Designing for dissemination: lessons in message design from "1-2-3 pap"

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

A Web-Based Decision Aid for Caregivers of Persons With Dementia With Firearm Access (Safe at Home Study): Protocol for a Randomized Controlled Trial

BACKGROUND

Firearm safety among individuals with Alzheimer disease and related dementias (ADRD) is an underdiscussed and underresearched concern in the United States, especially given the growing population of community-dwelling adults with ADRD. The "Safety in Dementia" (SiD) web-based decision aid was developed to support caregivers in addressing firearm access; the efficacy of SiD is unknown.

OBJECTIVE

Through the SiD decision aid, the Safe at Home (S@H) study aims to support caregivers in making decisions about home safety that align with their goals and values, and behaviors regarding firearm access for persons with ADRD and firearm access.

METHODS

The S@H study is a 2-armed randomized controlled trial to test the effect of the SiD decision aid on caregivers of community-dwelling adults with ADRD who have firearm access. S@H aims to recruit 500 ADRD caregivers (age ≥18 years, fluent in English or Spanish, and in the United States) through online or social media advertisements and through relevant organizations. Participants are randomized to view SiD or a control website at their own pace; all participants complete web-based questionnaires at baseline, 2 weeks, 2 months, and 6 months. The primary outcome is immediate preparation for decision-making; secondary outcomes include longitudinal decision outcomes and self-reported modifications to firearm access. The relative reach and effectiveness of each recruitment method (online/social media and through relevant organizations) will be assessed by examining differences in caregiver participation, retention rates, and relative cost.

RESULTS

The study enrollment began in May 2022. As of December 2022, a total of 117 participants had enrolled.

CONCLUSIONS

The S@H study is the first randomized trial of a firearm safety decision aid for ADRD caregivers. The results from this study will inform how best to support caregivers in decision-making regarding firearm safety. Further, results may guide approaches for recruiting caregivers and for dissemination of resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05173922; https://clinicaltrials.gov/ct2/show/NCT05173922.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43702.

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.

Classifying Community Organizational Health Communication Networks: Local Health Department Recognition of Public Information-Sharing Partners Across Sectors

OBJECTIVE

Local health departments (LHDs) operate within complex, multisectoral organizational communication networks. Network composition may affect priorities, processes, and the reach of health information to key stakeholders. This study seeks to elucidate variation in local network structures to examine how different constellations may affect information sharing across audiences.

DESIGN

This study analyzes data from a 2016 US survey of 491 metropolitan LHDs and 556 nonmetropolitan LHDs. Researchers first conducted social network analysis of network density, defined as the total number of potential organizations contributing to a jurisdiction's health communication activities. Researchers then conducted logistic regression to compare the relationship between network density and reported health communication activities targeting 3 specific audiences: policy makers, lay publics, and mass media.

RESULTS

Three network types emerged on the basis of the number of organizations that contribute to health communication activities, with low-density Minimal networks more common in nonmetropolitan jurisdictions and higher-density Expanded and Robust networks more common in metropolitan jurisdictions. LHDs in Minimal networks were significantly less likely to communicate with policy makers, lay publics, and mass media than their counterparts in higher-density networks (P < .05).

CONCLUSIONS

LHDs are embedded in organizational communication networks that vary in both the number of communication partners and the types of audiences reached. Examining their own local organizational communication networks may provide insights into LHDs that wish to improve the effectiveness of public health messaging. By adding organizational communication partners and reaching new audiences, LHDs in Minimal networks can expand the reach of messages designed to help policy makers, communities, and individuals promote health and prevent disease.

The NUDGE trial pragmatic trial to enhance cardiovascular medication adherence: study protocol for a randomized controlled trial

Background

Nearly half of patients do not take their cardiovascular medications as prescribed, resulting in increased morbidity, mortality, and healthcare costs. Mobile and digital technologies for health promotion and disease self-management offer an opportunity to adapt behavioral “nudges” using ubiquitous mobile phone technology to facilitate medication adherence. The Nudge pragmatic clinical trial uses population-level pharmacy data to deliver nudges via mobile phone text messaging and an artificial intelligent interactive chat bot with the goal of improving medication adherence and patient outcomes in three integrated healthcare delivery systems.

