A case study of a theory-based method for identifying and reporting core functions and forms of evidence-based interventions

Implementation and Impact of Perinatal Food Is Medicine Programs: A Qualitative Research Study

BACKGROUND

Improving social determinants of health, such as access to nutritious food, is crucial for achieving health equity. Nutrition insecurity, especially during pregnancy and postpartum, can lead to poor maternal and birth outcomes. Food is Medicine (FIM) programs, which integrate food into the health care system to prevent or manage disease, have the potential to improve nutrition insecurity, but research about perinatal FIM programs is limited.

OBJECTIVE

The purpose of this study was to explore perceptions of public health impacts of perinatal FIM programs from the perspectives of both program implementers and program supporters and implementation strategies used to enhance program adoption, implementation, and maintenance.

DESIGN

Qualitative data were collected through semi-structured interviews. The interview guide was based on the Reach, Effectiveness, Adoption, Implementation, Maintenance framework.

PARTICIPANTS/SETTING

Program implementers (n = 16) and program supporters (n = 20) were recruited across the United States through purposive sampling in 2022 and 2023.

ANALYSIS

Data were analyzed using deductive thematic analysis and an iterative feedback loop with the project partner.

RESULTS

Interviews were completed with program implementers and program supporters and generated meaning units (n = 1,942), which were coded into themes aligned with each Reach, Effectiveness, Adoption, Implementation, Maintenance dimension. Perinatal FIM programs reached multiple priority populations who were mainly recruited through health care systems. Effectiveness measures typically included nutrition patterns and practices, as well as return on investment. Motivations for adopting programs primarily included partnerships and connections, financing, and policies and laws. Program components varied and were adapted to meet participants and setting needs. Policy, evidence, funding, and partnerships could lead to program maintenance. Implementation strategies applied by the program supporters included financial strategies and infrastructure changes.

CONCLUSIONS

There is a need to identify the core functions and adaptable forms of perinatal FIM programs, which could lead to identification of standard evaluation metrics. This could result in greater uptake by potential delivery agents, increased funding and policy support, and enhanced benefits for perinatal population experiencing health disparities.

A mixed-methods, theory-driven assessment of the sustainability of a multi-sectoral preventive intervention for South Asian Americans at risk for cardiovascular disease

BACKGROUND

South Asian Americans bear a high burden of atherosclerotic cardiovascular disease (ASCVD), but little is known about the sustainability of evidence-based interventions (EBI) to prevent ASCVD in this population. Using community-based participatory research, we previously developed and implemented the South Asian Healthy Lifestyle Intervention (SAHELI), a culturally-adapted EBI targeting diet, physical activity, and stress management. In this study, we use the Integrated Sustainability Framework to investigate multisectoral partners' perceptions of organizational factors influencing SAHELI sustainability and strategies for ensuring sustainability.

METHODS

From 2022 to 2023, we conducted a mixed-methods study (quant- > QUAL) with 17 SAHELI partners in the Chicago area. Partners' settings included: community organization, school district, public health department, and healthcare system. Descriptive statistics summarized quantitative results. Two coders used a hybrid thematic analysis approach to identify qualitative themes. Qualitative and quantitative data were integrated and analyzed using mixed methods.

RESULTS

Surveys (score range 1-5: higher scores indicate facilitators; lower scores indicate barriers) indicated SAHELI sustainability facilitators to be its "responsiveness to community values and needs" (mean = 4.9). Barriers were "financial support" (mean = 3.5), "infrastructure/capacity to support sustainment" (mean = 4.2), and "implementation leadership" (mean = 4.3). Qualitative findings confirmed quantitative findings that SAHELI provided culturally-tailored cardiovascular health education responsive to the needs of the South Asian American community, increased attention to health issues, and transformed perceptions of research among community members. Qualitative findings expanded upon quantitative findings, showing that the organizational fit of SAHELI was a facilitator to sustainability while competing priorities were barriers for partners from the public health department and health system. Partners from the public health department and health system discussed challenges in offering culturally-tailored programming exclusively for one targeted population. Sustainability strategies envisioned by partners included: transitioning SAHELI to a program delivered by community members; integrating components of SAHELI into other programs; and expanding SAHELI to other populations. Modifications made to SAHELI (i.e., virtual instead of in-person delivery) had both positive and negative implications for sustainability.

DISCUSSION

This study identifies common sustainability barriers and facilitators across different sectors, as well as those specific to certain settings. Aligning health equity interventions with community needs and values, organizational activities, and local context and resources is critical for sustainability. Challenges also arise from balancing the needs of specific populations against providing programming for broader audiences.

Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): a modified Delphi study

BACKGROUND

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

METHOD

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability and inclusion (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

RESULTS

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

DISCUSSION

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

Sustaining efforts to improve family well-being with parents with mental ill health and substance (mis)use

Research conducted over the past 30 years has developed an extensive body of knowledge on families where parents experience mental ill health and/or substance (mis)use, and interventions that are effective in improving their outcomes. A more recent focus has also explored the importance and nuance of implementation. This perspective article reflects on the concept and practice of sustainability within this body of work and considers underlying assumptions in the field about the goal and direction of interventions that make clarity about sustainability difficult. We identify challenges for understanding sustainability, relating to how and who defines it, what is measured and the impact of context. We conclude by considering how we might be better able to plan and design for sustainability within this field.

Implementation of Parenting Programs in Real-World Community Settings: A Scoping Review

Implementing parenting programs in real-world community settings is fundamental to making effective programs widely available and consequently improving the lives of children and their families. Despite the literature acknowledging that the high-quality implementation of parenting programs is particularly challenging in real-world community settings, little is known about how the programs are implemented in these settings. This scoping review followed the methodological framework described by the Joanna Briggs Institute to map evidence on how evidence-based parenting programs have been implemented under real-world conditions. A systematic search of 12 scientific databases, gray literature, and the reference lists of the included studies identified 1918 records, of which 145 were included in the review. Fifty-three parenting programs were identified in studies documenting implementation in real-world community settings worldwide. Most studies included families in psychosocial risk engaged with family-support agencies. The qualitative synthesis identified several implementation outcomes, adaptations, barriers, and facilitators. Most studies reported a maximum of two implementation outcomes, mainly fidelity and acceptability. Providers frequently made adaptations, mainly to bring down barriers and to tailor the program to improve its fit. Findings highlight the need for a more detailed description of the implementation of programs, with greater consistency in terminology, operationalization, and measurement of implementation outcomes across studies. This will promote a more transparent, consistent, and accurate evaluation and reporting of implementation and increase the public health impact of parenting programs. Future studies should also assess the impact of adaptations and the cost-effectiveness and sustainability of programs in real-world community settings.

