Teaching community program clinicians motivational interviewing using expert and train-the-trainer strategies

Exploring the Impact of External Facilitation Using Evidence-Based Implementation Strategies for Increasing Motivational Interviewing Capacity Among Outpatient Substance Use Disorder (SUD) Treatment Providers

The large majority of individuals who access substance use disorders (SUD) treatment do not receive evidence-based care. Little attention has been paid to the notion that the scale-up of evidence-based practices (EBPs) has been limited in large part due to a weakness in the "distribution system" for bringing new innovations to the attention of practitioners and into practice settings. This study explores the impact of the Training and Practice Implementation Institute (TPII; funded by the New York City Department of Health and Mental Hygiene), an intensive technical assistance initiative that offers external facilitation to outpatient SUD treatment providers via the incorporation of multiple evidence-based implementation strategies to enhance the practice of motivational interviewing (MI). Findings from this study show that staff completed a large majority (86%) of required training/technical assistance (TTA) activities across the 9-month implementation period, demonstrating a high level of engagement among staff and the feasibility of externally facilitated intensive TTA delivered to community-based organizations for the purpose of enhancing implementation of MI for SUDs. Results also show statistically significant improvements in the delivery of MI's technical components among staff, though did not reveal corresponding improvements in the delivery of MI's relational components. An understanding of the potential return on investment associated with externally facilitated TA, offers organizations an opportunity to inform the allocation of limited resources to areas where they will have the greatest impact and ultimately improve the quality and efficacy of services.

Implementation fidelity, student outcomes, and cost-effectiveness of train-the-trainer strategies for Masters-level therapists in urban schools: results from a cluster randomized trial

BACKGROUND

Little is known about the effectiveness and cost-effectiveness of train-the-trainer implementation strategies in supporting mental health evidence-based practices in schools, and about the optimal level of support needed for TT strategies.

METHODS

The current study is part of a larger type 2 hybrid cluster randomized controlled trial. It compares two train-the-trainer strategies, Train-the-Trainer (TT) and Train-the-Trainer plus ongoing consultation for trainers (TT +) on the delivery of a group cognitive behavioral treatment protocol for anxiety disorders. Participants were 33 therapists, 29 supervisors, and 125 students who were at risk for anxiety disorders from 22 urban schools. Implementation outcomes were implementation fidelity and treatment dosage. Student outcomes were child- and parent-reported symptoms of anxiety, child-reported symptoms of depression, and teacher-reported academic engagement. We estimated the cost of implementing the intervention in each condition and examined the probability that a support strategy for supervisors (TT vs TT +) is a good value for varying values of willingness to pay.

RESULTS

Therapists in the TT and TT + conditions obtained similarly high implementation fidelity and students in the conditions received similar treatment dosages. A mixed effects modeling approach for student outcomes revealed time effects for symptoms of anxiety and depression reported by students, and emotional disaffection reported by teachers. There were no condition or condition × times effects. For both conditions, the time effects indicated an improvement from pre-treatment to post-treatment in symptoms of anxiety and depression and academic emotional engagement. The average cost of therapist, supervisor, and consultant time required to implement the intervention in each condition was $1002 for TT and $1431 for TT + (p = 0.01). There was a greater than 80% chance that TT was a good value compared to TT + for all values of willingness to pay per one-point improvement in anxiety scores.

CONCLUSIONS

A TT implementation approach consisting of a thorough initial training workshop for therapists and supervisors as well as ongoing supervision for therapists resulted in adequate levels of fidelity and student outcomes but at a lower cost, compared to the TT + condition that also included ongoing external expert consultation for supervisors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02651402.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: study protocol for a hybrid type 2 effectiveness-implementation cluster-randomized trial using train-the-trainer

BACKGROUND

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes and (b) providers' perceptions of fit.

METHODS

TTT will be implemented in nine CMHCs in California, USA (N = 60 providers; N = 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality), and (3) evaluate other possible moderators.

DISCUSSION

This trial has potential to (a) inform the process of embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) add to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advance our understanding of providers' perceptions of EBPT "fit" across TTT generations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05805657 . Registered on April 10, 2023.

A survey of motivational interviewing training experiences among internal medicine residents

OBJECTIVE

Assess resident physicians' training experiences and self-reported application of motivational interviewing (MI) skills.

METHODS

A cross-sectional nationally representative survey of internal medicine and medicine/pediatric residents from October 2021 - May 2022. Residents reported their MI skill training settings: lectures, standardized patients, role plays, group exercises, direct observation of patient encounters, and a full day or more course. Respondents reported frequency of using specific MI skills in the prior six months during behavior change conversations with patients.

