MBC would be appropriate, and (5) how MBC could impact a clinician's usual care.

CONCLUSION

Findings highlight the need for ongoing consultation and limitations of workshop training alone. Practical recommendations for addressing the common questions and concerns identified are presented to support MBC use.

The Role of Latina Peer Mentors in the Implementation of the Alma Program for Women With Perinatal Depression

This study examines the role that compañeras (peer mentors) play in the implementation of a program, Alma, which was designed to support Latina mothers who are experiencing depression during pregnancy or early parenting and implemented in the rural mountain West of the United States. Drawing from the fields of dissemination and implementation and Latina mujerista (feminist) scholarship, this ethnographic analysis demonstrates how the Alma compañeras facilitate the delivery of Alma by creating and inhabiting intimate mujerista spaces with other mothers and create relationships of mutual and collective healing in the context of relationships de confianza (of trust and confidence). We argue that these Latina women, in their capacity as compañeras, draw upon their cultural funds of knowledge to bring Alma to life in ways that prioritizes flexibility and responsiveness to the community. Shedding light on contextualized processes by which Latina women facilitate the implementation of Alma illustrates how the task-sharing model is well suited to the delivery of mental health services for Latina immigrant mothers and how lay mental health providers can be agents of healing.

The Stacked Community Engagement model: A practical model for developing community-engaged academic medical faculty

Introduction

There is an increasing recognition of the benefits of sustained community engagement (CE) that accrue to academic health centers and the communities they serve. However, the success and sustainability of CE projects rely on the efforts of individual faculty, learners, and community members, for whom CE efforts are typically added to their professional and personal priorities and responsibilities. This competition for time and resources between priorities and CE can discourage academic medical faculty from participating in CE activities. The Stacked Community Engagement model is proposed to synergize or "stack" responsibilities and goals onto the scaffolding of CE projects.

Methods

We examined the literature and expert CE practitioner opinion to identify the challenges faced by community-engaged academic faculty and the key characteristics of CE projects that successfully align and integrate with the priorities of faculty, learners, and community members. We synthesized this information to develop the conceptual Stacked CE model for developing CE academic medical faculty, then illustrated the model in heterogeneous CE programs to explore its generalizability, validity, and robustness.

Results

The Stacked CE model, when applied to a specific nutrition education program (The Food Doctors) and outreach program (StreetLife Communities), provided a practical framework for examining the sustained success of a partnership between Medical College of Wisconsin faculty and medical students and the community.

Conclusions

The Stacked CE model is a meaningful framework for developing community-engaged academic medical faculty. By identifying overlap and integrating CE into professional activities with intention, CE practitioners can benefit from the deeper connections and sustainability.

Strategic Priorities for Implementation of Father-Inclusive Practice in Mental Health Services for Children and Families: A Delphi Expert Consensus Study

The aim of this study was to investigate expert consensus on barriers and facilitators to the organizational implementation of Father-Inclusive Practice (FIP) in child and family services to establish strategic priorities for implementation. An international panel of 56 experts in child and family service provision and father inclusion were surveyed using the Delphi technique. Three online questionnaires were used to gather opinions and measure experts’ levels of agreement in regard to factors that enable or hinder the organizational implementation of FIP. Survey design, analysis and interpretation was guided by the Consolidated Framework for Implementation Research (CFIR). Consensus was achieved for 46.4% (n = 13) statements. Eight barriers and five facilitators were identified as strategic priorities to organizational implementation of FIP. The key factors were related to the following CFIR themes: leadership engagement, access to information and knowledge, implementation climate, structural characteristics, networks and communication, client needs and resources, external policies and incentives, and reflecting and evaluating. The study findings suggest that issues related to central prioritization, top-down organizational processes and external policy context should represent priority areas for implementation. Our results prioritise methods for improving FIP by highlighting the key areas of organizational practice to be addressed by tailored implementation strategies.

Developing criteria for research translation decision-making in community settings: a systematic review and thematic analysis informed by the Knowledge to Action Framework and community input

Background

There is a pressing need to translate empirically supported interventions, products, and policies into practice to prevent and control prevalent chronic diseases. According to the Knowledge to Action (K2A) Framework, only those interventions deemed “ready” for translation are likely to be disseminated, adopted, implemented, and ultimately institutionalized. Yet, this pivotal step has not received adequate study. The purpose of this paper was to create a list of criteria that can be used by researchers, in collaboration with community partners, to help evaluate intervention readiness for translation into community and/or organizational settings.

Methods

The identification and selection of criteria involved reviewing the K2A Framework questions from the “decision to translate” stage, conducting a systematic review to identify characteristics important for research translation in community settings, using thematic analysis to select unique research translation decision criteria, and incorporating researcher and community advisory board feedback.

Results

The review identified 46 published articles that described potential criteria to decide if an intervention appears ready for translation into community settings. In total, 17 unique research translation decision criteria were identified. Of the 8 themes from the K2A Framework that were used to inform the thematic analysis, all 8 were included in the final criteria list after research supported their importance for research translation decision-making. Overall, the criteria identified through our review highlighted the importance of an intervention’s public health, cultural, and community relevance. Not only are intervention characteristics (e.g., evidence base, comparative effectiveness, acceptability, adaptability, sustainability, cost) necessary to consider when contemplating introducing an intervention to the “real world,” it is also important to consider characteristics of the target setting and/or population (e.g., presence of supporting structure, support or buy-in, changing sociopolitical landscape).

Conclusions

Our research translation decision criteria provide a holistic list for identifying important barriers and facilitators for research translation that should be considered before introducing an empirically supported intervention into community settings. These criteria can be used for research translation decision-making on the individual and organizational level to ensure resources are not wasted on interventions that cannot be effectively translated in community settings to yield desired outcomes.