Fidelity-consistency and deliberateness of modifications in parenting programs

BACKGROUND

Evidence-based interventions (EBIs) are frequently modified in practice. It is recommended that decisions to modify EBIs should be made deliberately to ensure fidelity-consistency, yet the relationship between fidelity-consistency and deliberateness is not well understood. This study aims to explore modifications in a sample of practitioners delivering evidence-based parenting programs (i.e., interventions to strengthen parent-child relationships, reduce harmful interactions, and improve child health and well-being). The study investigated three research questions: (1) What kind of modifications are made during the delivery of parenting programs? (2) To what degree are the identified modifications consistent with the core functions of each program? and (3) Is deliberateness associated with the fidelity-consistency of the identified modifications?

METHODS

In total, 28 group leaders of five widely disseminated parenting programs in Sweden participated in five focus groups, and two participants from each group also participated in individual interviews (n = 10). A content analysis approach was used where the identification of modifications was directed by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and then assessed for fidelity-consistency and four levels of deliberateness (universal, situational, conditional, and unintentional). Chi-square tests were performed to compare consistent and inconsistent modifications, and logistic regression was performed to explore whether deliberateness predicted consistency.

RESULTS

A total of 137 content modifications were identified, covering most of the content modification categories in FRAME. The most common were tailoring/tweaking/refining, adding elements, shortening/condensing, lengthening/extending, and integrating another treatment. Modifications were mostly fidelity-consistent but consistency varied greatly among categories. Furthermore, modifications made unintentionally or situationally were more likely to be fidelity-inconsistent.

CONCLUSIONS

These results indicate that explicit consideration of modifications and their impact could be essential for sustaining the fidelity-consistent use of EBIs, even as such interventions are continuously modified.

The core functions and forms paradigm throughout EPIS: designing and implementing an evidence-based practice with function fidelity

There are numerous frameworks for implementing evidence-based practices (EBPs) in novel settings to achieve "fidelity." However, identifying appropriate referents for fidelity poses a challenge. The Core Functions and Forms paradigm offers a model that can inform adaptation decisions throughout all phases of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We applied the Core Functions-Forms paradigm throughout the Exploration and Preparation phases of EPIS in the design of two EBPs targeting family protective factors among Latinos in San Diego, as well as describe plans for its use in Implementation and Sustainment. We employed a distinct approach for each intervention element to contrast adaptation decisions that prioritize adherence to either form or function fidelity. We describe our application of the functions-forms paradigm within the EPIS framework, focusing on the Preparation phase. We also provide functions-forms matrices that map out the relationship between individual intervention components (forms) and the essential processes (functions) by which components are theorized to exert their impact. This case study of how the core functions-forms framework can be mapped onto EPIS can support a conceptual shift from prioritizing form fidelity to also focusing on function fidelity. This might allow interventionists to target appropriate fidelity referents when adapting an EBP, rather than defaulting to maintaining fidelity to forms as described in the protocol. We see great promise for using this framework for guiding actions throughout all EPIS phases and informing future applications of this paradigm to foster more robust fidelity to function.

Adapting Connect for Health pediatric weight management program for telehealth in response to the COVID-19 pandemic

BACKGROUND

To address the evolving needs and context changes due to the COVID-19 pandemic, we adapted Connect for Health, an evidence-based, primary care, pediatric weight management intervention. The objective of this study is to describe the planned adaptation process to ensure continued and equitable program uptake during the pandemic.

METHODS

Guided by adaptation frameworks, we identified the core functions and forms of Connect for Health and then adapted the intervention in response to a changing healthcare context. We engaged stakeholders and surveyed parents of children with a BMI ≥ 85th percentile and pediatric clinicians and examined their experiences using telehealth for pediatric weight management and needs and preferences. Using multivariable logistic regression, we examined the preferences of parents with limited English proficiency regarding key aspects of pediatric weight management.

RESULTS

We surveyed 200 parents and 43% had a primary language of Spanish. Parents wanted care to be a combination of in-person and virtual visits (80%). We found that parents with limited English proficiency had a higher odds ratio of affirming in-person visits are better than virtual visits for ensuring their child's health concern can be taken care of (OR: 2.91; 95% CI: 1.36, 6.21), feeling comfortable when discussing personal information (OR: 3.91; 95% CI: 1.82, 8.43), talking about healthy behaviors and setting goals (OR: 3.09; 95% CI: 1.39, 6.90), and talking about mental health and overall well-being (OR: 4.02; 95% CI: 1.83, 8.87) than parents without limited English proficiency. We surveyed 75 clinicians and 60% felt telehealth was a useful tool to provide care for pediatric weight management. Clinicians felt virtual visits did not pose barriers to all aspects of care. Informed by the surveys and stakeholder input, we made clinician- and family-level adaptations while retaining the program's function.

CONCLUSIONS

By engaging stakeholders and adapting the program for telehealth, we optimized the reach and fit of Connect for Health to ensure its continued uptake. We have provided a real-world example of how clinical innovations can evolve and how to systematically plan adaptations in response to changing healthcare contexts.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT04042493), Registered on August 2, 2019.

Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): A modified Delphi study

Background

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

Method

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

Results

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

Discussion

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

An external facilitation intervention to increase uptake of an adverse drug event reporting intervention

Background

Adverse drug events (ADEs) are a leading cause of emergency department visits and hospital admissions in Canada. ActionADE prevents repeat ADEs by enabling clinicians to document and communicate standardized ADE information across care settings. We used an external facilitation intervention to promote the uptake of ActionADE in four hospitals in British Columbia, Canada. This study examined whether, how and in what context external facilitation influenced the uptake of ActionADE.

Methods

In this convergent-parallel mixed-methods study, an external facilitator used a four-step iterative process to support site champions using context-specific implementation strategies to increase the ADE reporting rate at their sites. We extracted archival data to assess implementation determinants before and after the implementation of the external facilitation and implementation strategies. We also retrieved data on the mean monthly counts of reported ADEs for each user from the ActionADE server. Zero-inflated Poisson models were used to examine changes in mean monthly counts of reported ADEs per user between pre-intervention (June 2021 to October 2021) and intervention (November 2021 to March 2022) periods.