RESULTS

The response rate 71.2% (202/281). Respondents received MI training in medical school (67.7%), residency (27.2%), both (22.7%), or none (23.5%). Respondents reported MI training through formal lectures/information discussion (77.5%), MI exercises (77.5%), direct observation of a real patient encounter (38.7%), and one or more full-day workshops (8.5%). Most respondents never or only sometimes elicited change talk statements (73.2%), responded to a patient's sustain talk (64.3%), and developed discrepancies in behavior between individuals' current actions and desired behaviors (75%).

CONCLUSIONS

Significant training gaps exist within resident MI education, which may reduce the application of MI skills.

PRACTICAL IMPLICATIONS

Behavior change is crucial to many aspects of patient health outcomes. This lack of knowledge may impact future physicians' ability to comprehensively care for patients.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: Study protocol for a hybrid type 2 effectiveness-implementation cluster- randomized trial using train-the-trainer

Background

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes (b) providers' perceptions of fit.

Methods

TTT will be implemented in nine CMHCs in California, United States (N= 60 providers; N= 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will: (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality); and (3) evaluate other possible moderators.

Discussion

This trial has potential to inform the process of (a) embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) adding to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advancing our understanding of providers' perceptions of EBPT 'fit' across TTT generations.

Trial registration

Clinicaltrials.gov identifier: NCT05805657. Registered on April 10, 2023. https://clinicaltrials.gov/ct2/show/NCT05805657.

Handoffs and the challenges to implementing teamwork training in the perioperative environment

Perioperative handoffs are high-risk events for miscommunications and poor care coordination, which cause patient harm. Extensive research and several interventions have sought to overcome the challenges to perioperative handoff quality and safety, but few efforts have focused on teamwork training. Evidence shows that team training decreases surgical morbidity and mortality, and there remains a significant opportunity to implement teamwork training in the perioperative environment. Current perioperative handoff interventions face significant difficulty with adherence which raises concerns about the sustainability of their impact. In this perspective article, we explain why teamwork is critical to safe and reliable perioperative handoffs and discuss implementation challenges to the five core components of teamwork training programs in the perioperative environment. We outline evidence-based best practices imperative for training success and acknowledge the obstacles to implementing those best practices. Explicitly identifying and discussing these obstacles is critical to designing and implementing teamwork training programs fit for the perioperative environment. Teamwork training will equip providers with the foundational teamwork competencies needed to effectively participate in handoffs and utilize handoff interventions. This will improve team effectiveness, adherence to current perioperative handoff interventions, and ultimately, patient safety.

Training Male Sexual Abuse Survivors as Peer Leaders to Deliver Motivational Interviewing and Trauma-Informed Affirmative Care

This paper provides a description and evaluation of training male sexual abuse survivors to deliver Motivational Interviewing (MI) and Motivational Interviewing with Trauma-Informed Affirmative Care (MI-AC) online to sexual and gender minority (SGM) men with sexual assault histories and depression. After a search and selection process, 26 men with lived experience of sexual abuse received MI training that included the use of role-playing, video demonstrations, and practice followed by weekly supervision while co-leading groups. Peer leaders completed several measures pre and post training, including beliefs about MI and self-reported learning of MI and satisfaction with the training. A sample of MI and MI-AC audio sessions were independently rated for adherence and competence. Peer leaders' beliefs about MI changed over time, while self-rated skill level stayed consistent. Peer leaders demonstrated good adherence to the MI and MI-AC conditions. Results suggest that men with lived experience of sexual trauma effectively learned to deliver MI and/or MI-AC to SGM male survivors in online groups. These interventions have the potential to expand the reach of limited services for this population as well as reduce their depression and assist in SGM men with histories of sexual abuse entering into formal mental health services.

Tailoring an evidence-based clinical intervention and training package for the treatment and prevention of comorbid heavy drinking and depression in middle-income country settings: the development of the SCALA toolkit in Latin America

BACKGROUND

Effective interventions exist for heavy drinking and depression but to date there has been limited translation into routine practice in global health systems. This evidence-to-practice gap is particularly evident in low- and middle-income countries. The international SCALA project (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America) sought to test the impact of multilevel implementation strategies on rates of primary health care-based measurement of alcohol consumption and identification of depression in Colombia, Mexico, and Peru.

OBJECTIVE

To describe the process of development and cultural adaptation of the clinical intervention and training package.

METHODS

We drew on Barrero and Castro's four-stage cultural adaption model: 1) information gathering, 2) preliminary adaption, 3) preliminary adaption tests, and 4) adaption refinement. The Tailored Implementation in Chronic Diseases checklist helped us identify potential factors that could affect implementation, with local stakeholder groups established to support the tailoring process, as per the Institute for Healthcare Improvement's Going to Scale Framework.