The Fast and the Furious: The Rapid Implementation of Tele-mental Health Practices Within a Children’s Advocacy Center

We work at a large, urban children’s advocacy center (CAC) that provides treatment and services to approximately 2000 children and families each year who have experienced child abuse and other forms of trauma. While the complexity and impact of the COVID-19 pandemic on both physical and mental health are only beginning to be understood, families with histories of abuse and other traumatic experiences are particularly vulnerable to the negative impacts of isolation due to the extended lockdown. When the COVID-19 pandemic was identified as a public health crisis, the team of providers at the CAC pivoted to meet the newly emerging needs of the children and families served. Tele-mental health practices (TMH) were immediately implemented that required a deep understanding of the imminent safety concerns related to conducting TMH when the client may not feel safe at home. Further, while most of the clients referred for services have experienced child abuse and/or other types of trauma, COVID-19 is its own potentially traumatic event that can further exacerbate an individual’s lack of safety and vulnerability to trauma. The current paper provides an overview of the rapid implementation of TMH practices within a large, urban CAC setting. We share the specific tele-mental health practices and implementation strategies that were put into place because of COVID-19 and how they align with the Consolidated Framework for Implementation Research, as well as recommendations for how agency leadership can better facilitate the implementation of innovative practices in similar settings.

From "Homegrown" to Research-Ready: Converting an Existing Practitioner-Developed Violence Prevention Intervention Into an Evaluable Intervention

There is an increased call for research on promising prevention programs already embedded in communities ("homegrown interventions"). Unfortunately, there is limited guidance to help researchers prepare these types of interventions for rigorous evaluation. To address this need, this article presents our team's process for revising a promising community-based sexual violence prevention intervention for rigorous research. Our extensive and iterative process of reviewing and revising the intervention was guided by evaluability assessment (EA) approaches, implementation science, and a close collaboration with our community partners. Our EA process allowed us to specify the intervention's core components and develop a "research ready" standardized curriculum with implementation fidelity assessments. We offer four lessons learned from our process: (1) even with existing materials and an extensive history of community-based delivery, community-developed programs are not necessarily research-ready; (2) close collaboration and a trusting relationship between researchers and community partners throughout the revision process ensures the integrity of core program components are maintained and implementation in diverse community settings is feasible; (3) observations of program implementation are a crucial part of the revision process; and (4) it is important to budget adequate time and resources for such revisions.

The Effects of a Multi-Family Group Trauma Intervention on Caregiver Posttraumatic Stress Symptom Clusters

Strengthening Family Coping Resources (SFCR), a multi-family group intervention tailored to families experiencing traumatic stress, is associated with improved post-traumatic stress disorder (PTSD) symptoms and family functioning. To further SFCR research, we examined (1) SFCR's effects on caregiver PTSD symptom clusters (intrusions, avoidance, negative alterations in cognitions and mood [NACM], alterations in arousal and reactivity); and (2) whether effects differed by caregiver trauma type (interpersonal versus non-interpersonal; intrafamilial versus extrafamilial). Forty-two caregivers of primarily low socioeconomic status reporting trauma histories completed SFCR treatment. Significant decreases in PTSD intrusion, avoidance, and NACM subscale scores emerged from pre- to post-SFCR; there were no differences in subscale score changes by trauma type categorization. Findings support SFCR as a promising treatment for reducing PTSD severity among caregivers reporting diverse traumas.

Exploring contextual adaptations in caregiver interventions for families raising children with developmental disabilities

There are increasing efforts to scale up services globally for families raising children with developmental disabilities (DDs). Existing interventions, often developed in high income, Western settings, need substantial adaptation before they can be implemented in different contexts. The aim of this study was to explore perspectives on the role that context plays in the adaptation and implementation of interventions targeting caregivers of children with DDs across settings. The study question was applied to the Caregiver Skills Training (CST) programme of the World Health Organization specifically, as well as to stakeholder experiences with caregiver interventions more broadly. Two focus group discussions (FGDs; n = 15 participants) and 25 individual semi-structured interviews were conducted. Participants were caregivers of children with DDs and professionals involved in adapting or implementing the CST across five continents and different income settings. Data were analysed thematically. Four main themes were developed: 1) Setting the scene for adaptations; 2) Integrating an intervention into local public services; 3) Understanding the reality of caregivers; 4) Challenges of sustaining an intervention. Informants thought that contextual adaptations were key for the intervention to fit in locally, even more so than cultural factors. The socio-economic context of caregivers, including poverty, was highlighted as heavily affecting service access and engagement with the intervention. Competing health priorities other than DDs, financial constraints, and management of long-term collaborations were identified as barriers. This study validates the notion that attention to contextual factors is an essential part of the adaptation of caregiver interventions for children with DDs, by providing perspectives from different geographical regions. We recommend a stronger policy and research focus on contextual adaptations of interventions and addressing unmet socio-economic needs of caregivers.

A Dog with an Office: The Process of Embedding a Wellness Dog Intervention in a University Setting

Universities are places to promote the wellbeing of people who learn, work, and live within them. This article reports on an innovative, holistic, and embedded wellness dog program that was developed by the Faculty of Nursing to support the wellbeing of students, faculty, and staff. The innovation included a collaborative partnership between two faculties (the faculties of Veterinary Medicine and Nursing), and the targeted purchase, training, and socialization of a wellness dog. Pet wellness programs have the potential to be an important mental health intervention on university campuses. While the program was postponed due to COVID-19, the purpose of this article is to share processes used to create the wellness dog program, with suggestions regarding implementation and evaluation.