Results

The external facilitator and site champions co-created three functions: (1) educate pharmacists about what and how to report in ActionADE, (2) educate pharmacists about the impact of ActionADE on patient outcomes, and (3) provide social support for pharmacists to integrate ADE reporting into clinical workflows. Site champions used eight forms to address the three functions. Peer support and reporting competition were the two common strategies used by all sites. Sites' responses to external facilitation varied. The rate of mean monthly counts of reported ADEs per user significantly increased during the intervention period compared to the pre-intervention period at LGH (RR: 3.74, 95% CI 2.78 to 5.01) and RH (RR: 1.43, 95% CI 1.23 to 1.94), but did not change at SPH (RR: 0.68, 95% CI: 0.43 to 1.09) and VGH (RR: 1.17, 95% CI 0.92 to 1.49). Leave of absence of the clinical pharmacist champion and failure to address all identified functions were implementation determinants that influenced the effectiveness of external facilitation.

Conclusion

External facilitation effectively supported researchers and stakeholders to co-create context-specific implementation strategies. It increased ADE reporting at sites where clinical pharmacist champions were available, and where all functions were addressed.

Mechanisms to enhance racial equity in health care: Developing a model to facilitate translation of the ACCURE intervention

Background

As medical and public health professional organizations call on researchers and policy makers to address structural racism in health care, guidance on evidence-based interventions to enhance health care equity is needed. The most promising organizational change interventions to reduce racial health disparities use multilevel approaches and are tailored to specific settings. This study examines the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, which changed systems of care at two U.S. cancer centers and eliminated the Black-White racial disparity in treatment completion among patients with early-stage breast and lung cancer.

Purpose

We aimed to document key characteristics of ACCURE to facilitate translation of the intervention in other care settings.

Methods

We conducted semi-structured interviews with participants who were involved in the design and implementation of ACCURE and analyzed their responses to identify the intervention's mechanisms of change and key components.

Results

Study participants (n = 18) described transparency and accountability as mechanisms of change that were operationalized through ACCURE's key components. Intervention components were designed to enhance either institutional transparency (e.g., a data system that facilitated real-time reporting of quality metrics disaggregated by patient race) or accountability of the care system to community values and patient needs for minimally biased, tailored communication and support (e.g., nurse navigators with training in antiracism and proactive care protocols).

Conclusions

The antiracism principles transparency and accountability may be effective change mechanisms in equity-focused health services interventions. The model presented in this study can guide future research aiming to adapt ACCURE and evaluate the intervention's implementation and effectiveness in new settings and patient populations.

Fidelity to the ACT SMART Toolkit: an instrumental case study of implementation strategy fidelity

BACKGROUND

Evidence-based practices (EBPs) are shown to improve a variety of outcomes for autistic children. However, EBPs often are mis-implemented or not implemented in community-based settings where many autistic children receive usual care services. A blended implementation process and capacity-building implementation strategy, developed to facilitate the adoption and implementation of EBPs for autism spectrum disorder (ASD) in community-based settings, is the Autism Community Toolkit: Systems to Measure and Adopt Research-based Treatments (ACT SMART Toolkit). Based on an adapted Exploration, Adoption decision, Preparation, Implementation, Sustainment (EPIS) Framework, the multi-phased ACT SMART Toolkit is comprised of (a) implementation facilitation, (b) agency-based implementation teams, and (c) a web-based interface. In this instrumental case study, we developed and utilized a method to evaluate fidelity to the ACT SMART Toolkit. This study responds to the need for implementation strategy fidelity evaluation methods and may provide evidence supporting the use of the ACT SMART Toolkit.

METHODS

We used an instrumental case study approach to assess fidelity to the ACT SMART Toolkit during its pilot study with six ASD community agencies located in southern California. We assessed adherence, dose, and implementation team responsiveness for each phase and activity of the toolkit at both an aggregate and individual agency level.

RESULTS

Overall, we found that adherence, dose, and implementation team responsiveness to the ACT SMART Toolkit were high, with some variability by EPIS phase and specific activity as well as by ASD community agency. At the aggregate level, adherence and dose were rated notably lowest during the preparation phase of the toolkit, which is a more activity-intensive phase of the toolkit.

CONCLUSIONS

This evaluation of fidelity to the ACT SMART Toolkit, utilizing an instrumental case study design, demonstrated the potential for the strategy to be used with fidelity in ASD community-based agencies. Findings related to the variability of implementation strategy fidelity in the present study may also inform future adaptations to the toolkit and point to broader trends of how implementation strategy fidelity may vary by content and context.

Multi-method study of the implementation of Cognitive Symptom Management and Rehabilitation Training (CogSMART) in real-world settings

Cognitive Symptom Management and Rehabilitation Training (CogSMART) and Compensatory Cognitive Training (CCT) are evidence-based compensatory cognitive training interventions that improve cognition in persons with a history of traumatic brain injury or other neuropsychiatric disorders. Despite demonstrated efficacy, use and effectiveness of CogSMART/CCT in real-world settings is not known.We used a multi-method design to collect and analyze quantitative and qualitative survey data from several domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to gather information about use of CogSMART/CCT in real-world settings from provider and patient perspectives. Surveys were sent to email addresses from persons who registered on the CogSMART website seeking access to training manuals and other resources. Descriptive statistics were generated, and we used Natural Language Processing methods to study the self-report free responses. Using n-gram analysis, we identified the most frequently reported responses.We found CogSMART/CCT was broadly used in real-world settings and delivered by a variety of providers for several patient groups with high attendance and overall high satisfaction. CogSMART/CCT seemed to be offered in VA- or university-related clinics more than in private practice or rehabilitation centers. The diversity of providers and variety of formats by which to deliver CogSMART/CCT (i.e., individual, group, telehealth) seemed to play a role in its widespread implementation, as did its adaptability. Most providers made adaptations to the intervention that reduced the length or number of sessions. These changes were most likely to be based on client characteristics. The low rates of formal training, however, may have contributed to lower levels of perceived helpfulness among patients.Reach and Adoption of a cognitive rehabilitation intervention improved by increasing access to the manuals. Attention to characteristics of dissemination and implementation in the design of an intervention may enhance its use in real-world settings. The relevant outcomes, easy access to training manuals, and adaptability of CogSMART/CCT seem to have been important factors in its use in a variety of settings and for several disorders with cognitive impairment. The adoption of CogSMART/CCT by a variety of providers other than neuropsychologists suggests its use may be broadened to other healthcare providers, if adequately trained, to increase access to an intervention with demonstrated efficacy for cognitive rehabilitation for several neuropsychiatric disorders.

Shifting to virtual breastfeeding counseling for low-income women in the US during COVID-19: A partner-engaged multimethod evaluation of program adaptations

Background

The Breastfeeding Heritage and Pride program (BHP) provides evidence-based breastfeeding peer counseling to low-income women. Due to the COVID-19 pandemic, BHP shifted from delivering in-person and virtual services to providing only virtual services. Program adaptations can impact implementation success, which could influence program effectiveness. We documented program adaptations and explored their impacts on implementation outcomes, guided by the Model for Adaptation Design and Impact.

