Advancing the science of dissemination and implementation in behavioral medicine: evidence and progress

An orientation for new researchers to key domains, processes, and resources in implementation science

The growth of dissemination and implementation (D&I) research over the last decade has produced a wealth of theories, frameworks, methods, strategies, and resources to inform the translation of evidence into wider practice. This article seeks to frame and orient researchers from the behavioral sciences to the rapidly growing interdisciplinary field of D&I science. We describe five domains across D&I research and practice: context assessment and intervention selection, dissemination, adaptation, implementation, and sustainability. We also discuss evaluation and communication as critical processes to drive ongoing learning and improvement across the five domains. In each section, we include widely cited literature and resources that readers may use to orient themselves to the field, and identify areas that they may want to explore further. This article organizes major areas of D&I science focusing on key definitions, approaches, and commonly used resources. It provides an introduction to researchers new to this area on how to conceptualize and navigate the field of D&I science, with the ultimate goal of increasing the reach and impact of evidence-based interventions.

Oral health interventions for older people in residential aged care facilities: a protocol for a realist systematic review

INTRODUCTION

Poor oral health among older people is a global problem impacting on health and well-being. The economic cost to the health system is significant. An ageing population is intensifying the urgency for action. However, poor oral health, particularly for those in residential aged care facilities, continues to be highly resistant to resolution. The overall aims of this realist review are to: (A) explore and synthesise evidence on oral health interventions for older people in residential aged care facilities, (B) produce a causal theory on how contextual factors and mechanisms interact to produce outcomes, and (C) produce guidelines/policies to inform high-quality oral health interventions to improve older people's oral health in residential aged care facilities.

METHODS AND ANALYSIS

The review is guided by the RAMESES publication standards for realist synthesis. Participants include older people in residential aged care facilities, the aged care workforce, carers and families. Interventions include oral healthcare, oral health education, policy interventions and oral health promotion. The five-step realist review process of Pawson et al will guide the review: clarification of scope and development of initial framework, systematic searches, study appraisal and data extraction, synthesising evidence, drawing conclusions, and dissemination, implementation and evaluation. Expert input with key stakeholders will occur through a blog. Stakeholders will examine consistencies across studies and an explanatory causal theory will be developed to guide policy and practice.

ETHICS AND DISSEMINATION

Formal ethical approval was granted by the La Trobe University Ethics Committee HREC 20144. The developed theory will guide education, practice and policy decisions about interventions and the factors that impact on implementation. Using an integrated knowledge translation approach, traditional research outputs such as international conference presentations and publications will be supplemented with stakeholder forums, infographics, blogs, social media postings, webinars, podcasts and writing for web-based independent outlets.

PROSPERO REGISTRATION NUMBER

CRD42021155658.

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

OBJECTIVE

This study explored perspectives of researchers working with the National Institute of Mental Health (NIMH) Scale-Up Hubs, consisting of research partnerships for scaling up mental health interventions in low- and middle-income countries (LMICs), to: 1) identify common barriers to conducting impactful research on the implementation of evidence-based mental health services; and 2) provide recommendations to overcome these implementation challenges.

METHODS

A sequential qualitative approach was employed. First, an open-ended survey was distributed to the 10 Scale-Up Hubs and NIMH program staff asking informants to identify challenges in conducting mental health implementation research in LMICs. Second, survey findings guided an in-person workshop to generate implementation recommendations to inform the field.

RESULTS

In total, 46 respondents completed surveys, and 101 researchers attended the workshop. The workshop produced implementation recommendations for low-resource settings: 1) identifying impact of research on policy and practice; 2) sustaining careers of early researchers in global mental health; 3) engaging policymakers and donors to value mental health research; 4) supporting the workforce for delivering evidence-based treatments for mental disorders; and 5) promoting sustainability of programs.

CONCLUSIONS

These findings can strengthen collaboration between researchers and key stakeholders, and highlight important targets for improving mental health implementation research in LMICs.