Leveraging Innovative Financing Strategy to Increase Coverage and Resources Among Informal Sector for Social Health Insurance Within the Nigerian Context of Devolution: Evidence From Adoption Model Implementation

Background

Enrollment in sub-national social health insurance schemes (SSHIS) can be challenging in developing countries like Nigeria, particularly among people in the informal sector. This could be due to a lack of knowledge on its mode of operation and benefits, distrust in government, inimical religious and traditional beliefs, as well as constraining economic factors. A complementary and innovative financing strategy such as the philanthropist adoption model (ADM) could be beneficial in improving SSHIS coverage and financial resources among persons in the informal sector. The study provides new evidence on how ADM influenced health insurance coverage and resources within SSHIS among informal settings in Nigeria. It also highlights contextual factors influencing the implementation of ADM.

Methods

This study employed a mixed-methods case-study approach undertaken in Anambra State, Southeast Nigeria. Data were collected through in-depth interviews (n = 14), document review (n = 12), and quantitative (enrollment data) methods. The respondents were purposively selected based on their involvement with the implementation of the SSHIS. Data analysis for qualitative data was done using the manual thematic framework approach while descriptive analysis was performed for the quantitative data.

Results

The implementation of ADM was a valuable and effective strategy for improving knowledge, coverage, and resource mobilization (annual premium pool) within the SSHIS in the informal sector. The main enablers of the implementation of ADM include strong political will and commitment, wider stakeholders' consultation and collaboration, numerous public-spirited philanthropists, and legal institutionalization of health insurance. Other enablers include organizational factors like good teamwork among Anambra State Health Insurance Agency (ASHIA) staff, enabling work environment (incentives, supervision, office space), and experienced marketers in the agency. However, ADM had several barriers that affected its implementation—acceptability issues due to distrust for government and the health system, health systems barriers including substandard health facilities and equipment, and inimical cultural and religious beliefs about health insurance.

Conclusion

The study demonstrates a case for the implementation of innovative ADM as a strategy for enhancing SSHIS financial sustainability and coverage of persons in the informal sector. Hence, the strategy should be adopted in settings where philanthropy abounds for increasing access to quality healthcare delivery to poor beneficiaries toward achieving universal health coverage in developing countries.

Disseminating online parenting resources in the community during the COVID-19 pandemic: Lessons learned

Online parenting programs are an effective way to teach behavioral management skills to parents in the absence of in-person resources. This community-engaged study aimed to examine strategies for disseminating online parenting resources in schools. Online resources were disseminated to parents in a Northern California school district. Dissemination strategies were informed by conversations with school principals, teachers, and parents and considered agent, message, and format. A total of 685 parents and teachers clicked on the online resources: 151 parents and 114 teachers attended synchronous classes. The use of dissemination strategies had a compounding influence on the number of synchronous class attendees and clicks. Emails sent by the school district yielded the greatest number of clicks, which was influenced by message content and format. A community-academic partnership (CAP) led to the dissemination of evidence-based online parenting resources to a large population and led to lessons learned that could inform future research involving CAPs.

Using an Implementation Framework to Survey Outcome Measurement and Treatment Practices in Aphasia

PURPOSE

Best practices in the field of aphasia rehabilitation increasingly acknowledge a whole-person approach that values interventions aimed at reducing impairments, while also recognizing the impact of aphasia on participation and quality of life. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to examine whether current clinical practices along levels of service provision reflect this whole-person, multifaceted approach.

METHOD

Speech-language pathologists (SLPs) in the United States who provide intervention to people with aphasia across the continuum of care completed this cross-sectional online survey. Current outcome measurement and treatment practices were evaluated within the Living With Aphasia: Framework for Outcome Measurement via multiple-choice and open-text response questions. Data were analyzed descriptively and using ordinal logistic regression models to compare clinical practices along levels of service provision.

RESULTS

Data from 90 SLPs revealed that language and cognitive skills are assessed with equal consistency across clinical settings; however, functional communication, participation, and quality of life domains are prioritized in settings providing care to clients within the community. Psychological well-being is rarely assessed within clinical practice along most of the rehabilitation process and prioritized within the university clinic setting when clients are in the chronic stage of recovery.

CONCLUSIONS

Clinical practices related to a multifaceted approach to aphasia intervention are variable across levels of service provision. Further exploration of barriers and facilitators to multifaceted aphasia care along the domains of the CFIR is needed to provide an informed approach to implementing change.

Enablers and barriers in upscaling telemonitoring across geographic boundaries: a scoping review

INTRODUCTION AND OBJECTIVE

Telemonitoring is a method to monitor a person's vital functions via their physiological data at distance, using technology. While pilot studies on the proposed benefits of telemonitoring show promising results, it appears challenging to implement telemonitoring on a larger scale. The aim of this scoping review is to identify the enablers and barriers for upscaling of telemonitoring across different settings and geographical boundaries in healthcare.

METHODS

PubMed, Embase, Cinahl, Web of Science, ProQuest and IEEE databases were searched. Resulting outcomes were assessed by two independent reviewers. Studies were considered eligible if they focused on remote monitoring of patients' vital functions and data was transmitted digitally. Using scoping review methodology, selected studies were systematically assessed on their factors of influence on upscaling of telemonitoring.

RESULTS

A total of 2298 titles and abstracts were screened, and 19 articles were included for final analysis. This analysis revealed 89 relevant factors of influence: 26 were reported as enabler, 18 were reported as barrier and 45 factors were reported being both. The actual utilisation of telemonitoring varied widely across studies. The most frequently mentioned factors of influence are: resources such as costs or reimbursement, access or interface with electronic medical record and knowledge of frontline staff.