Methods

Through a community-clinical-academic partnership, we conducted in-depth interviews with 12 program implementers and peer counselors and conducted a rapid qualitative analysis. To efficiently capture information on adaptations over time, we collected and analyzed information from program meetings and extracted data from a program report. We then triangulated data from these multiple sources.

Results

Peer counselors received training on virtual service delivery and increased supportive supervision. They recruited women via phone instead of in hospitals, which was viewed as feasible. In-person counseling visits at hospitals and clients' homes were replaced with phone and video calls. Examples of changes to the content delivered included breastfeeding education in the context of the pandemic such as the latest COVID-related infant feeding guidance, provision of face masks, and more assistance with social and economic challenges. Although peer counselors increasingly adopted video calls as a substitute for in-person visits, they emphasized that in-person visits were better for relationship building, helping with breastfeeding problems like latching, and identifying barriers to breastfeeding in the home environment like limited familial support. While adaptations were reactive in that they were made in response to the unanticipated COVID-19 pandemic, most were made with clear goals and reasons such as to ensure the safety of peer counselors and clients while maintaining service delivery. Most adaptations were made through a systematic process based on program implementers' expertise and best practices for peer counseling and were largely but not fully consistent with BHP's core functions.

Discussion

BHP was able to shift to virtual service delivery for continued provision of breastfeeding counseling during the pandemic. Overall, virtual services worked well but were less optimal for several aspects of counseling. Evaluations of program effectiveness of virtual services are still needed.

Core functions and forms of Bright IDEAS: A multi-methods evaluation of the adoption of an evidence-based psychosocial training program through iterative adaptation

Background

Despite efforts to widely disseminate interventions designed to increase access to quality supportive care to pediatric cancer patients and their families, many of these interventions fail to meet expectations once deployed in real-life clinical settings. This study identifies the functions and forms of Bright IDEAS: Problem-Solving Skills Training, an evidence based psychosocial intervention for caregivers of children recently diagnosed with cancer, to identify pragmatic program adaptations in its real-world clinical implementation. We compare intervention adoption before and after adaptations to the Bright IDEAS training program as part of a national training program designed to disseminate the intervention.

Methods

209 pediatric psychosocial oncology practitioners representing 134 unique institutions were trained during 10 in-person 8-hour workshops (2015-2019). Functions and forms of Bright IDEAS were identified, and adaptations made to the training agenda and curriculum based on practitioner feedback following implementation in local institutions. Mixed method evaluation included longitudinal surveys at 6- and 12-months post training; and qualitative interviews among a subgroup of practitioners (N = 47) to understand and compare perspectives on intervention adoption and barriers to implementation before and after adaptations to the Bright IDEAS training program. The RE-AIM framework was used to guide dissemination evaluation.

Results

A total of four adaptations were tailored to the identified forms of the intervention: case studies; pre-training reading materials; training videos; and letters of institutional support from primary supervisor. Pre- and post-training adaptations to the Bright IDEAS training program were mapped to RE-AIM constructs. Quantitative findings demonstrate that adaptations appeared to improve adoption and usage overall.

Conclusion

This study provides insight into how contextual factors influence psychosocial practitioners' capacity to adopt, implement, and maintain Bright IDEAS in the clinical setting. This study demonstrates the use of real-time stakeholder feedback to guide intervention translation from research to practice settings.

Identifying core strategies and mechanisms for spreading a national medicines optimisation programme across England-a mixed-method study applying qualitative thematic analysis and Qualitative Comparative Analysis

Background

Achieving widespread adoption of innovations across health systems remains a challenge. Past efforts have focused on identifying and classifying strategies to actively support innovation spread (replicating an innovation across sites), but we lack an understanding about the mechanisms which such strategies draw on to deliver successful spread outcomes. There is also no established methodology to identify core strategies or mechanisms which could be replicated with fidelity in new contexts when spreading innovations. We aimed to understand which strategies and mechanisms are connected with successful spread using the case of a national medicines optimisation programme in England.

Methods

The study applied a comparative mixed-method case study approach. We compared spread activity in 15 Academic Health Science Networks (AHSN) in England, applied to one innovation case, Transfers of Care Around Medicines (TCAM). We followed two methodological steps: (1) qualitative thematic analysis of primary data collected from 18 interviews with AHSN staff members to identify the strategies and mechanisms and related contextual determinants and (2) Qualitative Comparative Analysis (QCA) combining secondary quantitative data on spread outcome and qualitative themes from step 1 to identify the core strategies and mechanisms.

Results

We identified six common spread strategy-mechanism constructs that AHSNs applied to spread the TCAM national spread programme: (1) the unique intermediary position of the AHSN as “honest broker” and local networking organisation, (2) the right capacity and position of the spread facilitator, (3) an intersectoral and integrated stakeholder engagement approach, (4) the dynamic marriage of the innovation with local health and care system needs and characteristics, (5) the generation of local evidence, and (6) the timing of TCAM. The QCA resulted in the core strategy/mechanism of a timely start into the national spread programme in combination with the employment of a local, senior pharmacist as an AHSN spread facilitator.

Conclusions

By qualitatively comparing experiences of spreading one innovation across different contexts, we identified common strategies, causal mechanisms, and contextual determinants. The QCA identified one core combination of two strategies/mechanisms. The identification of core strategies/mechanisms and common pre-conditional and mediating contextual determinants of a specific innovation offers spread facilitators and implementers a priority list for tailoring spread activities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00364-5.

Program adaptation by health departments

Introduction

The dissemination of evidence-based interventions (i.e., programs, practices, and policies) is a core function of US state health departments (SHDs). However, interventions are originally designed and tested with a specific population and context. Hence, adapting the intervention to meet the real-world circumstances and population's needs can increase the likelihood of achieving the expected health outcomes for the target population from the implemented intervention. This study identified how SHD employees decide to adapt public health programs and what influences decisions on how to adapt them.

Materials and methods

SHD employees (n = 45) were interviewed using a qualitative semi-structured interview guide. Telephone interviews were audio-recorded and transcribed verbatim. The transcripts were consensus-coded and themes were identified using thematic analysis. Several themes aligned with the Model for Adaptation Design and Impact.