Methods

The Theory of mHealth, the Expanded RE-AIM/PRISM, and the PRECIS-2 frameworks were used for program planning, implementation, and evaluation, along with a focus on dissemination and cost considerations. During the planning phase, the Nudge study team developed and piloted a technology-based nudge message and chat bot of optimized interactive content libraries for a range of diverse patients. Inclusion criteria are very broad and include patients in one of three diverse health systems who take medications to treat hypertension, atrial fibrillation, coronary artery disease, diabetes, or hyperlipidemia. A target of approximately 10,000 participants will be randomized to one of 4 study arms: usual care (no intervention), generic nudge (text reminder), optimized nudge, and optimized nudge plus interactive AI chat bot. The PRECIS-2 tool indicated that the study protocol is very pragmatic, although there is variability across PRECIS-2 dimensions.

Discussion

The primary effectiveness outcome is medication adherence defined by the proportion of days covered (PDC) using pharmacy refill data. Implementation outcomes are assessed using the RE-AIM framework, with a particular focus on reach, consistency of implementation, adaptations, cost, and maintenance/sustainability. The project has limitations including limited power to detect some subgroup effects, medication complications (bleeding), and longer-term outcomes (myocardial infarction). Strengths of the study include the diverse healthcare systems, a feasible and generalizable intervention, transparent reporting using established pragmatic research and implementation science frameworks, strong stakeholder engagement, and planning for dissemination and sustainment.

Trial registration

ClinicalTrials.govNCT03973931. Registered on 4 June 2019. The study was funded by the NIH; grant number is 4UH3HL144163-02 issued 4/5/19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05453-9.

Scale up mHealth HIV interventions: site and public health perspectives and lessons learned from P3

A number of mobile health (mHealth) interventions have been shown to be effective and highly acceptable tools for improving human immunodeficiency virus (HIV) prevention and care for youth. Scale-up of efficacious technology-based interventions is challenging and best practices for scale-up have not been clearly established. Developers of mHealth interventions should have plans in mind for wide scale implementation throughout all stages of development including planning, during trials and during analysis and dissemination. We discuss an approach of focus on researchers, funders and potential implementers including members of the community, public health practitioners and policymakers during initial planning, trials, analysis and dissemination, and planning for scale-up. Development of the P3 (Prepared, Protected, emPowered) mobile application (app), an intervention built to encourage and increase pre-exposure prophylaxis (PrEP) adherence among young men who have sex with men (YMSM) and young transgender women who have sex with men (YTWSM), is discussed in terms of designing for scale-up and lessons learned.

From Need to Policy: Community Supported Development and Implementation of the South Carolina Vulnerable Adult Guardian Ad Litem (SC VAGAL) Program

Adult guardian ad litem programs are a necessary public service to protect adults from abuse and neglect. This article describes the development and implementation of an adult guardian ad litem program. We discuss the program's impetus, pilot testing, evaluation, and implementation of the program. Our experience highlights the vital role of diverse inter-sectoral stakeholders. Furthermore, the development process highlights the need for flexibility in program development, tension negotiation among stakeholders, and engagement of aging stakeholders in nontraditional arenas.

Evaluating a Technology-Mediated HPV Vaccination Awareness Intervention: A Controlled, Quasi-Experimental, Mixed Methods Study

College-aged women and men are an important catch-up population for human papillomavirus (HPV) vaccination interventions. Limited research has explored technology-mediated HPV vaccination awareness interventions aimed at college students. The purpose was to evaluate a novel, technology-mediated, social media-based intervention to promote HPV vaccination among college students. A controlled, quasi-experimental, mixed methods study examined the feasibility of a technology-based intervention among two undergraduate classes (n = 58) at a public university in the southeastern United States of America. Classes were randomized to receive one of two cancer prevention programs (i.e., HPV vaccination (intervention) or healthy weight (control)). Both programs contained eight technology-mediated sessions, including weekly emails and private Facebook group posts. Participants completed pre-/post-test surveys and submitted weekly qualitative reflections. Data were analyzed using descriptive statistics and thematic review for qualitative data. Knowledge improved among participants in the HPV vaccination intervention relative to those in the control condition. Participants (97%) interacted on Facebook by "liking" a post or comment or posting a comment. Participants demonstrated robust engagement and high treatment satisfaction. Results suggests that social media is an effective platform to reach college students with health promotion interventions and increase HPV vaccination awareness in this important catch-up population.