Implementation and effectiveness of a multi-domain program for older adults at risk of cognitive impairment at neighborhood senior centres

To address the paucity of research investigating the implementation of multi-domain dementia prevention interventions, we implemented and evaluated a 24-week, bi-weekly multi-domain program for older adults at risk of cognitive impairment at neighborhood senior centres (SCs). It comprised dual-task exercises, cognitive training, and mobile application-based nutritional guidance. An RCT design informed by the Reach, Effectiveness, Adoption, Implementation, Maintenance framework was adopted. Outcome measures include cognition, quality of life, blood parameters, and physical performance. Implementation was evaluated through questionnaires administered to participants, implementers, SC managers, attendance lists, and observations. The program reached almost 50% of eligible participants, had an attrition rate of 22%, and was adopted by 8.7% of the SCs approached. It was implemented as intended; only the nutritional component was re-designed due to participants' unfamiliarity with the mobile application. While there were no between-group differences in cognition, quality of life, and blood parameters, quality of life reduced in the control group and physical function improved in the intervention group after 24 weeks. The program was well-received by participants and SCs. Our findings show that a multi-domain program for at-risk older adults has benefits and can be implemented through neighborhood SCs. Areas of improvement are discussed.Trial registration: ClinicalTrials.gov NCT04440969 retrospectively registered on 22 June 2020.

Using telemedicine to support care for people with type 2 diabetes mellitus: a qualitative analysis of patients' perspectives

OBJECTIVE

Telemedicine has been promoted as an economical and effective way to enhance patient care, but its acceptance among patients in low-income and middle-income countries is poorly understood. This study is aimed to explore the experiences and perspectives of people with type 2 diabetes mellitus that used telemedicine to manage their condition.

DESIGN

In-depth and focus group interviews were conducted with participants who have engaged in telemedicine. Questions included were participants' perception on the programme being used, satisfaction as well as engagement with the telemedicine programme. All interviews and focus groups were audio-recorded and transcribed verbatim. Data were analysed using a thematic approach.

PARTICIPANTS AND SETTING

People with type 2 diabetes (n=48) who participated in a randomised controlled study which examined the use of telemedicine for diabetes management were recruited from 11 primary care clinics located within the Klang Valley.

RESULTS

Twelve focus groups and two in-depth interviews were conducted. Four themes emerged from the analysis: (1) generational difference; (2) independence and convenience, (3) sharing of health data and privacy and (4) concerns and challenges. The main obstacles found in patients using the telemedicine systems were related to internet connectivity and difficulties experienced with system interface. Cost was also another significant concern raised by participants. Participants in this study were primarily positive about the benefits of telemedicine, including its ability to provide real-time data and disease monitoring and the reduction in clinic visits.

CONCLUSION

Despite the potential benefits of telemedicine in the long-term care of diabetes, there are several perceived barriers that may limit the effectiveness of this technology. As such, collaboration between educators, healthcare providers, telecommunication service providers and patients are required to stimulate the adoption and the use of telemedicine.NCT0246680.

Opinion: psychiatry formal education courses have been lost in transition

OBJECTIVE

With reference to relevant literature, this article explores the impact of moving to a competency-based training programme upon psychiatry formal education courses (FECs).

CONCLUSIONS

In the context of major changes in psychiatry training, FECs have lost clarity of role, alignment and governance. Strategic decisions made with key stakeholders are required to continue to train psychiatrists best able to meet future community needs.

Accelerating implementation of shared decision-making in the Netherlands: An exploratory investigation

OBJECTIVE

To prioritize strategies to implement shared decision-making (SDM) in daily practice, resulting in an agenda for a nationwide approach.

METHODS

This was a qualitative, exploratory investigation involving: Interviews (N = 43) to elicit perceived barriers to and facilitators of change, focus group discussions (N = 51) to develop an implementation strategy, and re-affirmation through written feedback (n = 19). Professionals, patients, researchers and policymakers from different healthcare sectors participated. Determinants for change were addressed at four implementation levels: (1) the concept of SDM, (2) clinician and/or patient, (3) organizational context and (4) socio-political context.

RESULTS

Following the identification of perceived barriers, four strategies were proposed to scale up SDM: 1) stimulating intrinsic motivation among clinicians via an integrated programmatic approach, 2) training and implementation in routine practice, 3) stimulating the empowerment of patients, 4) creating an enabling socio-political context.

