Customer discovery as a tool for moving behavioral interventions into the marketplace: insights from the NCI SPRINT program

Scaling and sustaining research tested interventions: Lessons learned from Rhode Island Childhood Obesity Research Demonstration 3.0

Childhood obesity is a significant health problem associated with negative physical and mental health outcomes. Although evidence-based family healthy weight programs (FHWPs), such as JOIN for ME, have been developed, there is a significant lag before these are disseminated more broadly. This study outlines the process of participating in the Speeding Research-tested Interventions (SPRINT) program, highlighting lessons learned, to increase the reach of a previously tested and efficacious FHWP, JOIN for ME. Qualitative interviews were conducted with policymakers, benefits providers, employers, philanthropists, community stakeholders, and medical providers to iteratively test the developed JOIN for ME business model and identify themes regarding effective scaling and sustainability of an evidence-based FHWP. Rapid qualitative analysis of 45 interviews identified four key themes regarding scaling of an FHWP. These were (i) virtual program delivery, (ii) focus on equity, (iii) return on investment, and (iv) tie-in to local community. The process of engaging stakeholders from multiple backgrounds is critical to refining an efficacious program to ensure scalability and sustainment. The SPRINT process allows researchers to understand the marketplace for evidence-based interventions and develop adaptations for sustaining and scaling research tested programs.

Using a customer discovery process to enhance the potential dissemination and scalability of a family healthy weight program for rural communities and small towns

AIM

Customer discovery, an entrepreneurial and iterative process to understand the context and needs of potential adoption agencies, may be an innovative strategy to improve broader dissemination of evidence-based interventions. This paper describes the customer discovery process for the Building Healthy Families (BHF) Online Training Resources and Program Package (BHF Resource Package) to support rural community adoption of an evidence-based, family healthy weight program.

METHODS

The customer discovery process was completed as part of a SPeeding Research-tested INTerventions (SPRINT) training supported by the U.S. Centers for Disease Control and Prevention. Customer discovery interviews (n=47) were conducted with people that could be potential resource users, economic buyers, and BHF adoption influencers to capture multiple contextual and needs-based factors related to adopting new evidence-based interventions. Qualitative analyses were completed in an iterative fashion as each interview was completed.

RESULTS

The BHF Resource Package was designed to be accessible to a variety of implementation organizations. However, due to different resources being available in different rural communities, customer discovery interviews suggested that focusing on rural health departments may be a consistent setting for intervention adoption. We found that local health departments prioritize childhood obesity but lacked the training and resources necessary to implement effective programming. Several intervention funding approaches were also identified including (1) program grants from local and national foundations, (2) healthcare community benefit initiatives, and (3) regional employer groups. Payment plans recommended in the customer discovery interviews included a mix of licensing and technical support fees for BHF delivery organizations, potential insurance reimbursement, and family fees based on ability to pay. Marketing a range of BHF non-weight related outcomes was also recommended during the customer discovery process to increase the likelihood of BHF scale-up and sustainability.

CONCLUSIONS

Engaging in customer discovery provided practical directions for the potential adoption, implementation, and sustainability of the BHF Resource Package. However, the inconsistent finding that health departments are both the ideal implementation organization, but also see childhood obesity treatment as a clinical service, is concerning.

Assessing the market viability of a packaged intensive health behavior and lifestyle treatment

In the USA, more than 14 million children are impacted by obesity. Despite intensive health behavior and lifestyle treatments being found effective, gaps exist in moving these interventions into widespread use. Focusing on market viability could improve the dissemination and sustainment of interventions. The purpose of this paper is to outline the process and results of our market viability assessment for the Healthy Weight Clinic (HWC), a Centers for Disease Control and Prevention-recognized Family Health Weight Program. We conducted a market viability assessment using the Speeding Research-test INTerventions (SPRINT) program to gain insights into the commercialization and marketplace for the HWC. Through the process of customer discovery, we interviewed 50 stakeholders to test our hypotheses pertaining to our business model. Key takeaways were the need for packaged interventions that offer support and training for providers, and interventions that are multidisciplinary and located within the medical home. We also learned that (i) the intervention goals must align with the healthcare organization's performance metrics; (ii) services need to be reimbursable; and (iii) the importance of understanding different customer segments (i.e. program users vs. organization decision-makers) and their unique needs. The market viability assessment is a critical step to transforming the HWC into a viable commercial product. The process we have outlined is replicable by others and by encouraging other teams to design for dissemination we can increase the number of evidence-based, packaged IHBLTs available to children with obesity.