CONCLUSION

Successful upscaling of telemonitoring requires insight into its critical success factors, especially at an overarching national level. To future-proof and facilitate upscaling of telemonitoring, it is recommended to use this type of technology in usual care and to find means for reimbursement early on. A wide programme on change management, nationally or regionally coordinated, is key. Clear regulatory conditions and professional guidelines may further facilitate widespread adoption and use of telemonitoring. Future research should focus on converting the 'enablers and barriers' as identified by this review into a guideline supporting further nationwide upscaling of telemonitoring.

Implementation of a novel malaria management strategy based on self-testing and self-treatment in remote areas in the Amazon (Malakit): confronting a-priori assumptions with reality

BACKGROUND

A novel strategy to combat malaria was tested using a methodology adapted to a complex setting in the Amazon region and a hard-to-reach, mobile community. The intervention strategy tested was the distribution, after training, of malaria self-management kits to gold miners who cross the Surinamese and Brazilian borders with French Guiana to work illegally in the remote mining sites in the forest of this French overseas entity.

MAIN TEXT

This article aims at presenting all process and implementation outcomes following the Conceptual Framework of Implementation Fidelity i.e. adherence, including content and exposure, and moderators, comprising participant responsiveness, quality of delivery, facilitation strategies, and context. The information sources are the post-intervention survey, data collected longitudinally during the intervention, a qualitative study, data collected during an outreach mission to a remote gold mining site, supervisory visit reports, in-depth feedback from the project implementers, and videos self-recorded by facilitators based on opened ended questions. As expected, being part of or close to the study community was an essential condition to enable deliverers, referred to as "facilitators", to overcome the usual wariness of this gold mining population. Overall, the content of the intervention was in line with what was planned. With an estimated one third of the population reached, exposure was satisfactory considering the challenging context, but improvable by increasing ad hoc off-site distribution according to needs. Participant responsiveness was the main strength of the intervention, but could be enhanced by reducing the duration of the process to get a kit, which could be disincentive in some places. Regarding the quality of delivery, the main issue was the excess of information provided to participants rather than a lack of information, but this was corrected over time. The expected decrease in malaria incidence became a source of reduced interest in the kit. Expanding the scope of facilitators' responsibilities could be a suitable response. Better articulation with existing malaria management services is recommended to ensure sustainability.

CONCLUSIONS

These findings supplement the evaluation outcomes for assessing the relevance of the strategy and provide useful information to perpetuate and transfer it in comparable contexts.

TRIAL REGISTRATION

ClinicalTrials.gov.  NCT03695770 . 10/02/2018 "Retrospectively registered".

Qualitative study exploring factors affecting the implementation of a vocational rehabilitation intervention in the UK major trauma pathway

OBJECTIVES

This study aimed to: (1) understand the context for delivering a trauma vocational rehabilitation (VR) intervention; (2) identify potential barriers and enablers to the implementation of a VR intervention post-trauma.

DESIGN

Qualitative study. Data were collected in person or via phone using different methods: 38 semistructured interviews, 11 informal 'walk-through care pathways' interviews, 5 focus groups (n=25), 5 codesign workshops (n=43). Data were thematically analysed using the framework approach, informed by the Consolidated Framework for Implementation Research.

SETTING

Stakeholders recruited across five UK major trauma networks.

PARTICIPANTS

A variety of stakeholders were recruited (n=117) including trauma survivors, rehabilitation physicians, therapists, psychologists, trauma coordinators and general practitioners. We recruited 32 service users (trauma survivors or carers) and 85 service providers.

RESULTS

There were several issues associated with implementing a trauma VR intervention including: culture within healthcare/employing organisations; extent to which healthcare systems were networked with other organisations; poor transition between different organisations; failure to recognise VR as a priority; external policies and funding. Some barriers were typical implementation issues (eg, funding, policies, openness to change). This study further highlighted the challenges associated with implementing a complex intervention like VR (eg, inadequate networking/communication, poor service provision, perceived VR priority). Our intervention was developed to overcome these barriers through adapting a therapist training package, and by providing early contact with patient/employer, a psychological component alongside occupational therapy, case coordination/central point of contact, and support crossing sector boundaries (eg, between health/employment/welfare).

CONCLUSIONS

Findings informed the implementation of our VR intervention within the complex trauma pathway. Although we understand how to embed it within this context, the success of its implementation needs to be measured as part of a process evaluation in a future trial.

A Framework for Successful Adoption of Surgical Innovation

Background

Innovation Adoption Frameworks are applied in healthcare industry, but surgical innovation does not follow the same models as medical innovation and it is not always adopted fully by members of the team.

Purpose

The aim of this paper is to develop a framework for successful adoption of surgical innovation.

Research design

This paper is inspired by design thinking. Based on a pragmatic research philosophy, a mixed method approach was selected including semi-structured interview and focus groups, following a questionnaire.

Study sample

A sample of five specialists in the field (doctors and managers) were selected for interview. Six focus groups were conducted. On average, five people were involved in each focus groups, 30 participants in total, including consultants, senior and junior ward nurses, health care assistant (HCA), cancer nurse specialist, stoma nurses, theatre senior and junior staff.

Data collection/analysis

Qualitative data was collected and analyzed using Thematic Analysis.

Results

Following a design thinking approach; firstly, an initial Surgical Adoption Model was proposed, based on the existing literature. Then, the challenges, processes and teams involved in Robotic Surgery adoption, an existing surgical innovation in a local NHS hospital, were explored. Five main themes were extracted from interviews and focus groups data - ‘Innovation Perception’, ‘Guilty vs. Undervalued’, ‘Knowledge is Power’, ‘Ex-novation’ and ‘Facilitators and Super-users’. This resulted into the development of an adapted Surgical Innovation Framework.

Conclusions

The Surgical Innovation Framework incorporated the themes extracted from the data. The framework is unique within the field of surgical innovation and is designed with the aim of improving surgical innovation adoption success rate. Future research can trial the framework to evaluate its effectiveness.