Results

Data, outcomes, and health department evaluations influenced decisions to adapt a program (pre-adaptation), and reasons to adapt a program included organizational and sociopolitical contextual factors. SHD middle-level managers, program managers and staff, and local agencies were involved in the decisions to adapt the programs. Finally, the goals for adapting a program included enhancing effectiveness/outcomes, reach and satisfaction with the program; funding; and partner engagement. After SHD employees decided to adapt a program, data and evidence guided the changes. Program staff and evaluators were engaged in the adaptation process. Program managers consulted partners to gather ideas on how best to adapt a program based on partners' experiences implementing the program and obtaining community input. Lastly, program managers also received input on adapting content and context from coalition meetings and periodic technical assistance calls.

Discussion

The findings related to decisions to adapt public health programs provide practitioners with considerations for adapting them. Findings reaffirm the importance of promoting public health competencies in program evaluation and adaptation, as well as systematically documenting and evaluating the adaptation processes. In addition, the themes could be studied in future research as mechanisms, mediators, and moderators to implementation outcomes.

Conceptualizing clinical decision support as complex interventions: a meta-analysis of comparative effectiveness trials

OBJECTIVES

Complex interventions with multiple components and behavior change strategies are increasingly implemented as a form of clinical decision support (CDS) using native electronic health record functionality. Objectives of this study were, therefore, to (1) identify the proportion of randomized controlled trials with CDS interventions that were complex, (2) describe common gaps in the reporting of complexity in CDS research, and (3) determine the impact of increased complexity on CDS effectiveness.

MATERIALS AND METHODS

To assess CDS complexity and identify reporting gaps for characterizing CDS interventions, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting tool for complex interventions. We evaluated the effect of increased complexity using random-effects meta-analysis.

RESULTS

Most included studies evaluated a complex CDS intervention (76%). No studies described use of analytical frameworks or causal pathways. Two studies discussed use of theory but only one fully described the rationale and put it in context of a behavior change. A small but positive effect (standardized mean difference, 0.147; 95% CI, 0.039-0.255; P < .01) in favor of increasing intervention complexity was observed.

DISCUSSION

While most CDS studies should classify interventions as complex, opportunities persist for documenting and providing resources in a manner that would enable CDS interventions to be replicated and adapted. Unless reporting of the design, implementation, and evaluation of CDS interventions improves, only slight benefits can be expected.

CONCLUSION

Conceptualizing CDS as complex interventions may help convey the careful attention that is needed to ensure these interventions are contextually and theoretically informed.

Identifying Core Functions of an Evidence-Based Intervention to Improve Cancer Care Quality in Rural Hospitals

Background

Rural patients experience worse cancer survival outcomes than urban patients despite similar incidence rates, due in part to significant barriers to accessing quality cancer care. Community hospitals in non-metropolitan/rural areas play a crucial role in providing care to patients who desire and are able to receive care locally. However, rural community hospitals typically face challenges to providing comprehensive care due to lack of resources. The University of Kentucky's Markey Cancer Center Affiliate Network (MCCAN) is an effective complex, multi-level intervention, improving cancer care in rural/under-resourced hospitals by supporting them in achieving American College of Surgeons Commission on Cancer (CoC) standards. With the long-term goal of adapting MCCAN for other rural contexts, we aimed to identify MCCAN's core functions (i.e., the components key to the intervention's effectiveness/implementation) using theory-driven qualitative data research methods.

Methods

We conducted eight semi-structured virtual interviews with administrators, coordinators, clinicians, and certified tumor registrars from five MCCAN affiliate hospitals that were not CoC-accredited prior to joining MCCAN. Study team members coded interview transcripts and identified themes related to how MCCAN engaged affiliate sites in improving care quality (intervention functions) and implementing CoC standards (implementation functions) and analyzed themes to identify core functions. We then mapped core functions onto existing theories of change and presented the functions to MCCAN leadership to confirm validity and completeness of the functions.

Results

Intervention core functions included: providing expertise and templates for achieving accreditation, establishing a culture of quality-improvement among affiliates, and fostering a shared goal of quality care. Implementation core functions included: fostering a sense of community and partnership, building trust between affiliates and Markey, providing information and resources to increase feasibility and acceptability of meeting CoC standards, and mentoring and empowering administrators and clinicians to champion implementation.

Conclusion

The MCCAN intervention presents a more equitable strategy of extending the resources and expertise of large cancer centers to assist smaller community hospitals in achieving evidence-based standards for cancer care. Using rigorous qualitative methods, we distilled this intervention into its core functions, positioning us (and others) to adapt the MCCAN intervention to address cancer disparities in other rural contexts.

Less Is More: Implementing the Minimal Intervention Needed for Change Approach to Increase Contextual Fit of Speech-Language Interventions

PURPOSE

Speech-language pathologists (SLPs) and researchers face difficulties in moving evidence-based practices from clinical research into widespread practice, in part due to a mismatch between the design of typical intervention research studies and the realities of clinical settings. SLPs must adapt interventions from the literature or established programs to fit the needs of specific clients and settings. Researchers must design studies that better reflect clinical practice.

METHOD

Here, we provide an overview of the Minimal Intervention Needed for Change (MINC) approach, a systematic approach to developing and adapting interventions that focuses on achieving meaningful outcomes within specific contexts. We outline the principles of MINC and illustrate this process through the use of a case study.

RESULTS

MINC can support systematic development and adaptation of interventions in clinical and research settings, particularly settings with resource limitations.

CONCLUSIONS

Researchers should work to align research intervention work with typical clinical settings. This involves both targeting outcomes that are functional and clinically significant and acknowledging resource limitations. SLPs should adapt evidence-based interventions systematically and carefully to meet the needs of clients and settings while retaining the core components of intervention that result in meaningful change for clients.

Understanding how context and culture in six communities can shape implementation of a complex intervention: a comparative case study

Background

Contextual factors can act as barriers or facilitators to scaling-up health care interventions, but there is limited understanding of how context and local culture can lead to differences in implementation of complex interventions with multiple stakeholder groups. This study aimed to explore and describe the nature of and differences between communities implementing Health TAPESTRY, a complex primary care intervention aiming to keep older adults healthier in their homes for longer, as it was scaled beyond its initial effectiveness trial.

Methods

We conducted a comparative case study with six communities in Ontario, Canada implementing Health TAPESTRY. We focused on differences between three key elements: interprofessional primary care teams, volunteer program coordination, and the client experience. Sources of data included semi-structured focus groups and interviews. Data were analyzed through the steps of thematic analysis. We then created matrices in NVivo by splitting the qualitative data by community and comparing across the key elements of the Health TAPESTRY intervention.