A Select Bibliography of Actions to Promote Vaccine Literacy: A Resource for Health Communication

In this bibliography, the researchers provide an introduction to the available evidence base of actions to promote vaccine literacy. The research team organized interventions to create a tool that can inform health communicators and practitioners seeking a resource focused on strategy and implementation design for actions that support vaccine literacy. This scoping bibliography is honed specifically to respond to the urgency of the current pandemic, when supporting and increasing vaccine literacy offers promise for achieving the critically needed high levels of vaccination. Over the course of the coming months and year, this bibliography will be a dynamic and "living" document hosted and maintained on vaccineliteracy.com.

Epidemiology and Implementation of Cancer Prevention in Disparate Populations and Settings

Successful cancer prevention strategies must be tailored to support usability. In this article, we will focus on cancer prevention strategies in populations that differ by race and ethnicity, place and location, sexual orientation and gender identity, and age by providing examples of effective approaches. An individual may belong to none of these categories, to all of these categories, or to some. This intersectionality of belonging characterizes individuals and shapes their experiences. Even within a category, broad diversity exists. Effective cancer prevention strategies comprehensively engage the community at multiple levels of influence and may effectively include lay health workers and faith-based cancer education interventions. Health system efforts that integrate cancer health with other health promotion activities show promise. At the individual physician level, culturally literate approaches have demonstrated success. For example, when discussing cancer screening tests with older adults, clinicians should indicate whether any data suggest that the screening test improves quality or quantity of life and the lag time to benefit from the screening test. This will allow older adults to make an informed cancer screening decision based on a realistic understanding of the potential benefits and risks and their values and preferences. Addressing individual and health system bias remains a challenge. Quality improvement strategies can address gaps in quality of care with respect to timeliness of care, coordination of care, and patient experience. The time is ripe for research on effective and interdisciplinary prevention strategies that harness expertise from preventive medicine, behavioral medicine, implementation science, e-health, telemedicine, and other diverse fields of health promotion.

'Lock to Live': development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide

OBJECTIVES

We sought to (1) clarify decision needs among suicidal adults with home firearm access; (2) identify accurate, unbiased and acceptable approaches for content and messaging; and (3) develop a tablet-delivered decision aid for firearm storage options.

METHODS

Following international standards, we used stakeholder interviews to develop a decision aid for the decision, 'what option(s) to choose to reduce home access to firearms for an adult at risk of suicide'. Participants were adults with personal or family history of suicidal ideation or behaviours, firearm ownership or employment in a firearm range or store, involvement in suicide prevention field, or work as emergency department or other healthcare provider.

RESULTS

Through 64 interviews, we created the 'Lock to Live' decision aid, which includes (1) introduction specifying the decision, (2) clarification of preferences and logistics, (3) table of storage options and (4) summary with specific next steps. The final tool had high user acceptability.

CONCLUSIONS

Should the 'Lock to Live' decision aid prove useful in a pilot feasibility trial and subsequent testing, it could enhance lethal means counselling and help prevent firearm suicide.

A Social-Ecological Review of Cancer Disparities in Kentucky

Cancer continuously ranks among the top 10 leading causes of death in the United States. The burden of cancer is particularly elevated in the Commonwealth of Kentucky and its 54-county Appalachian region, where cancer is the leading cause of death. Kentucky's high rates of cancer have been attributed to a wide range of socioeconomic, behavioral, environmental, and policy influences, resulting in numerous disparities. The present review specifically evaluates the burden of lung, colorectal, cervical, and head and neck cancers in Kentucky, along with resultant cancer control research and community outreach efforts conducted by the state's only National Cancer Institute-designated cancer center using an adapted version of McLeroy's Social-Ecological Model. Here, we categorize disparities and identify relevant intervention approaches based on their level of influence (ie, individual, community, and policy).

An analysis of adaptations to multi-level intervention strategies to enhance implementation of clinical practice guidelines for treating tobacco use in dental care settings

Introduction

Our team conducted a cluster randomized controlled trial (DUET) that compared the effectiveness of three theory-driven, implementation strategies on dental provider adherence to tobacco dependence treatment guidelines (TDT). In this paper we describe the process of adapting the implementation strategies to the local context of participating dental public health clinics in New York City.