Obesity prevention practices in early care and education settings: an adaptive implementation trial

Background

Despite the potential for Early Care and Education (ECE) settings to promote healthy habits, a gap exists between current practices and evidence-based practices (EBPs) for obesity prevention in childhood.

Methods

We will use an enhanced non-responder trial design to determine the effectiveness and incremental cost-effectiveness of an adaptive implementation strategy for Together, We Inspire Smart Eating (WISE), while examining moderators and mediators of the strategy effect. WISE is a curriculum that aims to increase children’s intake of carotenoid-rich fruits and vegetables through four evidence-based practices in the early care and education setting. In this trial, we will randomize sites that do not respond to low-intensity strategies to either (a) continue receiving low-intensity strategies or (b) receive high-intensity strategies. This design will determine the effect of an adaptive implementation strategy that adds high-intensity versus one that continues with low-intensity among non-responder sites. We will also apply explanatory, sequential mixed methods to provide a nuanced understanding of implementation mechanisms, contextual factors, and characteristics of sites that respond to differing intensities of implementation strategies. Finally, we will conduct a cost effectiveness analysis to estimate the incremental effect of augmenting implementation with high-intensity strategies compared to continuing low-intensity strategies on costs, fidelity, and child health outcomes.

Discussion

We expect our study to contribute to an evidence base for structuring implementation support in real-world ECE contexts, ultimately providing a guide for applying the adaptive implementation strategy in ECE for WISE scale-up. Our work will also provide data to guide implementation decisions of other interventions in ECE. Finally, we will provide the first estimate of relative value for different implementation strategies in this setting.

Trial registration

NCT05050539; 9/20/21.

Safety culture in emergency medicine: An exploratory qualitative study

BACKGROUND

Safety culture in Emergency Departments (EDs) requires special attention due to unique operational feature of the ED environment. Which may influence a culture of patients' safety in the ED.

OBJECTIVE

To identify the factors that influence patient safety culture in EDs.

METHODS

A qualitative study using semi-structured interviews with 12 ED staff was carried out in two Australian EDs. The data was thematically analysed to identify and describe the factors perceived by staff as influencing patient safety culture.

RESULTS

The findings revealed four super-ordinate themes and 19 categories. The themes were the following: (1) Environmental and Organisational; (2) Healthcare Professional (3) Managerial factors; and (4) Patients factors.

CONCLUSIONS

Safety culture in the ED is influenced by complex set of factors. The results of this study may help ED workers with improving patient safety culture and healthcare quality in the ED.

Communication strategies to facilitate the implementation of new clinical practices: a qualitative study of community mental health therapists

Although communication is widely observed to be central to the implementation process, the field of implementation science has largely overlooked the details of how communication may best be utilized to facilitate implementation. This paper draws on relevant insights from Rogers' Diffusion of Innovations Theory, which laid the foundation for explicitly attending to the role of communication as a mechanism for implementation strategies to exert their effects. To offer empirically-derived and theory-informed recommendations regarding communication processes to support the effective introduction of new clinical practices. This investigation leverages data from 61 therapists poised to undergo implementation of measurement-based care (MBC) for depressed adults receiving psychotherapy in community mental health settings. Data were collected via focus groups across 12 sites. Themes emergent in the data analysis suggest five practices to facilitate effective communication in the introduction of new clinical practices like MBC: the communication of a clear rationale for the new practice; the provision of necessary procedural knowledge; communication about the change via multiple methods; sufficient lead time to prepare for the change; and the opportunity for bidirectional engagement. In addition to indicating several best practices to improve communication prior to implementation, our results suggest that the current conceptualization of implementation strategies may not yet be complete. Components and/or methods of effective communication about new practices should be included among the growing set of implementation strategies. Existing implementation strategies might also benefit from more temporal specificity, with more attention to the exploration and preparation phases. (Trial Registration: Clinicaltrials.gov NCT02266134. Registered 12 October 2014.).

Implementation of the Wolverine Mental Health Program, Part 1: Adoption Phase

Residential treatment facilities (RTFs) are a first-line treatment option for juvenile justice-involved youth. However, RTFs rarely offer evidence-based interventions for youth with internalizing or externalizing mental health problems. Wolverine Human Services (WHS) is one of the first RTFs in the nation to implement cognitive-behavioral therapy (CBT) to enhance mental health care for their youth. This study outlines the preimplementation phase of a 5-year collaborative CBT implementation effort among WHS, the Beck Institute, and an implementation science research team. The preimplementation phase included a needs assessment across two sites of WHS to identify and prioritize barriers to CBT implementation. Of the 76 unique barriers, 23 were prioritized as important and feasible to address. Implementation teams, consisting of clinician and staff champions and opinion leaders, worked across 8 months to deploy 10 strategies from a collaboratively designed blueprint. Upon reevaluation of the needs assessment domains, all prioritized barriers to CBT implementation were removed and WHS's readiness for CBT implementation was enhanced. This study serves as a model of a preimplementation process that can be employed to enhance the potential for successful evidence-based practice implementation in youth RTFs.

Implementation of the Wolverine Mental Health Program, Part 3: Sustainment Phase

Sustaining the implementation of an evidence-based practice (EBP) is the ultimate goal of often years of significant personnel and financial investment. Some conceptualize sustainment as a distinct phase following an active implementation period where the contextual factors, processes, and supports are bolstered to ensure continued EBP delivery. This study provides an overview of the sustainment strategies deployed to embed cognitive-behavioral therapy (CBT) in a Midwestern residential treatment facility serving youth with complex mental health needs. Seven key strategies and their outcomes are described: use of CBT teams, new hire orientation plans, monthly campaigns, change in job descriptions and performance evaluations, development of a behavioral reinforcement system for youth, and a pathway to CBT certification. This study provides a window into how one might sustain an EBP by addressing barriers unique to this phase of work.