Results

Overall 135 people participated (39 clients, 8 clinical managers, 59 health providers, 6 volunteer coordinators, and 23 volunteers). The six communities had differences in size and composition of both their primary care practices and communities, and how the volunteer program and Health TAPESTRY were implemented. Distinctions between communities relating to the work of the interprofessional teams included characteristics of the huddle lead, involvement of physicians and the volunteer coordinator, and clarity of providers’ role with Health TAPESTRY. Key differences between communities relating to volunteer program coordination included the relationship between the volunteers and primary care practices, volunteer coordinator characteristics, volunteer training, and connections with the community. Differences regarding the client experience between communities included differing approaches used in implementation, such as recruitment methods.

Conclusions

Although all six communities had the same key program elements, implementation differed community-by-community. Key aspects that seemed to lead to differences across categories included the size and spread of communities, size of primary care practices, and linkages between program elements. We suggest future programs engaging stakeholders from the beginning and provide clear roles; target the most appropriate clients; and consider the size of communities and practices in implementation.

Trial registration

ClinicalTrials.gov: NCT03397836.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07615-0.

A mixed methods investigation of implementation determinants for a school-based universal prevention intervention

Background

Effective implementation of evidence-based prevention interventions in schools is vital to reducing the burden of drug use and its consequences. Universal prevention interventions often fail to achieve desired public health outcomes due to poor implementation. One central reason for suboptimal implementation is the limited fit between the intervention and the setting. Research is needed to increase our understanding of how intervention characteristics and context influence intervention implementation in schools to design implementation strategies that will address barriers and improve public health impact.

Methods

Using a convergent mixed methods design we examined qualitative and quantitative data on implementation determinants for an evidence-based health curriculum, the Michigan Model for HealthTM (MMH) from the perspective of health teachers delivering the curriculum in high schools across the state. We examined data strands independently and integrated them by investigating data alignment, expansion, and divergence.

Results

We identified three mixed methods domains: (1) Acceptability, (2) intervention-context fit, and (3) adaptability. We found alignment across data strands as teachers reporting low acceptability also reported low fidelity. The fit between student needs and the curriculum predicted fidelity (expansion). Teachers mentioned instances of poor intervention-context fit (discordance), including when meeting the needs of trauma-exposed youth and keeping updated on youth drug use trends. Teachers reported high adaptability (concordance) but also instances when adaptation was challenging (discordance).

Conclusions

This investigation advances implementation research by deepening our understanding of implementation determinants for an evidence-based universal prevention intervention in schools. This will support designing effective implementation strategies to address barriers and advance the public health impact of interventions that address important risk and protective factors for all youth.

Plain Language Summary

(1) What is Already Known About the Topic? While many evidence-based interventions (EBIs) exist to address key health issues among youth including substance use and mental health, few of these interventions are effectively implemented in community settings, such as schools. Notable multilevel barriers exist to implement universal prevention in schools. Researchers identify that misalignment between the intervention and the context is a key reason why many implementation efforts do not achieve desired outcomes. (2) What Does This Paper Add? This paper combines the strengths of qualitative and quantitative research methods to identify and understand challenges to intervention-context fit for a comprehensive health curriculum, the Michigan Model for HealthTM (MMH) which is widely adopted throughout Michigan, from the perspective of end users. This paper also utilizes the consolidated framework for implementation research and implementation outcomes framework to guide our understanding of implementing complex interventions and key barriers to implementation in schools. This research provides a foundation to design effective strategies that will balance curriculum fidelity and adaptation to achieve public health objectives. (3) What are the Implications for Practice, Research, or Policy? We need implementation strategies that guide flexibility and fidelity in EBI delivery in schools. While overall teachers felt the curriculum was adaptable and met student needs, they also mentioned specific instances when they would benefit from additional implementation support, such as making adaptations to meet the needs of trauma-exposed youth and keeping up-to-date with emerging drugs. Implementation strategies designed to address these challenges can improve fidelity and ultimately student well-being.

An Evidence-Based Practice Developed in-situ: Let's Talk About Children and a Consolidation of Its Evidence Base

BACKGROUND

Traditional models of evidence-based practice assume knowledge is developed in research settings before being installed in practice settings. The role practice settings can play in enhancing effectiveness and enabling sustainability is not therefore acknowledged. Developing interventions in-situ alongside developing their evidence base, provides another pathway to evidence-based practice. One example is Let's Talk about Children (LTC), a brief family-focused intervention that promotes parent, family and child wellbeing. Let's Talk about Children has been developed and adapted to respond to the context into which it has been established, leading to different descriptions reported in its 20 year collection of evidence. Collating the diverse literature on LTC, this paper showcases an evidence-based practice developed in-situ in order to guide future innovation.

METHOD

Using an integrative review, key literature using LTC were identified through electronic databases and snowballing techniques. Constant comparison analysis synthesized the data to develop patterns and themes.

FINDINGS

From the 26 records, three forms of LTC were identified and outcomes related to parents, family and child wellbeing, implementation and sustainability were collated. Consolidated outcomes show overall agreement in effectiveness and acceptability outcomes across different settings and populations. Implementation and sustainability impacts are entwined with the context, and influenced by its development in-situ.

CONCLUSIONS

The study documents that the in-situ model is effective at developing sustainable evidence-based practice. In consolidating the evidence, the review clarified LTC's forms and outcomes, and draws attention to the importance of research on mechanisms of change.

Adaptation of Water, Sanitation, and Hygiene Interventions: A Model and Scoping Review of Key Concepts and Tools

Background

Safe water, sanitation, and hygiene (WaSH) is important for health, livelihoods, and economic development, but WaSH programs have often underdelivered on expected health benefits. Underperformance has been attributed partly to poor ability to retain effectiveness following adaptation to facilitate WaSH programs' implementation in diverse contexts. Adaptation of WaSH interventions is common but often not done systematically, leading to poor outcomes. Models and frameworks from the adaptation literature have potential to improve WaSH adaptation to facilitate implementation and retain effectiveness. However, these models and frameworks were designed in a healthcare context, and WaSH interventions are typically implemented outside traditional health system channels. The purpose of our work was to develop an adaptation model tailored specifically to the context of WaSH interventions.

Methods

We conducted a scoping review to identify key adaptation steps and identify tools to support systematic adaptation. To identify relevant literature, we conducted a citation search based on three recently published reviews on adaptation. We also conducted a systematic database search for examples of WaSH adaptation. We developed a preliminary model based on steps commonly identified across models in adaptation literature, and then tailored the model to the WaSH context using studies yielded by our systematic search. We compiled a list of tools to support systematic data collection and decision-making throughout adaptation from all included studies.

