Predicting utilization of evidence-based parenting interventions with organizational, service-provider and client variables

Racial and Practical Barriers to Diagnostic and Treatment Services for Black Families of Autistic Youth: A Mixed-Method Exploration

The present study explored the role race-related barriers and practical barriers to treatment participation play in treatment effectiveness and satisfaction among Black families with autistic youth using a mixed-method approach. In a sample of Black caregivers with autistic youth (N = 101), multiple regressions were conducted to examine the impact of reported racial and practical barriers on parental stress, treatment effectiveness, and treatment satisfaction. Caregivers provided further narratives on their experience navigating diagnostic and treatment services in qualitative interviews. The study demonstrated that Black caregivers of autistic youth are still encountering several racial and logistical barriers when seeking treatment and diagnostic services for their children. These barriers negatively impact caregiver stress and caregiver perceived treatment quality. Contrary to the barriers and stress experienced by Black caregivers, caregivers are generally satisfied with the treatments they are utilizing and find them helpful. The narratives told by caregivers further elucidate the tumultuous experiences of Black caregivers as they seek diagnostic and treatment services for their children. An experience that may be worsened by family, professional, and systemic barriers, and can be improved by advocacy, acceptance, peer and community support, and increased knowledge. Black families of autistic youth call for increased compassion, support, training, and humility among professionals who serve autistic youth.

Identifying Beneficial Training Elements: Clinician Perceptions of Learning the Evidence-Based GenerationPMTO Intervention

Improving the process through which mental health professionals are trained in evidence-based practices (EBPs) represents an important opportunity for extending the implementation of EBPs in community settings. In this study, we used a qualitative approach to examine the specific training elements that were beneficial to clinicians' experiences learning an evidence-based intervention. Individual, semi-structured interviews were conducted with mental health professionals completing training in the GenerationPMTO parenting intervention. Data were analyzed using the tenets of thematic analysis. Overall, participants reported positive experiences in the training and growth in their attitudes, knowledge, and confidence in GenerationPMTO. The qualitative findings also suggested seven specific training elements that participants perceived as beneficial: support, role plays, engagement, structure, writing/visuals, working with training families, and experiencing the GenPMTO model. These results are discussed within the context of the existing literature on EBP training and more broadly as they relate to expanding the implementation of evidence-based interventions. We also suggest implications for practice meant to enhance future EBP training efforts.

Predicting the Sustained Implementation of an Evidence-Based Parenting Program: A Structural Equation Modelling Approach

PURPOSE

Sustained implementation is required for evidence-based parenting programs to promote children and their families' wellbeing at the societal level. Previous literature has examined the role of a range of different factors in enhancing sustainability. However, the inter-relationship between, and the relative importance of different factors remain largely unknown. The overall aim of this study is to identify predictors of sustained program use, the relative importance of factors, and potential mediation pathways.

METHODS

We surveyed 1202 practitioners who were trained in at least one variant of the Triple P-Positive Parenting Program, at least one and half years before data collection. The present data were linked with data collected during professional training. We first examined the independent effect of each factor on sustained program use, then, developed and evaluated a structural equation model of sustained program use.

RESULTS

The structural equation model explained a considerable amount of variance in sustained program use, with seven positive predictors and one negative predictor identified. Organisational support was identified as a key facilitator, which was not only positively linked with other facilitators but also had an independent positive effect. Perceived usefulness of the program was the most important practitioner-level facilitator, which might be contributed by both research-based evidence and practice-based evidence. Practitioners' self-regulation in program delivery impacted sustained use by influencing other factors such as perceived usefulness of the program.

CONCLUSION

The findings provided insight into factors influencing the sustainability of evidence-based parenting programs which could be used to inform future implementation practice.