CONCLUSION

Clinicians mentioned that applying SDM makes their job more rewarding and indicated that implementation in daily practice needs ground-up redesign. The challenge is to effectively influence the behavior of clinicians and patients alike, and adapt clinical pathways to facilitate the exploration of patient values.

PRACTICE IMPLICATIONS

Stakeholders should connect nationwide initiatives to pool information, and make the healthcare system supportive of implementing SDM.

A group-based lifestyle intervention for diabetes prevention in low- and middle-income country: implementation evaluation of the Kerala Diabetes Prevention Program

BACKGROUND

While several efficacy trials have demonstrated diabetes risk reduction through targeting key lifestyle behaviours, there is a significant evidence gap in relation to the successful implementation of such interventions in low- and middle-income countries (LMICs). This paper evaluates the implementation of a cluster randomised controlled trial of a group-based lifestyle intervention among individuals at high-risk of developing type 2 diabetes mellitus (T2DM) in the state of Kerala, India. Our aim is to uncover provider-, participant- and community-level factors salient to successful implementation and transferable to other LMICs.

METHODS

The 12-month intervention program consisted of (1) a group-based peer-support program consisting of 15 sessions over a period of 12 months for high-risk individuals, (2) peer leader (PL) training and ongoing support for intervention delivery, (3) diabetes education resource materials and (4) strategies to stimulate broader community engagement. The evaluation was informed by the RE-AIM and PIPE frameworks.

RESULTS

Provider-level factors: Twenty-nine (29/30, 97%) intervention groups organised all 15 sessions. A 2-day PL training was attended by 51(85%) of 60 PLs. The PL handbook was found to be 'very useful' by 78% of PLs. Participant-level factors: Of 1327 eligible individuals, 1007(76%) participants were enrolled. On average, participants attended eight sessions. Sixty-eight percent rated their interest in group sessions as 'very interested', and 55% found the group sessions 'very useful' in making lifestyle changes. Inconvenient time (43%) and location (21%) were found to be important barriers for participants who did not attend any sessions. Community-level factors: Community-based activities reached to 41% of the participants for walking groups, 40% for kitchen garden training, and 31% for yoga training. PLs were readily available for support outside the sessions, as 75% of participants reported extracurricular contacts with their PLs. The commitment from the local partner institute and political leaders facilitated the high uptake of the program.

CONCLUSION

A comprehensive evaluation of program implementation from the provider-, participant- and community-level perspectives demonstrates that the K-DPP program was feasible and acceptable in changing lifestyle behaviours in high-risk individuals. The findings from this evaluation will guide the future delivery of structured lifestyle modification diabetes programs in LMICs.

TRIAL REGISTRATION

Trial registration: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909 . Registered 10 March 2011.

Randomised-controlled trial of a web-based dietary intervention for patients with type 2 diabetes: changes in health cognitions and glycemic control

BACKGROUND

Increasing prevalence and disease burden has led to an increasing demand of programs and studies focused on dietary and lifestyle habits, and chronic diseases such as type 2 diabetes mellitus (T2DM). We evaluated the effects of a 6-month web-based dietary intervention on Dietary Knowledge, Attitude and Behaviour (DKAB), Dietary Stages of Change (DSOC), fasting blood glucose (FBG) and glycosylated haemoglobin (HbA1c) in patients with uncontrolled HbA1c (> 7.0%) in a randomised-controlled trial (myDIDeA) in Malaysia.

METHODS

The e-intervention group (n = 62) received a 6-month web-delivered intensive dietary intervention while the control group (n = 66) continued with their standard hospital care. Outcomes (DKAB and DSOC scores, FBG and HbA1c) were compared at baseline, post-intervention and follow-up.