Designing for Dissemination and Sustainability to Promote Equitable Impacts on Health

Designing for dissemination and sustainability (D4DS) refers to principles and methods for enhancing the fit between a health program, policy, or practice and the context in which it is intended to be adopted. In this article we first summarize the historical context of D4DS and justify the need to shift traditional health research and dissemination practices. We present a diverse literature according to a D4DS organizing schema and describe a variety of dissemination products, design processes and outcomes, and approaches to messaging, packaging, and distribution. D4DS design processes include stakeholder engagement, participatory codesign, and context and situation analysis, and leverage methods and frameworks from dissemination and implementation science, marketing and business, communications and visualarts, and systems science. Finally, we present eight recommendations to adopt a D4DS paradigm, reflecting shifts in ways of thinking, skills and approaches, and infrastructure and systems for training and evaluation.

Sharpening our focus on designing for dissemination: Lessons from the SPRINT program and potential next steps for the field

Few patients who smoke receive evidence-based smoking cessation treatment in outpatient clinics. A novel electronic referral to SmokefreeTXT, the National Cancer Institute stop-smoking text program, referred 14.4% of outpatients who smoke.

Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation

BACKGROUND

Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated.

OBJECTIVE

This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed.

METHODS

We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time.

RESULTS

A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers.

CONCLUSIONS

This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.

Planning for Implementation Success Using RE-AIM and CFIR Frameworks: A Qualitative Study

Background: RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) and CFIR (Consolidated Framework for Implementation Research) dissemination and implementation frameworks define theory-based domains associated with the adoption, implementation and maintenance of evidence-based interventions. Used together, the two frameworks identify metrics for evaluating implementation success, i.e., high reach and effectiveness resulting in sustained practice change (RE-AIM), and modifiable factors that explain and enhance implementation outcomes (CFIR). We applied both frameworks to study the implementation planning process for a technology-delivered asthma care intervention called Breathewell within an integrated care organization. The goal of the Breathewell intervention is to increase the efficiency of delivering resource-intensive asthma care services. Methods: We reviewed historical documents (i.e., meeting agendas; minutes) from 14 months of planning to evaluate alignment of implementation team priorities with RE-AIM domains. Key content was extracted and analyzed on topics, frequency and amount of discussion within each RE-AIM domain. Implementation team members were interviewed using questions adapted from the CFIR Interview Guide Tool to focus their reflection on the process and contextual factors considered during pre-implementation planning. Documents and transcripts were initially coded using RE-AIM domain definitions, and recoded using CFIR constructs, with intent to help explain how team decisions and actions can contribute to adoption, implementation and maintenance outcomes. Results: Qualitative analysis of team documents and interviews demonstrated strong alignment with the RE-AIM domains: Reach, Effectiveness, and Implementation; and with the CFIR constructs: formal inclusion of provider and staff stakeholders in implementation planning, compatibility of the intervention with workflows and systems, and alignment of the intervention with organizational culture. Focus on these factors likely contributed to RE-AIM outcomes of high implementation fidelity. However, team members expressed low confidence that Breathewell would be adopted and maintained post-trial. A potential explanation was weak alignment with several CFIR constructs, including tension for change, relative priority, and leadership engagement that contribute to organizational receptivity and motivation to sustain change. Conclusions: While RE-AIM provides a practical framework for planning and evaluating practice change interventions to assure their external validity, CFIR explains why implementation succeeded or failed, and when used proactively, identifies relevant modifiable factors that can promote or undermine adoption, implementation, and maintenance.