Successful implementation of parenting support at preschool: An evaluation of Triple P in Sweden

Although emotional and behavioural problems among young children are common and, if unaddressed, can lead to multi-facetted problems later in life, there is little research investigating the implementation of parenting programs that target these problems. In this study, the RE-AIM framework was used to evaluate the implementation of the Triple P parenting program in a preschool setting at a medium-sized municipality in Sweden. Reach increased over time, showing an overall increase in participating fathers and parents with lower education. Effectiveness outcomes showed an improvement in emotional and behavioural problems in children and less mental health-related symptoms and higher self-efficacy in parents. Adoption rate was 93.3%. To ensure staff “buy-in”, designated coordinators made changes in recruitment procedures, and provided supervision and training to all Triple P practitioners. Implementation adaptations were made, such as minor revisions of parenting strategies and other program content, as well as providing child care during seminars and groups, and setting up weekend-groups. Maintenance assessed through 12 month follow-up data suggested that several child and parent outcomes were maintained over time. Uppsala municipality continues to offer Triple P to parents. The reach, effectiveness, adoption, implementation and maintenance of the program were all satisfactory and demonstrated the suitability of delivering evidence-based parenting support using preschools as an arena.

How do Lay Health Worker Engage Caregivers? A Qualitative Study to Enhance Equity in Evidence-Based Parenting Programs

Engaging caregivers in their children's mental health treatment is critical for delivering high quality, evidence-based care, particularly for young children with externalizing behaviors. Lay health workers (LHWs), including peer providers and promotoras de salud, have been identified as important workforces in addressing structural and stigma-related barriers to engagement in mental health services. Importantly, research has suggested that LHWs may be integral in efforts to address engagement disparities in evidence-based behavioral parent training programs (BPTs) for Latinx caregivers. The purpose of the study was to understand how different LHW workforces engage caregivers within their usual services, in order to inform strategies that improve access to and engagement in BPTs. Qualitative interviews were conducted with two different LHW workforces: volunteer LHWs (i.e., promotoras de salud) (n = 14), who were part of a community-embedded network, and paid LHWs (i.e., parent support partners, home visitors) (n = 9) embedded within children's mental health agencies. Participants were predominately Latinx (79%) and female (96%). Qualitative analyses revealed three primary themes related to engagement strategies used by LHWs to address barriers to care: 1.) Building Trust, 2.) Empowerment, 3.) Increasing Access. Although the majority of themes and sub-themes were consistent across the two LHW workforces, agency-embedded LHWs often discussed having the means to provide resources through their organizations, whereas community-embedded LHWs discussed acting as a bridge to services by providing information and conducting outreach. Findings have implications for partnering with different workforces of LHWs to increase equity in access to BPTs.

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.

Knowledge of Evidence-Based Services Questionnaire: Development and Validation of a Short Form

The Knowledge of Evidence-Based Services Questionnaire (KEBSQ) is an objective measure of therapist knowledge of practices derived from the evidence base for the treatment of youth psychopathology. However, the length of this measure (i.e., 40 items) and respondent demands associated with each item makes it burdensome for researchers and clinicians. This study developed and validated a Short Form of the KEBSQ using Item Response Theory measurement models. The Short Form consists of 17 items and generates two separate scores: Correct Endorsements and Correct Rejections. The Short Form was found to correlate highly with and perform similarly to the Full Form, providing preliminary validity evidence.

Exploring Staff Implementation of a Self-directed Parenting Intervention for Parents with Mental Health Difficulties

Parents with mental health difficulties face significant barriers in accessing evidence-based parenting interventions. Self-directed approaches may be a destigmatising, accessible alternative. Evidence has suggested that Triple P Positive Parenting Programme's self-directed format is as effective as more time- and cost-intensive delivery methods. The aim of the current study was to establish whether staff were able to use this intervention with parents with mental health difficulties and to explore staff experiences of implementation. Triple P self-help workbooks were provided to practitioners across three teams. Data were collected regarding workbook uptake and use. Interviews with staff exploring their experiences of implementation were analysed using thematic analysis. Overall, 41 participants were recruited, of which 12 (29.27%) also consented to interviews. Overall, six practitioners (14.63%) reported that they utilised the workbook. Uptake and utilisation were varied, but practitioners who used the workbook reported positive outcomes. Interviews revealed themes regarding practitioner concerns, views of the intervention and implementation issues. Self-directed Triple remains a promising intervention but its feasibility is dependent on addressing barriers to implementation and facilitating a family-focused approach to meet the needs of these parents and their children.