RESULTS

In Stage 1, international best practice guidelines for preventing heavy drinking and depression, and intelligence on the local implementation context, were synthesised to provide an outline clinical intervention and training package. In Stage 2, feedback was gathered from local stakeholders and materials refined accordingly. These materials were piloted with local trainers in Stage 3, leading to further refinements including developing additional tools to support delivery in busy primary care settings. Stage 4 comprised further adaptions in response to real-world implementation, a period that coincided with the onset of the COVID-19 pandemic, including translating the intervention and training package for online delivery, and higher priority for depression screening in the clinical pathway.

CONCLUSION

Our experience highlights the importance of meaningful engagement with local communities, alongside the need for continuous tailoring and adaptation, and collaborative decision-making.

Comparative effectiveness of in-person vs. remote delivery of the Common Elements Treatment Approach for addressing mental and behavioral health problems among adolescents and young adults in Zambia: protocol of a three-arm randomized controlled trial

BACKGROUND

In low- and middle-income countries (LMIC), there is a substantial gap in the treatment of mental and behavioral health problems, which is particularly detrimental to adolescents and young adults (AYA). The Common Elements Treatment Approach (CETA) is an evidence-based, flexible, transdiagnostic intervention delivered by lay counselors to address comorbid mental and behavioral health conditions, though its effectiveness has not yet been tested among AYA. This paper describes the protocol for a randomized controlled trial that will test the effectiveness of traditional in-person delivered CETA and a telehealth-adapted version of CETA (T-CETA) in reducing mental and behavioral health problems among AYA in Zambia. Non-inferiority of T-CETA will also be assessed.

METHODS

This study is a hybrid type 1 three-arm randomized trial to be conducted in Lusaka, Zambia. Following an apprenticeship model, experienced non-professional counselors in Zambia will be trained as CETA trainers using a remote, technology-delivered training method. The new CETA trainers will subsequently facilitate technology-delivered trainings for a new cohort of counselors recruited from community-based partner organizations throughout Lusaka. AYA with mental and behavioral health problems seeking services at these same organizations will then be identified and randomized to (1) in-person CETA delivery, (2) telehealth-delivered CETA (T-CETA), or (3) treatment as usual (TAU). In the superiority design, CETA and T-CETA will be compared to TAU, and using a non-inferiority design, T-CETA will be compared to CETA, which is already evidence-based in other populations. At baseline, post-treatment (approximately 3-4 months post-baseline), and 6 months post-treatment (approximately 9 months post-baseline), we will assess the primary outcomes such as client trauma symptoms, internalizing symptoms, and externalizing behaviors and secondary outcomes such as client substance use, aggression, violence, and health utility. CETA trainer and counselor competency and cost-effectiveness will also be measured as secondary outcomes. Mixed methods interviews will be conducted with trainers, counselors, and AYA participants to explore the feasibility, acceptability, and sustainability of technology-delivered training and T-CETA provision in the Zambian context.

DISCUSSION

Adolescents and young adults in LMIC are a priority population for the treatment of mental and behavioral health problems. Technology-delivered approaches to training and intervention delivery can expand the reach of evidence-based interventions. If found effective, CETA and T-CETA would help address a major barrier to the scale-up and sustainability of mental and behavioral treatments among AYA in LMIC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03458039 . Prospectively registered on May 10, 2021.

Implementation of the Wolverine Mental Health Program, Part 3: Sustainment Phase

Sustaining the implementation of an evidence-based practice (EBP) is the ultimate goal of often years of significant personnel and financial investment. Some conceptualize sustainment as a distinct phase following an active implementation period where the contextual factors, processes, and supports are bolstered to ensure continued EBP delivery. This study provides an overview of the sustainment strategies deployed to embed cognitive-behavioral therapy (CBT) in a Midwestern residential treatment facility serving youth with complex mental health needs. Seven key strategies and their outcomes are described: use of CBT teams, new hire orientation plans, monthly campaigns, change in job descriptions and performance evaluations, development of a behavioral reinforcement system for youth, and a pathway to CBT certification. This study provides a window into how one might sustain an EBP by addressing barriers unique to this phase of work.

Implementation of the Wolverine Mental Health Program, Part 2: Implementation Phase

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic-community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).

Maintenance of Training Effects of Two Models for Implementing Evidence-Based Psychological Treatment

OBJECTIVE

The authors compared maintenance of training outcomes for two approaches to training college therapists in interpersonal psychotherapy (IPT): train the trainer versus expert training.

METHODS

A cluster-randomized trial was conducted in 24 college counseling centers. Therapists were recruited from enrolled centers, and the therapists enrolled students with depression and eating disorder symptoms. The therapists (N=184) provided data during baseline, posttraining (during the 12 months of expert consultation offered to the expert training group), and maintenance (approximately 7 months after the expert consultation ended). Outcomes were therapist fidelity (i.e., adherence and competence) and IPT knowledge.

RESULTS

Both groups showed within-group improvement from baseline to the maintenance period for adherence, competence, and IPT knowledge; however, the train-the-trainer group had greater improvement over time in adherence and competence.