Understanding the Use of Optimal Formatting and Plain Language When Presenting Key Information in Clinical Trials

Recent revisions to the Common Rule require that consent documents begin with a focused presentation of the study's key information that is organized to facilitate understanding. We surveyed 1,284 researchers working with older adults or individuals with Alzheimer's disease, supplemented with 60 qualitative interviews, to understand current use and barriers to using evidence-based formatting and plain language in key information. Researchers reported using formatting in 42% of their key information sections, and plain language in 63% of their key information sections. Perceived barriers included lack of knowledge, Institutional Review Board, other members of their team, and the burden associated with implementation. Education and training are required to increase adoption of the practices.

Implementation of the Wolverine Mental Health Program, Part 2: Implementation Phase

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic-community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).

Applying Implementation Science to Support Active Collaboration in Noninvasive Brain-Computer Interface Development and Translation for Augmentative and Alternative Communication

PURPOSE

The purpose of this article is to consider how, alongside engineering advancements, noninvasive brain-computer interface (BCI) for augmentative and alternative communication (AAC; BCI-AAC) developments can leverage implementation science to increase the clinical impact of this technology. We offer the Consolidated Framework for Implementation Research (CFIR) as a structure to help guide future BCI-AAC research. Specifically, we discuss CFIR primary domains that include intervention characteristics, the outer and inner settings, the individuals involved in the intervention, and the process of implementation, alongside pertinent subdomains including adaptability, cost, patient needs and recourses, implementation climate, other personal attributes, and the process of engaging. The authors support their view with current citations from both the AAC and BCI-AAC fields.

CONCLUSIONS

The article aimed to provide thoughtful considerations for how future research may leverage the CFIR to support meaningful BCI-AAC translation for those with severe physical impairments. We believe that, although significant barriers to BCI-AAC development still exist, incorporating implementation research may be timely for the field of BCI-AAC and help account for diversity in end users, navigate implementation obstacles, and support a smooth and efficient translation of BCI-AAC technology. Moreover, the sooner clinicians, individuals who use AAC, their support networks, and engineers collectively improve BCI-AAC outcomes and the efficiency of translation, the sooner BCI-AAC may become an everyday tool in the AAC arsenal.

A typology of power in implementation: Building on the exploration, preparation, implementation, sustainment (EPIS) framework to advance mental health and HIV health equity

Background

Persistent inequities in HIV health are due, in part, to barriers to successful HIV-related mental health intervention implementation with marginalized groups. Implementation Science (IS) has begun to examine how the field can promote health equity. Lacking is a clear method to analyze how power is generated and distributed through practical implementation processes and how this power can dismantle and/or reproduce health inequity through intervention implementation. The aims of this paper are to (1) propose a typology of power generated through implementation processes, (2) apply this power typology to expand on the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to advance HIV and mental health equity and (3) articulate questions to guide the explicit examination and distribution of power throughout implementation.

Methods

This paper draws on the work of an Intermediary Purveyor organization implementing trauma-informed care and harm reduction organizational change with HIV service organizations. The expanded framework was developed through analyzing implementation coaching field notes, grant reporting, and evaluation documents, training feedback, partner evaluation interviews, and existing implementation literature.

Results

The authors identify three types of power working through implementation; (1) discursive power is enacted through defining health-related problems to be targeted by intervention implementation, as well as through health narratives that emerge through implementation; (2) epistemic power influences whose knowledge is valued in decision-making and is recreated through knowledge generation; and (3) material power is created through resource distribution and patterns of access to health resources and acquisition of health benefits provided by the intervention. Decisions across all phases and related to all factors of EPIS influence how these forms of power striate through intervention implementation and ultimately affect health equity outcomes.

Conclusions

The authors conclude with a set of concrete questions for researchers and practitioners to interrogate power throughout the implementation process.

Plain language summary

Over the past few years, Implementation Science researchers have committed increased attention to the ways in which the field can more effectively address health inequity. Lacking is a clear method to analyze how implementation processes themselves generate power that has the potential to contribute to health inequity. In this paper, the authors describe and define three types of power that are created and distributed through intervention implementation; discursive power, epistemic power, and material power. The authors then explain how these forms of power shape factors and phases of implementation, using the well-known EPIS (exploration, preparation, implementation, sustainment) framework. The authors draw from their experience working with and Intermediary Purveyor supporting HIV service organizations implementing trauma-informed care and harm reduction organizational change projects. This paper concludes with a set of critical questions that can be used by researchers and practitioners as a concrete tool to analyze the role of power in intervention implementation processes.

Barriers and Facilitators to Automated Self-Scheduling: Consensus from a Delphi Panel of Key Stakeholders

INTRODUCTION

Automated self-scheduling may benefit healthcare organizations, yet uptake has been slow. The aim of this study was to develop a consensus statement regarding the organizational-level determinants of implementation success based on the collective knowledge of experts. A three-stage modified Delphi method was used to reach consensus on the top determinants of implementation of self-scheduling solutions by healthcare organizations. A panel of 53 experts representing 41 academic health systems identified barriers and facilitators involving the organization's inner and outing settings, as well as the characteristics of the intervention and the individuals engaged in the solution. Offering convenience for patients is the leading enabler for organizations to implement the technology. The consensus may aid healthcare organizations and suppliers engaged in adopting and developing self-scheduling technology to improve implementation success. Further research is recommended to diagnose and examine each barrier and facilitator and how these factors interact.

OBJECTIVE

The aim of this study was to develop a consensus statement regarding the determinants of implementation success based on the collective knowledge of experts working in the field.