Train-to-Sustain: Predictors of Sustainment in a Large-Scale Implementation of Parent-Child Interaction Therapy

Sustainment of evidence-based practices is necessary to ensure their public health impact. The current study examined predictors of sustainment of Parent-Child Interaction Therapy (PCIT) within a large-scale system-driven implementation effort in Los Angeles County. Data were drawn from PCIT training data and county administrative claims between January 2013 and March 2018. Participants included 241 therapists from 61 programs. Two sustainment outcomes were examined at the therapist- and program-levels: 1) PCIT claim volume and 2) PCIT claim discontinuation (discontinuation of claims during study period; survival time of claiming in months). Predictors included therapist- and program-level caseload, training, and workforce characteristics. On average, therapists and programs continued claiming to PCIT for 17.7 and 32.3 months, respectively. Across the sustainment outcomes, there were both shared and unshared significant predictors. For therapists, case-mix fit (higher proportions of young child clients with externalizing disorders) and participation in additional PCIT training activities significantly predicted claims volume. Furthermore, additional training activity participation was associated with lower likelihood of therapist PCIT claim discontinuation in the follow-up period. Programs with therapists eligible to be internal trainers were significantly less likely to discontinue PCIT claiming. Findings suggest that PCIT sustainment may be facilitated by implementation strategies including targeted outreach to ensure eligible families in therapist caseloads, facilitating therapist engagement in advanced trainings, and building internal infrastructure through train-the-trainer programs.

The Role of Professional Training Experiences and Manualized Programs in ABA Providers' Use of Parent Training With Children With Autism

Parent training, in which providers teach parents intervention strategies to promote their children's skill acquisition and/or behavior management, is considered a best practice in the treatment for children with autism spectrum disorder (ASD) and yet is underutilized in community settings. The present study examined the role of training experiences and manual use in promoting the use of parent training by community providers who serve children with ASD. Applied behavior analysis (ABA) providers (N = 1,089) from across the United States completed self-report questionnaires online. The total number of professional training experiences related to parent training significantly predicted the extensiveness of providers' use of parent training. Receiving supervision in parent training, being trained in a specific parent training approach, taking a course related to parent training, and participating in self-guided learning (e.g., webinar) were unique predictors of parent training extensiveness. While only 15% of ABA providers used manualized parent training programs, using a manual was also a unique predictor of parent training extensiveness. Parallel multiple mediator analyses demonstrated that family-, provider-, and organization-level barriers all partially mediated the relationship between number of training experiences and parent training extensiveness; only provider- and organization-level barriers mediated the relationship between manual use and parent training extensiveness. Recommendations for training and supporting providers at the pre-service and in-service levels are discussed as a means of increasing access to parent training for children with ASD in community settings.

Providers' Perspectives on Implementing a Multiple Family Group for Children with Disruptive Behavior

OBJECTIVES

The adoption of research-supported treatments is contingent upon multiple interactional levels, including provider level factors. Provider-level factors have been shown to be critical to uptake. The purpose of this study is to examine the relationship between sociodemographic factors, attitudes, and perceived barriers/facilitators to implementation through a comparative approach involving practitioners trained to facilitate a multiple family group intervention for children with disruptive behavior.

METHODS

Participants included 91 practitioners who participated in an intervention study regarding barriers to adopting an evidence-based practice. Demographic characteristics were collected via a socio-demographic questionnaire. Barriers and facilitators were assessed via open-ended questions as well as a scale, developed by the authors and guided by the Consolidated Framework for Implementation Research that explored provider views regarding the intervention, the systemic and organizational context, experience facilitating groups and involving families in treatment, and feelings toward involving families in treatment. Between group analyses were conducted to examine demographic and characteristic differences of providers by implementation status. Independent samples t-tests for continuous characteristics and chi-square tests for categorical characteristics were used. Responses to open-ended questions were compiled, reviewed, and coded, and frequencies and percentages were calculated.