Results and Conclusions

Our model presents adaptation steps in five phases: intervention selection, assessment, preparation, implementation, and sustainment. Phases for assessment through sustainment are depicted as iterative, reflecting that once an intervention is selected, adaptation is a continual process. Our model reflects the specific context of WaSH by including steps to engage non-health and lay implementers and to build consensus among diverse stakeholders with potentially competing priorities. We build on prior adaptation literature by compiling tools to support systematic data collection and decision-making, and we describe how they can be used throughout adaptation steps. Our model is intended to improve program outcomes by systematizing adaptation processes and provides an example of how systematic adaptation can occur for interventions with health goals but that are implemented outside conventional health system channels.

Understanding key implementation determinants for a school-based universal prevention intervention: a qualitative study

This study examined how teachers discuss various factors as impacting their ability to execute with fidelity the Michigan Model for Health (MMH), an evidence-based health universal prevention curriculum widely adopted throughout Michigan. Researchers have found a robust relationship between fidelity and participant outcomes, including in schools. While previous studies have identified barriers that inhibit fidelity, few have focused on identifying key barriers and deepening our understanding of how these factors influence intervention fidelity. We conducted a thematic analysis using the reflexive thematic approach to identify key barriers and facilitators and deepen our understanding of how these factors influence MMH implementation. Guided by the Consolidated Framework for Implementation Research (CFIR) and the Implementation Outcomes Framework, we conducted semistructured interviews with 23 high school health teachers across Michigan. Teachers identified intervention characteristics (e.g., design quality, packaging, and program adaptability), student needs (e.g., trauma exposure, substances), and the fit between the intervention and the context as factors that contributed to acceptability. They also discussed the curriculum and its alignment with their teaching style and/or experiences as contributing to fidelity. Teachers shared how they would often go "off protocol" to improve intervention-context fit and meet students' needs. Our results identified acceptability, a perceptual implementation outcome, as demonstrating an important role in shaping the relationship between CFIR factors and fidelity. Results provide guidance for systematically designing implementation strategies that address key barriers to improve acceptability, enhance fidelity, and ultimately achieve desired public health objectives.

Implementation processes in a cognitive rehabilitation intervention for people with dementia: a complexity-informed qualitative analysis

OBJECTIVES

Healthcare is often delivered through complex interventions. Understanding how to implement these successfully is important for optimising services. This article demonstrates how the complexity theory concept of 'self-organisation' can inform implementation, drawing on a process evaluation within a randomised controlled trial of the GREAT (Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer's and related dementias: a multi-centre single-blind randomised controlled Trial) intervention which compared a cognitive rehabilitation intervention for people with dementia with usual treatment.

DESIGN

A process evaluation examined experiences of GREAT therapists and participants receiving the intervention, through thematic analysis of a focus group with therapists and interviews with participants and their carers. Therapy records of participants receiving the intervention were also analysed using adapted framework analysis. Analysis adopted a critical realist perspective and a deductive-inductive approach to identify patterns in how the intervention operated.

SETTING

The GREAT intervention was delivered through home visits by therapists, in eight regions in the UK.

PARTICIPANTS

Six therapists took part in a focus group, interviews were conducted with 25 participants and 26 carers, and therapy logs for 50 participants were analysed.

INTERVENTION

A 16-week cognitive rehabilitation programme for people with mild-to-moderate dementia.

RESULTS

'Self-organisation' of the intervention occurred through adaptations made by therapists. Adaptations included simplifying the intervention for people with greater cognitive impairment, and extending it to meet additional needs. Relational work by therapists produced an emergent outcome of 'social support'. Self-organised aspects of the intervention were less visible than formal components, but were important aspects of how it operated during the trial. This understanding can help to inform future implementation.

CONCLUSIONS

Researchers are increasingly adopting complexity theory to understand interventions. This study extends the application of complexity theory by demonstrating how 'self-organisation' was a useful concept for understanding aspects of the intervention that would have been missed by focusing on formal intervention components. Analysis of self-organisation could enhance future process evaluations and implementation studies.

TRIAL REGISTRATION NUMBER

ISRCTN21027481.

Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio

BACKGROUND

Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging.

OBJECTIVE

The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care.

RESEARCH DESIGN

Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research.

RESULTS

Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results.

CONCLUSION

These lessons can help guide future pragmatic studies of care transitions.

The what, why and when of adapting interventions for new contexts: A qualitative study of researchers, funders, journal editors and practitioners' understandings

BACKGROUND

The adaptation of interventions for new contexts is a rapidly developing research area. To date there is no consensus-based guidance to support decision-making and recommend adaptation processes. The ADAPT study is developing such guidance. This aim of the qualitative component of the study was to explore stakeholders' understandings of adaptation, as to date there has limited consideration of how different concepts and meanings shape decision-making and practice.

METHODS

A case study research design was used. Participants/cases were purposefully sampled based on study outcome, study design, expertise, context and country. Semi-structured interviews were conducted with a sample of researchers (n = 23); representatives from research funding panels (n = 6); journal editors (n = 5) and practitioners (n = 3). Data were analysed using the Framework approach. Overarching themes were discussed with the ADAPT study team, with further iterative refinement of subthemes.

RESULTS

The results generated four central themes. Four themes related to stakeholders' understanding: 1) definitions of adaptation and related concepts; 2) rationales for undertaking adaptation; 3) the appropriate timing for adaptation; and 4) ensuring fidelity when implementing adapted interventions.

CONCLUSION

The findings highlight the lack of clarity around key concepts and uncertainty about central decision-making processes, notably why interventions should be adapted, when and to what extent. This has informed the ADAPT study's guidance, shaping the scope and nature of recommendations to be included and surfacing key uncertainties that require future consideration.

Context counts: a qualitative study exploring the interplay between context and implementation success

PURPOSE

Implementing change in healthcare is difficult to accomplish due to the unpredictability associated with challenging the status quo. Adapting the intervention/practice/program being implemented to better fit the complex context is an important aspect of implementation success. Despite the acknowledged influence of context, the concept continues to receive insufficient attention at the team-level within implementation research. Using two heterogeneous multidisciplinary healthcare teams as implementation case studies, this study evaluates the interplay between context and implementation and highlights the ways in which context influences the introduction of a collective leadership intervention in routine practice.

DESIGN/METHODOLOGY/APPROACH

The multiple case study design adopted, employed a triangulation of qualitative research methods which involved observation (Case A = 16 h, Case B = 15 h) and interview data (Case A = 13 participants, Case B = 12 participants). Using an inductive approach, an in-depth thematic analysis of the data outlined the relationship between team-level contextual factors and implementation success.

FINDINGS

Themes are presented under the headings: (1) adapting to the everyday realities, a key determinant for implementation success and (2) implementation stimulating change in context. The findings demonstrate a dynamic relationship between context and implementation. The challenges of engaging busy healthcare professionals emphasised that mapping the contextual complexity of a site and adapting implementation accordingly is essential to enhance the likelihood of successful implementation. However, implementation also altered the surrounding context, stimulating changes within both teams.