Methods

Eighteen dental clinics were randomized to one of three study arms testing several implementation strategies: Current Best Practices (CBP) (i.e. staff training, clinical reminder system and Quitline referral system); CBP + Performance Feedback (PF) (i.e. feedback reports on provider delivery of TDT); and CBP + PF + Pay-for-Performance (i.e. financial incentives for provision of TDT). Through an iterative process, we used Stirman's modification framework to classify, code and analyze modifications made to the implementation strategies.

Results

We identified examples of six of Stirman's twelve content modification categories and two of the four context modification categories. Content modifications were classified as: tailoring, tweaking or refining (49.8%), adding elements (14.1%), departing from the intervention (9.3%), loosening structure (4.4%), lengthening and extending (4.4%) and substituting elements (4.4%). Context modifications were classified as those related to personnel (7.9%) and to the format/channel (8.8%) of the intervention delivery. Common factors associated with adaptations that arose during the intervention included staff changes, time constraints, changes in leadership preferences and functional limitations of to the Electronic Dental Record.

Conclusions

This study offers guidance on how to capture intervention adaptation in the context of a multi-level intervention aimed at implementing sustainable changes to optimize TDT in varying public health dental settings.

Using the Theory of Planned Behavior to Guide Focus Group Development of Messages Aimed at Increasing Compliance With a Tobacco-Free Policy

Purpose:

This study details the persuasive message development for a theory-based campaign designed to increase compliance with a university’s tobacco-free policy.

Approach:

The theory of planned behavior (TPB) guided message design and evaluation for focus group–tested messages that were adapted to the context of complying with a tobacco-free policy.

Setting:

The study was conducted at a university located in the tobacco belt.

Participants:

Undergraduate focus group participants (n = 65) were mostly male (69%), white (82%), and freshman (62%) who smoked at least 1 cigarette in the last 30 days; on-campus smoking percentages were never/rare (60%), occasionally (23%), and often/frequently (16%).

Method:

Data analysis used a theoretical thematic approach to identify how the TPB constructs related to perceptions of message effectiveness.

Results:

Participants responded favorably to attitudinal strategies about health, respect, and university figures; they rejected approaches they considered juvenile and offensive. They also discussed the impact of noncompliance and avoiding overgeneralized statements for addressing subjective norms, suggesting shortening text, adjusting picture location, and emphasizing the importance of compliance to increase perceptions of behavioral control.

Conclusion:

Applying theory to preexisting messages is challenging. The design approach in this study is an evidence-based strategy that can be used as a universal process for message adaptation. Results offer health promotion suggestions for designing messages aimed at improving undergraduate smokers’ willingness to comply with tobacco-free campus policies.

Adoption of Evidence-Based Interventions in Local Health Departments: "1-2-3 Pap NC"

Descriptions of barriers and facilitators to adoption of evidence-based interventions in local health departments (LHDs) are limited. This study was conducted by the North Carolina Public Health Practice-Based Research Network to identify factors associated with adoption of an evidence-based human papillomavirus video intervention, "1-2-3 Pap NC," in North Carolina LHDs. A sequential mixed-method study design was used. Data from the 2013 National Profile of Local Health Departments were used to test associations between LHD characteristics and adoption of the intervention. Qualitative, key stakeholder interviews with LHD directors provided the context for quantitative data. Data collection and analysis continued from March 3, 2014, to September 15, 2014. Overall, 28% of North Carolina health jurisdictions (33 of 100 counties) implemented the intervention. Of the three channels used to deliver the intervention to clients, most LHDs opted to show the video in the exam room (42%), followed by website/other social media (36%) and video loop in the lobby/waiting room (22%). In logistic regression, gender of the director (female) was significantly and positively associated with adoption of the intervention (AOR=4.44, p<0.05). Being a first-time director was marginally significant (AOR=0.28, p=0.074), suggesting first-time directors were less likely to adopt. Qualitative results suggested that aspects of communication (awareness and positive attitudes) and agency directors' evaluation of resources, balanced against intervention complexity and flexibility, competing priorities, and mandates, influenced adoption. Adoption of evidence-based interventions by LHDs is critical to improve population health. Practice-based research can contribute to understanding facilitators and modifying barriers to this process.