RESULTS

Results demonstrated that providers who implemented the intervention were significantly more likely to have favorable attitudes toward the intervention compared to those who did not implement it. Prior experience facilitating groups was significantly associated with implementation. Common barriers to implementation included ineligible caseloads and feeling unqualified to deliver the intervention.

CONCLUSIONS

Further attention on improving recruitment rates and promoting adequate training and supervision is needed.

Practitioners' Perceptions of and Use of Triple P

A challenge of large-scale adoptions of Triple P is low uptake among accredited practitioners. The purpose of this study was to understand facilitators to program use among 249 practitioners in seven counties involved in a large-scale adoption of Triple P. In an adjusted ordinal logistic regression including length of accreditation and county, the frequency with which practitioners used Triple P was higher among those who perceived a more positive parent response to Triple P services and among those practitioners who perceived Triple P to fit better within their typical services. Agency support was not associated with frequency of use.

Measuring and Predicting Service Providers' Use of an Evidence-Based Parenting Program

This study addressed the predictors of service providers' use of a multi-level evidence-based program (EBP). Of the 92 trained providers participating in the study, 67 (72.8%) used the EBP at least once. A multidimensional index of the amount of usage (MUI) was created using three indicators. Providers' self-efficacy and the amount of training they had received predicted their amount of usage. The community to which the providers belonged was also associated with their amount of usage. The findings underline the importance of studying many indicators of usage in implementation research and considering both provider-level and broader contextual variables as determinants of the use of EBPs.

Self-Regulation Approach to Training Child and Family Practitioners

Evidence-based psychotherapies or programs (EBPs) exist for most mental health disorders that occur in childhood; however, the majority of children with a mental health disorder do not receive such treatments. This research-practice gap has been attributed to a range of factors that complicate the delivery of EBPs in everyday practice. While most suggestions to bridge this gap have focused on how to develop EBPs that will have a better fit for the clinical settings in which they will ultimately be deployed, a useful adjunct is to enhance practitioners' capacity to flexibly deliver EBPs to manage these factors. We propose that the extent to which a practitioner is able to change their own behaviour in response to cues and information about the current needs of their clients, and do so while maintaining the integrity of an EBP, may be a function of practitioners' self-regulatory capacity. In this conceptual paper, we describe a model of self-regulation that can be applied to child and family practitioners. We argue that practitioners with greater self-regulatory capacity are more likely to take up EBPs, sustain their use of them and have superior outcomes with clients. We draw on our experience in disseminating a system of parenting support to illustrate how practitioners' self-regulatory capacity can be enhanced while simultaneously receiving training in an EBP. Advantages and disadvantages of a self-regulatory approach to training are discussed and directions for future research are offered.

Pace and determinants of implementation of the self-management of well-being group intervention: a multilevel observational study

Background

When implementing an empirically supported intervention (ESI) arrays of influencing factors operate on the professional and organizational level, but so far dependency between these levels has often been ignored. The aim of this study is to describe the pace and identify determinants of implementation of the Self-Management of Well-being (SMW) group intervention while taking the dependency between professionals and organizations into account.

Methods

Pace of implementation was measured as the time between training of professionals and first use of the SMW intervention in months. Determinants of first use were derived from the Fleuren framework and assessed using web-based questionnaires and telephone interviews. First, univariate analyses, Fisher’s exact tests and t-tests, were performed to identify determinants of first use of the SMW intervention on the individual professional and the organizational level independently. Second, multilevel analyses were performed to correct for the dependency between professionals and organizations. Simple multilevel logistic regression analyses were performed with determinants found significant in the univariate analyses as independent variables, first use as dependent variable, professionals entered in the first level, and organizations in the second level.