ORIGINALITY/VALUE

By exposing the reciprocal relationship between team-level contextual factors and implementation, this research supports the improved design of implementation strategies through better understanding the interplay and mutual evolution of evidence-based healthcare interventions within different contexts.

Using Health Systems Engineering Approaches to Prepare for Tailoring of Implementation Interventions

BACKGROUND

Implementation of evidence-based practices often requires tailoring implementation strategies to local contextual factors, including available resources, expertise, and cultural norms. Using an exemplar case, we describe how health systems engineering methods can be used to understand system-level variation that must be accounted for prior to broad implementation.

METHODS

Within the context of a single-center quality improvement activity, a multi-disciplinary stakeholder team used health systems engineering methods to describe how pre-endoscopy antithrombotic management was executed, and implemented a redesigned process to improve clinical care. The research team then conducted multiple stakeholder focus groups at four different health-care systems to describe and compare current processes for pre-endoscopy antithrombotic medication management. Detailed work flow maps for each health-care system were developed, analyzed, and integrated to develop an overarching current work flow map, identify key process steps, and describe areas of process variation.

RESULTS

Five key process steps were identified across the four health systems: (1) place an endoscopy order, (2) screen for antithrombotic use, (3) coordinate medication management, (4) instruct the patient, and (5) confirm appropriate medication management before procedure. Across health systems, we found a high degree of variation in each step (e.g., who performed, use of technology, systematic vs. ad hoc process). This variation was influenced by two key system-level contextual factors: (1) degree of health system integration and (2) role and training level of available staff. These key steps, areas of variation, and contextual factors were integrated into an assessment tool designed to facilitate tailoring of a future implementation and dissemination strategy.

CONCLUSIONS

Tools from health systems engineering can be used to identify key work flow process steps, variations in how those steps are executed, and influential contextual factors. This process and the associated assessment tool may facilitate broader implementation tailoring.

Towards a comprehensive model for understanding adaptations' impact: the model for adaptation design and impact (MADI)

Background

Implementation science is shifting from qualifying adaptations as good or bad towards understanding adaptations and their impact. Existing adaptation classification frameworks are largely descriptive (e.g., who made the adaptation) and geared towards researchers. They do not help practitioners in decision-making around adaptations (e.g., is an adaptation likely to have negative impacts? Should it be pursued?). Moreover, they lack constructs to consider “ripple effects” of adaptations (i.e., both intended and unintended impacts on outcomes, recognizing that an adaptation designed to have a positive impact on one outcome may have unintended impacts on other outcomes). Finally, they do not specify relationships between adaptations and outcomes, including mediating and moderating relationships. The objective of our research was to promote systematic assessment of intended and unintended impacts of adaptations by using existing frameworks to create a model that proposes relationships among constructs.

Materials and methods

We reviewed, consolidated, and refined constructs from two adaptation frameworks and one intervention-implementation outcome framework. Using the consolidated and refined constructs, we coded qualitative descriptions of 14 adaptations made to an existing evidence-based intervention; the 14 adaptations were designed in prior research by a stakeholder panel using a modified Delphi approach. Each of the 14 adaptations had detailed descriptions, including the nature of the adaptation, who made it, and its goal and reason. Using coded data, we arranged constructs from existing frameworks into a model, the Model for Adaptation Design and Impact (MADI), that identifies adaptation characteristics, their intended and unintended impacts (i.e., ripple effects), and potential mediators and moderators of adaptations’ impact on outcomes. We also developed a decision aid and website (MADIguide.org) to help implementation scientists apply MADI in their work.

Results and conclusions

Our model and associated decision aids build on existing frameworks by comprehensively characterizing adaptations, proposing how adaptations impact outcomes, and offering practical guidance for designing adaptations. MADI encourages researchers to think about potential causal pathways of adaptations (e.g., mediators and moderators) and adaptations’ intended and unintended impacts on outcomes. MADI encourages practitioners to design adaptations in a way that anticipates intended and unintended impacts and leverages best practice from research.

Iterative Decision-making for Evaluation of Adaptations (IDEA): A decision tree for balancing adaptation, fidelity, and intervention impact

BACKGROUND

Evidence-based practices (EBPs) are frequently adapted to maximize outcomes while maintaining fidelity to core EBP elements. Many step-by-step frameworks for adapting EBPs have been developed, but these models may not account for common complexities in the adaptation process. In this paper, we introduce the Iterative Decision-making for Evaluation of Adaptations (IDEA), a tool to guide adaptations that addresses these issues.

FRAMEWORK DESIGN AND USE

Adapting EBPs requires attending to key contingencies incorporated into the IDEA, including: the need for adaptations; fidelity to core EBP elements; the timeframe in which to make adaptations; the potential to collect pilot data; key clinical and implementation outcomes; and stakeholder viewpoints. We use two examples to illustrate application of the IDEA.

CONCLUSIONS

The IDEA is a practical tool to guide EBP adaptation that incorporates important decision points and the dynamism of ongoing adaptation. Its use may help implementation scientists, clinicians, and administrators maximize EBP impact.

Focusing on fidelity: narrative review and recommendations for improving intervention fidelity within trials of health behaviour change interventions

Background: Interventions to change behaviour have substantial potential to impact positively on individual and overall public health. Despite an increasing focus on health behaviour change intervention research, interventions do not always have the desired effect on outcomes, while others have diluted effects once implemented into real-life settings. There is little investment into understanding how or why such interventions work or do not work. Methodological inadequacies of trials of behavioural interventions have been previously suggested as a barrier to the quality and advancement of behavioural research, with intervention fidelity acknowledged as a key area for improvement. However, there is much ambiguity regarding the terminology and conceptualisation of intervention fidelity and a lack of practical guidance regarding how to address it sufficiently, particularly within trials of complex behavioural interventions. Objectives: This article outlines specific issues concerning intervention fidelity within trials of health behaviour change interventions and suggests practical considerations and specific recommendations for researchers, with examples from the literature presented. Conclusions: Recommendations pertain to (1) clarifying how fidelity is defined and conceptualised, (2) considering fidelity beyond intervention delivery, (3) considering strategies to both enhance and assess fidelity, (4) making use of existing frameworks and guidance, (5) considering the quality and comprehensiveness of fidelity assessment strategies, (6) considering the balance between fidelity and adaptation and (7) reporting the use of fidelity enhancement and assessment strategies and their results. Suggestions for future research to improve our understanding of, and ability to, address fidelity in behaviour change interventions are also provided.