METHODS

A Delphi panel was constructed based on selected participants employed by academic health systems and experienced with self-scheduling implementation. Panelists were recruited based on participation in an educational event that featured the topic. Purposive and snowball sampling were used. Panelists participated in surveys collected over three rounds. An 80 percent agreement among panelists and interquartile range (IQR) <1 determined the barriers and facilitators. The top-10 determinants were presented in rank order.

RESULTS

Between January 6, 2021, and May 26, 2021, 53 panelists representing 41 academic health systems participated in three rounds of surveys to reach consensus on the barriers and facilitators to implementation of self-scheduling by healthcare organizations in the United States. In round one, panelists documented 530 determinants. In round two, the determinants were grouped into 72 barriers and 85 facilitators, each of which participants rated on a five-point Likert scale. Fifteen determinants met the 80 percent threshold and 1.0 IQR. The final round concluded with a top-10, rank-ordered listing of determinants (seven facilitators and three barriers) that also incorporated a median rating score using five-point Likert scale.

CONCLUSION

A three-stage modified Delphi method was used to reach consensus on the top determinants of implementation of self-scheduling solutions by academic health systems. The consensus may aid healthcare organizations and suppliers engaged in adopting and developing self-scheduling technology to improve implementation success. Further research is recommended to diagnose and examine each barrier and facilitator and how these factors interact.

Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one

PURPOSE OF REVIEW

Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group.

RECENT FINDINGS

Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy.

SUMMARY

Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.

Tailored isn't always better: Impact of standardized versus tailored training on intention to use measurement-based care

Background: Brief educational trainings are often used for disseminating and implementing evidence-based practices (EBPs). However, many accessible trainings are ubiquitously standardized. Tailored training focused on modifying individual or contextual factors that may hinder EBP implementation is recommended, but there is a dearth of research comparing standardized versus tailored training. This study sought to: (a) assess the impact of MBC training on clinician intention to use measurement-based care (MBC); (b) compare the effect of standardized versus tailored training on clinician intention to MBC; and (c) identify clinician-level predictors of intention. Methods: Clinicians (n = 152) treating adult clients with depression at 12 community mental health clinics were randomized to either tailored or standardized MBC training. Clinic-specific barriers and facilitators were used to inform training content and structure tailoring. Linear mixed modeling tested the association between training condition and post-training intention to use MBC, as well as hypothesized individual-level predictors of post-training intention (e.g., age, gender). Results: Clinician intention pre- and post-training increased across training conditions (B = 0.38, t = -5.95, df = 36.99, p < .01, Cohen's d = 0.58). Results of linear mixed modeling procedures suggest no significant difference in clinician intention between conditions post-training (B = -0.03, SE = .19, p > .05, Cohen's d = .15). Only baseline intention emerged as a predictor of post-training intention (B = 0.39, SE = .05, p < .05). Conclusions: These findings suggest the additional effort to tailor training may not yield incremental benefit over standardized training, at least in the short term. As a result, implementation efforts may be able to reserve time and finances for other elements of implementation beyond the training component.

Plain Language Summary

Educational training is a common approach for enhancing knowledge about research-supported mental health treatments. However, these trainings are often not tailored to meet the needs of the trainees, and there is insufficient evidence about whether tailoring might improve the impact of training compared to a one-size-fits-all, standard version. This study compared the impact of a tailored versus standard training on mental health clinician's intentions to use measurement-based (MBC) care for monitoring treatment progress for clients with depression. Study results indicated that intention to use MBC improved for clinicians receiving both the tailored and standard training after training completion. There were no differences in intention to use MBC care when the two types of training were compared. These study findings suggest that tailoring, which may require substantial time and effort, may not be a necessary step to improve the short-term impact of educational trainings.

Identifying the Facilitators and Barriers in Disseminating and Adopting a Health Intervention Developed by a Community-Academic Partnership

The literature regarding implementation science of evidence-based health interventions in Māori communities is limited, and there is a push for new and innovative delivery methods of health interventions in New Zealand. The purpose of the study was to identify the facilitators and barriers in implementing a health intervention designed by others and was framed by the Consolidated Framework for Implementation Research (CFIR). This study explored general perceptions of the implementation process and also included a case study, the Kaumātua Mana Motuhake (older people's autonomy and self-actualization) project; a codesigned peer education intervention for older Māori. Semistructured interviews (N = 17) were conducted via face-to-face, phone, or Zoom with health and social service professionals with experience working with Māori communities. Thematic analysis was used to analyze the data. The facilitators included community engagement, program structure, program adaptability and creators' experience. The barriers consisted of funding access, funding constraints and organizational constraints. The findings support key elements within the CFIR, highlighting the importance of community engagement and adaptability. Additionally, this study identified nuanced aspects of funding and resources that constrain organisations in employing health interventions designed by others.

Perceived barriers to assessing understanding and appreciation of informed consent in clinical trials: A mixed-method study

Introduction:

Participants and research professionals often overestimate how well participants understand and appreciate consent information for clinical trials, and experts often vary in their determinations of participant’s capacity to consent to research. Past research has developed and validated instruments designed to assess participant understanding and appreciation, but the frequency with which they are utilized is unknown.

Methods:

We administered a survey to clinical researchers working with older adults or those at risk of cognitive impairment (N = 1284), supplemented by qualitative interviews (N = 60).

Results:

We found that using a validated assessment of consent is relatively uncommon, being used by only 44% of researchers who had an opportunity. Factors that predicted adoption of validated assessments included not seeing the study sponsor as a barrier, positive attitudes toward assessments, and being confident that they had the resources needed to implement an assessment. The perceived barriers to adopting validated assessments of consent included lack of awareness, lack of knowledge, being unsure of how to administer such an assessment, and the burden associated with implementing this practice.