Results

Forty-eight professionals from 18 organizations were trained to execute the SMW intervention. Thirty-two professionals achieved first use, at a mean pace of 7.5 months ± 4.2. Determinants on the professional level were ‘ownership’, ‘relative advantage’, ‘support from colleagues’ and ‘compatibility’. Determinants on the organizational level were ‘organizational size’ and ‘innovation-task orientation fit’. Multilevel analysis showed that ‘compatibility’, a factor on the professional level, was the only significant determinant contributing to first use in the multilevel model.

Conclusions

This implementation study revealed a strong dependency between professionals and organizations. Results showed that a majority of professionals used the SMW intervention in about 8 months. When the dependency between professionals and organization was taken into account, the professionals’ perception of compatibility was the only remaining determinant of implementation on the professional level. Organizational size and managers’ perception of ‘innovation-task orientation fit’ were determinants of implementation on the organizational level. It is advisable to discuss the compatibility between new and current tasks among managers and professionals before adopting a new intervention.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3891-x) contains supplementary material, which is available to authorized users.

Characterizing Intervention Strategies Used in Community-Based Mental Health Care for Infants and Their Families

Mental health interventions for infants typically target high-risk groups and can prevent long-term negative outcomes. Despite federal initiatives promoting early intervention, minimal research has examined usual care services for infants, which is important to improve routine care. The current study characterized usual care practices in infant mental health through the adaptation and administration of a provider survey. Providers (n = 126) reported using a wide range of intervention strategies and few intervention programs with varied evidence. Findings can inform future research to identify quality improvement targets of usual mental health care for high-risk infants and their families.

Barriers and Facilitators to Implementing Functional Family Therapy in a Community Setting: Client and Practitioner Perspectives

While Functional Family Therapy (FFT) is known to be effective in addressing adolescent behavioral problems, there has been little exploration of issues relevant to its transport from the tightly controlled setting of clinical trials into routine service delivery. This study sought the views of key stakeholders, clients, and practitioners, on barriers and facilitators to the successful implementation of FFT. Undertaken in a community setting in Scotland, interviews were carried out with 12 adolescents, 14 parents/caregivers, and 6 practitioners. Results focus on: Referral process and pre-intervention contact; Engagement of families; Structure and delivery; Organizational factors. Although barriers to engagement were identified, FFT was viewed as an acceptable, appropriate and feasible intervention with the potential to improve adolescent wellbeing in 'real-world' settings.

An Exploratory Factor Analysis of the Knowledge of Evidence-Based Services Questionnaire

Recent developments for disseminating and implementing evidence-based practices (EBPs) have emphasized the importance of increasing therapists' knowledge of such techniques. However, systematic efforts to measure knowledge in therapists serving youth have mostly relied on poorly researched study-specific measures. This study investigated the structure of EBP knowledge in a large sample of youth community therapists (N = 240) via a therapist report instrument emphasizing therapeutic commonalities across various types of treatment approaches. Findings supported a three-factor structure of knowledge with scores on factors varying by therapists' primary practice setting and education level. The relationships between therapist knowledge of and attitudes towards EBPs are also discussed.

Identifying the determinants of use of the G&G interventions for older adults in health and social care: protocol of a multilevel approach

Background

Despite aging-related losses, many older adults are able to maintain high levels of subjective well-being. However, not all older adults are able to self-manage and adapt. The GRIP&GLEAM [Dutch: GRIP&GLANS] (G&G) interventions have shown to significantly improve self-management ability, well-being and loneliness in older adults. Actual use of the evidence-based G&G interventions, however, remains limited as long as the interplay between implementation factors at different hierarchical stakeholder levels is poorly understood. The aim of the study is to identify the determinants of successful implementation of the G&G interventions.

Methods/design

The study is performed in health and social care organizations in the northern part of the Netherlands. The degree of implementation success is operationalized by four parameters: use (yes/no), pace (time to initial use), performance (extent of use) and prolongation (intention to continue use). Based on the Fleuren model, factors at four hierarchical stakeholder levels (i.e. target group, professionals, organizations and financial-political context) are assessed at three measurement points in 2 years. The nested data are analyzed applying multilevel modeling techniques.