RESULTS

While both study groups showed improvement in total DKAB score, the margin of improvement in mean DKAB score in e-intervention group was larger than the control group at post-intervention (11.1 ± 0.9 vs. 6.5 ± 9.4,p < 0.001) and follow-up (19.8 ± 1.1 vs. 7.6 ± 0.7,p < 0.001), as compared to the baseline. Although there was no significant difference between intervention and control arms with respect to DSOC score and glycaemic control, the e-intervention group showed improved DSOC score (199.7 ± 18.2 vs193.3 ± 14.6,p = 0.046), FBG (7.9 ± 2.5 mmol/L vs. 8.9 ± 3.9 mmol/L,p = 0.015) and HbA1c (8.5 ± 1.8% vs. 9.1 ± 2.0%,p = 0.004) at follow-up compared to the baseline, whereas such improvement was not seen in the control group.

CONCLUSIONS

Most important impact of myDIDeA was on the overall DKAB score. This study is one of the first to demonstrate that an e-intervention can be a feasible method for implementing chronic disease management in developing countries. Concerns such as self-monitoring, length of intervention, intense and individualized intervention, adoption of other domains of Transtheoretical Model and health components, and barriers to change have to be taken into consideration in the development of future intervention programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246687 .

Interventions for acute stroke management in Africa: a systematic review of the evidence

BACKGROUND

The past decades have witnessed a rapid evolution of research on evidence-based acute stroke care interventions worldwide. Nonetheless, the evidence-to-practice gap in acute stroke care remains variable with slow and inconsistent uptake in low-middle income countries (LMICs). This review aims to identify and compare evidence-based acute stroke management interventions with alternative care on overall patient mortality and morbidity outcomes, functional independence, and length of hospital stay across Africa.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. An electronic search was conducted in six databases comprising MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Academic Search Complete and Cochrane Library for experimental and non-experimental studies. Eligible studies were abstracted into evidence tables and their methodological quality appraised using the Joanna Briggs Institute checklist. Data were analysed and presented narratively with reference to observed differences in patient outcomes, reporting p values and confidence intervals for any possible relationship.

RESULTS

Initially, 1896 articles were identified and 37 fully screened. Four non-experimental studies (three cohort and one case series studies) were included in the final review. One study focused on the clinical efficacy of a stroke unit whilst the remaining three reported on thrombolytic therapy. The results demonstrated a reduction in patient deaths attributed to stroke unit care and thrombolytic therapy. Thrombolytic therapy was also associated with reductions in symptomatic intracerebral haemorrhage (SICH). However, the limited eligible studies and methodological limitations compromised definitive conclusions on the extent of and level of efficacy of evidence-based acute stroke care interventions across Africa.

CONCLUSION

Evidence from this review confirms the widespread assertion of low applicability and uptake of evidence-based acute stroke care in LMICs. Despite the limited eligible studies, the overall positive patient outcomes following such interventions demonstrate the applicability and value of evidence-based acute stroke care interventions in Africa. Health policy attention is thus required to ensure widespread applicability of such interventions for improved patients' outcomes. The review findings also emphasises the need for further research to unravel the reasons for low uptake.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016051566.

Behavioral and Social Sciences at the National Institutes of Health: adoption of research findings in health research and practice as a scientific priority

The National Institutes of Health's Office of Behavioral and Social Sciences Research (OBSSR) recently released its Strategic Plan for 2017 to 2021. This plan highlights three scientific priorities: (1) improve the synergy of basic and applied behavioral and social sciences research, (2) enhance and promote the research infrastructure, methods, and measures needed to support a more cumulative and integrated approach to behavioral and social sciences research, and (3) facilitate the adoption of behavioral and social sciences research findings in health research and in practice. This commentary focuses on the challenges and opportunities to facilitate the adoption of research findings in health research and in practice. In addition to the ongoing NIH support for dissemination and implementation (D&I) research, we must address transformative challenges and opportunities such as better disseminating and implementing D&I research, merging research and practice, adopting more rigorous and diverse methods and measures for both D&I and clinical trials research, evaluating technological-based delivery of interventions, and transitioning from minimally adaptable intervention packages to planned adaptations rooted in behavior change principles. Beyond translation into practice and policy, the OBSSR Strategic Plan also highlights the need for translation of behavioral and social science findings into the broader biomedical research enterprise.

Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals

OBJECTIVE

Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings.

DESIGN

A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes.

SETTING

A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana.

PARTICIPANTS

A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian.

RESULTS

Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals.

CONCLUSION

Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.