Conclusions:

Increasing the use of validated assessments of consent will require educating researchers on the practice and emphasizing very practical assessments, and may require Institutional Review Boards (IRBs) or study sponsors to champion the use of assessments.

Sustainability of a biobehavioral intervention implemented by therapists and sustainment in community settings

The ultimate aim of dissemination and implementation of empirically supported treatments (ESTs) in behavioral medicine is (a) sustainability of the therapist/provider's EST usage and (b) sustainment of EST delivery in the setting. Thus far, sustainability has been understudied, and the therapist and setting variables that may be influential are unclear. The purpose of the study was to test the therapists' sustainability of a cancer-specific EST using a prospective longitudinal design and examine its predictors. Oncology mental health therapists (N = 134) from diverse settings (N = 110) completed training in the biobehavioral intervention (BBI) and were provided with 6 months of support for implementation, with no support thereafter. BBI usage (percent of patients treated) was reported at 2, 4, 6, and 12 months. Using a generalized estimating equation with a logistic link function, 12-month sustainability (a nonsignificant change in usage from 6 to 12 months) was studied along with therapist, supervisor, and setting variables as predictors. BBI usage increased through 6 months and, importantly, usage was sustained from 6 (68.4% [95% CI = 62.2%-73.9%]) to 12 months (70.9% [95% CI = 63.6%-77.3%]), with sustainment in 66 settings (60.0%). Predictors of implementation-to-sustainability usage were therapists' early intentions to use the BBI (p < .001) and from the setting, supervisors' positive attitudes toward ESTs (p = .016). Adding to the DI literature, a health psychology intervention was disseminated, implemented, and found sustainable across diverse therapists and settings. Therapists and setting predictors of usage, if modified, might facilitate future sustainability/sustainment of ESTs.

Yoga for hypertensive patients: a study on barriers and facilitators of its implementation in primary care

Background

International guidelines for hypertension treatment recommend the use of yoga, particularly among low-risk patients. However, evidence is lacking on the implementation potential of health-worker-led yoga interventions in low-resource, primary care settings.

Objective

To assess barriers to and facilitators of the implementation of a yoga intervention for hypertensive patients in primary care in Nepal.

Methods

The study was conducted using focus group discussions, in-depth interviews, key informant interviews, and telephone interviews. Data were collected from the ‘Yoga and Hypertension’ (YoH) trial participants, YoH intervention implementers, and officials from the Ministry of Health and Population in Nepal.

Results

Most YoH trial participants stated that: (1) it was easy to learn yoga during a five-day training period and practise it for three months at home; (2) practising yoga improved their health; and (3) group yoga sessions in a community centre would help them practise yoga more regularly. Most YoH intervention implementers stated that: (1) they were highly motivated to implement the intervention; (2) the cost of implementation was acceptable; (3) they did not need additional staff to effectively implement the intervention; (4) providing remuneration to the staff involved in the intervention would increase their motivation; and (5) the yoga programme was ‘simple and easy to follow’ and ‘easily performed by participants of any age’. The government officials stated that: (1) yoga is considered as a key health promotional activity in Nepal; and (2) the integration of the yoga intervention into the existing health care programme would not be too challenging, because the existing personnel and other resources can be utilised.

Conclusion

While there is a good potential that a yoga intervention can be implemented in primary care, capacity development for health workers and the involvement of community yoga centres in the delivery of the interventions may be required to facilitate this implementation.

Barriers and facilitators to delivery of group audiological rehabilitation programs: a survey based on the COM-B model

OBJECTIVE

To canvas the views of Australia-based hearing healthcare clinicians regarding group audiological rehabilitation practices.

DESIGN

A national cross-sectional self-report survey. Data were analysed using descriptive statistics and content analysis.

STUDY SAMPLE

Sixty-two Australia-based hearing healthcare clinicians, with experience working in an adult rehabilitation setting.

RESULTS

Clinicians appeared to positively view the provision of group audiological rehabilitation services, yet were limited in their ability to deliver these services due to organisational barriers. Although some organisational barriers were non-modifiable by the clinician (such as group AR services not prioritised within their workplace, a lack of support from colleagues/managers, lack of resources, and a lack of funding for the delivery of group AR services), others were within the clinicians' ability to change (such as habit formation for recommending these services during clinical appointments). Participants expressed a desire for resources to assist them in delivering group AR, including downloadable lesson plans and information sheets for clients, clinician training videos and client educational videos. Clinicians called for increased diversity in program offerings, specifically relating to the emotional, relational and social impacts of hearing loss.

CONCLUSIONS

These results provide a framework for the development of interventional studies to increase the utilisation of group audiological rehabilitation services.

CBPR Implementation Framework for Community-Academic Partnerships

The Engage for Equity (E2) study is an intervention trial for community-academic research partnerships that seeks to improve partnering practices and health equity outcomes by providing community and academic partners with tools to enhance and advance power sharing and health equity. Twenty-five community/academic research teams completed a two-day training intervention where they were introduced to the CBPR Conceptual Model and corresponding applied tools to their partnerships. We report on team interviews conducted immediately after the training, where teams discussed opportunities and challenges using the CBPR Model as an implementation framework as they considered their own contexts, their partnering processes/practices, actions, and their desired outcomes. We applied Diffusion of Innovation theory to guide data collection and analysis; augmented by intent to use and collective reflection. Results pointed to the flexibility of the CBPR model, concrete use of tools (e.g., planning/evaluation), and broader use in inspiring collective reflection to improve partnering practices and inform equity values. As an implementation framework, the CBPR model incorporates collaborative processes and strategies to mitigate power differentials into key phases of implementation studies, adding factors central to health equity work, not existing in previous implementation frameworks.