Discussion

In this study, health and social care organizations are considered to be part of multilevel functional systems, in which factors at different hierarchical stakeholder levels impede or facilitate use of the G&G interventions. Strengths of the study are the multifaceted measurement of use, and the multilevel approach in identifying the determinants. The study will contribute to the development of ecologically valid implementation strategies of the G&G interventions and comparable evidence-based practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1262-1) contains supplementary material, which is available to authorized users.

Are inner context factors related to implementation outcomes in cognitive-behavioral therapy for youth anxiety?

Among the challenges facing the mental health field are the dissemination and implementation of evidence-based practices. The present study investigated the relationships between inner context variables (i.e., adopter characteristics and individual perceptions of intra-organizational factors) and two implementation outcomes-independently rated therapist fidelity on a performance-based role-play (i.e., adherence and skill) and self-reported penetration of cognitive behavioral therapy for youth anxiety following training. A significant relationship was found between inner context variables and fidelity. Specifically, adopter characteristics were associated with adherence and skill; individual perceptions of intra-organizational factors were associated with adherence. Inner context variables were not associated with penetration. Future directions are discussed.

"If it's worth my time, i will make the time": school-based providers' decision-making about participating in an evidence-based psychotherapy consultation program

This study evaluated influences on school-based clinicians' decision-making surrounding participation in a modular psychotherapy training and consultation program lasting one academic year. Clinicians were recruited from three participation groups: those who never engaged, those who engaged and then discontinued, and those who participated fully. Qualitative interviews explored influences on initial and continued participation, as well as differences in decision-making by participation group, knowledge about evidence-based practices, and attitudes toward evidence-based practices. Eight major themes were identified: time, practice utility, intervention/training content, training process, attitudes toward training, social influences, commitment to training, and expectations. Some themes were discussed universally across all comparison groups, while others varied in frequency or content. Recommendations for increasing participation are presented, based on the findings.

Organizational factors influencing implementation of evidence-based practices for integrated treatment in behavioral health agencies

Objective. In recent years, New Mexico has prioritized integrated treatment for cooccurring mental health and substance use disorders within its public behavioral health system. This report describes factors likely to be important when implementing evidence-based practices (EBPs) in community agencies. Methods. Our mixed-method research design consisted of observations, semistructured interviews, and surveys undertaken with employees at 14 agencies at baseline and after 18 months. We developed four-agency typologies based on iterative coding and analysis of observations and interviews. We then examined survey data from employees at the four exemplar agencies to validate qualitative findings. Results. Financial resources and strong leadership impacted agency capacity to train providers and implement EBPs. Quantitative analysis of service provider survey responses from these agencies (N = 38) supported qualitative findings and demonstrated significant mean score differences in leadership, organizational climate, and attitudes toward EBPs in anticipated directions. Conclusion. The availability of strong leadership and financial resources were key components to initial implementation success in this study of community agencies in New Mexico. Reliance only on external funding poses risks for sustainment when demoralizing work climates precipitate employee turnover. Strong agency leadership does not always compensate for deficient financial resources in vulnerable communities.

Exploration-Stage Implementation Variation

The present study examines the effect of agency-level implementation variation on the cost-effectiveness of an evidence-based parent training program (Positive Parenting Program: “Triple P”). Staff from six community-based agencies participated in a five-day training to prepare them to deliver a 12-week Triple P parent training group to caregivers. Prior to the training, administrators and staff from four of the agencies completed a site readiness process intended to prepare them for the implementation demands of successfully delivering the group, while the other two agencies did not complete the process. Following the delivery of each agency’s first Triple P group, the graduation rate and average cost per class graduate were calculated. The average cost-per-graduate was over seven times higher for the two agencies that had not completed the readiness process than for the four completing agencies ($7,811 vs. $1,052). The contrast in costs was due to high participant attrition in the Triple P groups delivered by the two agencies that did not complete the readiness process. The odds of Triple P participants graduating were 12.2 times greater for those in groups run by sites that had completed the readiness process. This differential attrition was not accounted for by between-group differences in participant characteristics at pretest. While the natural design of this study limits the ability to empirically test all alternative explanations, these findings indicate a striking cost savings for sites completing the readiness process and support the thoughtful application of readiness procedures in the early stages of an implementation initiative.

Dissemination and implementation of evidence-based practices for child and adolescent mental health: a systematic review

OBJECTIVE

Although there has been a dramatic increase in the number of evidence-based practices (EBPs) to improve child and adolescent mental health, the poor uptake of these EBPs has led to investigations of factors related to their successful dissemination and implementation. The purpose of this systematic review was to identify key findings from empirical studies examining the dissemination and implementation of EBPs for child and adolescent mental health.

METHOD

Of 14,247 citations initially identified, 73 articles drawn from 44 studies met inclusion criteria. The articles were classified by implementation phase (exploration, preparation, implementation, and sustainment) and specific implementation factors examined. These factors were divided into outer (i.e., system level) and inner (i.e., organizational level) contexts.

RESULTS

Few studies used true experimental designs; most were observational. Of the many inner context factors that were examined in these studies (e.g., provider characteristics, organizational resources, leadership), fidelity monitoring and supervision had the strongest empirical evidence. Albeit the focus of fewer studies, implementation interventions focused on improving organizational climate and culture were associated with better intervention sustainment as well as child and adolescent outcomes. Outer contextual factors such as training and use of specific technologies to support intervention use were also important in facilitating the implementation process.

CONCLUSIONS

The further development and testing of dissemination and implementation strategies is needed to more efficiently move EBPs into usual care.

Engineering youth service system infrastructure: Hawaii's continued efforts at large-scale implementation through knowledge management strategies

Hawaii's Child and Adolescent Mental Health Division provides a unique illustration of a youth public mental health system with a long and successful history of large-scale quality improvement initiatives. Many advances are linked to flexibly organizing and applying knowledge gained from the scientific literature and move beyond installing a limited number of brand-named treatment approaches that might be directly relevant only to a small handful of system youth. This article takes a knowledge-to-action perspective and outlines five knowledge management strategies currently under way in Hawaii. Each strategy represents one component of a larger coordinated effort at engineering a service system focused on delivering both brand-named treatment approaches and complimentary strategies informed by the evidence base. The five knowledge management examples are (a) a set of modular-based professional training activities for currently practicing therapists, (b) an outreach initiative for supporting youth evidence-based practices training at Hawaii's mental health-related professional programs, (c) an effort to increase consumer knowledge of and demand for youth evidence-based practices, (d) a practice and progress agency performance feedback system, and (e) a sampling of system-level research studies focused on understanding treatment as usual. We end by outlining a small set of lessons learned and a longer term vision for embedding these efforts into the system's infrastructure.

Implementing an evidence-based parenting program in community agencies: what helps and what gets in the way?

Adoption of evidence-based programs for families by community agencies requires an understanding of variables that influence implementation. Managers and service providers from 64 community agencies reported on variables that affected the implementation of Triple P, an evidence-based parenting program. Both types of stakeholders reported adequate office resources; over half the managers and over two-thirds of service providers reported adequate training. Adequate office resources and positive agency characteristics, including organizational climate, were associated with higher program usage. Service providers' reports of the variables impacted their individual adherence rates; managers had broader perspectives of the quality of implementation in their organizations.

Effects of workshop trainings on evidence-based practice knowledge and attitudes among youth community mental health providers

Enhancing the public health impact of evidence-based practices (EBPs) in usual care settings is a key priority of the National Institute of Mental Health. Longitudinal data from community mental health providers (N = 268) participating in a series of state-sponsored workshops in modular approaches to EBPs for youth are presented. EBP workshop attendance for youth anxiety resulted in increased knowledge for EBPs for anxiety (and not other conditions) and EBP workshop attendance for youth disruptive behaviors resulted in increased knowledge for EBPs for disruptive behaviors (and not other conditions). Providers' tendencies toward incorrectly classifying non-EBP therapies as evidence-based increased over time, suggesting that providers over-generalize the EBP label as a result of attending these types of workshops. Regarding EBP attitudes, most measures of attitudes improved when providers attended a workshop. Additionally, an overly inclusive view of what constitutes an EBP at intake was related to significant decreases in openness to trying EBPs over time, whereas more positive attitudes at intake was related to achieving a more refined view of what constitutes an EBP over the course of attending trainings. Study limitations and implications for implementation of EBPs in usual care settings are discussed.

Facilitators and barriers to implementation of an evidence-based parenting intervention to prevent child maltreatment: the Triple P-Positive Parenting Program

The prevention of child maltreatment via parenting interventions requires implementation on a broad scale, which is facilitated by drawing on a multidisciplinary array of service workers located in multiple settings. This underscores the importance of understanding factors that impact worker implementation of evidenced-based parenting and family support interventions. This study involved structured interviews with 174 service providers from several disciplines who had been trained previously in the delivery of the Triple P-Positive Parenting Program. These follow-up interviews, conducted an average of about 2 years after professional in-service training, provided the basis for examining predictors of sustained program use. Predictors examined included facilitators and barriers to program use, as well as organizational and provider-level characteristics such as attitudes toward evidence-based interventions. Highlighting the importance of a systems-contextual perspective on implementation, several provider and organization-level characteristics significantly predicted program use including provider self-confidence after training, fit of program with ongoing duties, availability of posttraining support, and perceived benefit of intervention for children and families. Implications for prevention and implementation science are discussed in view of the challenges inherent in the field of child maltreatment.

Preventing behavioural and emotional problems in children who have a developmental disability: a public health approach

Children with developmental disabilities are at substantially greater risk of developing emotional and behavioural problems compared to their typically developing peers. While the quality of parenting that children receive has a major effect on their development, empirically supported parenting programs reach relatively few parents. A recent trend in parenting intervention research has been the adoption of a public health approach to improve the quality of parenting at a population level. This has involved delivering parenting interventions on a large scale and in a cost-effective manner. Such trials have been demonstrated to reduce negative parenting practices, prevent child maltreatment, and reduce child behavioural and emotional problems. However, these trials have been restricted to parents of children who are developing typically. This paper explores the rational for the extension of a population health approach to parenting interventions for children with developmental disabilities. It is argued that a population-based implementation and evaluation trial of an empirically supported system of interventions is needed to determine whether this approach is viable and can have a positive impact on parents and their children in a disability context. The Stepping Stones Triple P--Positive Parenting Program is presented as an example of a parenting intervention that satisfies the requirements for such a trial. Tasks and challenges of such a trial are discussed.

Therapist training in empirically supported treatments: a review of evaluation methods for short- and long-term outcomes

Therapist training efforts have been assessed using several outcomes. A model for evaluating therapist training in empirically supported treatments is presented, adapted from Kirkpatrick's (in: Craig and Bittel (eds.) Training and development handbook, 1967) training evaluation model. The adapted framework includes short-term outcomes, such as reactions to training and changes in attitude, knowledge, or skills, and longer-term outcomes, such as changes in therapist behavior in practice or client outcomes. Evaluation methods for these outcomes are reviewed, with information on their validity, reliability, and feasibility. An agenda for further research to improve therapist training evaluation is presented, with discussion of how evaluation can inform other areas of the field.

Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective

Evidence-based practice (EBP), a preferred psychological treatment approach, requires training of community providers. The systems-contextual (SC) perspective, a model for dissemination and implementation efforts, underscores the importance of the therapist, client, and organizational variables that influence training and consequent therapist uptake and adoption of EBP. This review critiques the extant research on training in EBP from an SC perspective. Findings suggest that therapist knowledge improves and attitudinal change occurs following training. However, change in therapist behaviors (e.g., adherence, competence, and skill) and client outcomes only occurs when training interventions address each level of the SC model and include active learning. Limitations as well as areas for future research are discussed.