CONCLUSIONS

Given that the effects of the train-the-trainer approach were better maintained, and this model's potential to train more therapists over time, the train-the-trainer approach may help increase dissemination of evidence-based treatments such as IPT.

Improving implementation of smoking cessation guidelines in pregnancy care: development of an intervention to address system, maternity service leader and clinician factors

Background

Smoking during pregnancy increases the risk of multiple serious adverse infant, child and maternal outcomes, yet nearly 10% of Australian women still smoke during pregnancy. Despite evidence-based guidelines that recommend routine and repeated smoking cessation support (SCS) for all pregnant women, the provision of recommended SCS remains poor. Guidance on developing complex interventions to improve health care recommends drawing on existing theories, reviewing evidence, undertaking primary data collection, attending to future real-world implementation and designing and refining interventions using iterative cycles with stakeholder input throughout. Here, we describe using the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework to apply these principles in developing an intervention to improve the provision of SCS in Australian maternity services.

Methods

Working closely with key stakeholders in the New South Wales (NSW) health system, we applied the steps of the BCW method then undertook a small feasibility study in one service to further refine the intervention. Stakeholders were engaged in multiple ways—as a core research team member, through a project Advisory Group, targeted meetings with policymakers, a large workshop to review potential components and the feasibility study.

Results

Barriers to and enablers of providing SCS were identified in five of six components described in the BCW method (psychological capability, physical opportunity, social opportunity and reflective and automatic motivation). These were mapped to intervention types and we selected education, training, enablement, environmental restructuring, persuasion, incentivisation and modelling as suitable in our context. Through application of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects and Equity) in the stakeholder workshop, behaviour change techniques were selected and applied in developing the intervention which includes systems, clinician and leadership elements. The feasibility study confirmed the feasibility and acceptability of the midwifery component and the need to further strengthen the leadership component.

Conclusions

Using the BCW method combined with strong stakeholder engagement from inception resulted in transparent development of the MOHMQuit intervention, which targets identified barriers to and enablers of the provision of SCS and is developed specifically for the context in which it will be implemented. The intervention is being trialled in eight public maternity services in NSW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00235-5.

Home environmental assessments and modification delivered by occupational therapists to reduce falls in people aged 65 years and over: the OTIS RCT

BACKGROUND

Falls and fall-related fractures are highly prevalent among older people and are a major contributor to morbidity and costs to individuals and society. Only one small pilot trial has evaluated the effectiveness of a home hazard assessment and environmental modification in the UK. This trial reported a reduction in falls as a secondary outcome, and no economic evaluation was undertaken. Therefore, the results need to be confirmed and a cost-effectiveness analysis needs to be undertaken.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of a home hazard assessment and environmental modification delivered by occupational therapists for preventing falls among community-dwelling people aged ≥ 65 years who are at risk of falling, relative to usual care.

DESIGN

This was a pragmatic, multicentre, modified cohort randomised controlled trial with an economic evaluation and a qualitative study.

SETTING

Eight NHS trusts in primary and secondary care in England.

PARTICIPANTS

In total, 1331 participants were randomised (intervention group, n = 430; usual-care group, n = 901) via a secure, remote service. Blinding was not possible.

INTERVENTIONS

All participants received a falls prevention leaflet and routine care from their general practitioner. The intervention group were additionally offered one home environmental assessment and modifications recommended or provided to identify and manage personal fall-related hazards, delivered by an occupational therapist.

MAIN OUTCOME MEASURES

The primary outcome was the number of falls per participant during the 12 months from randomisation. The secondary outcomes were the proportion of fallers and multiple fallers, time to fall, fear of falling, fracture rate, health-related quality of life and cost-effectiveness.

RESULTS

The primary analysis included all 1331 randomised participants and indicated weak evidence of a difference in fall rate between the two groups, with an increase in the intervention group relative to usual care (adjusted incidence rate ratio 1.17, 95% confidence interval 0.99 to 1.38; p = 0.07). A similar proportion of participants in the intervention group (57.0%) and the usual-care group (56.2%) reported at least one fall over 12 months. There were no differences in any of the secondary outcomes. The base-case cost-effectiveness analysis from an NHS and Personal Social Services perspective found that, on average per participant, the intervention was associated with additional costs (£18.78, 95% confidence interval £16.33 to £21.24), but was less effective (mean quality-adjusted life-year loss -0.0042, 95% confidence interval -0.0041 to -0.0043). Sensitivity analyses demonstrated uncertainty in these findings. No serious, related adverse events were reported. The intervention was largely delivered as intended, but recommendations were followed to a varying degree.

LIMITATIONS

Outcome data were self-reported by participants, which may have led to inaccuracies in the reported falls data.

CONCLUSIONS

We found no evidence that an occupational therapist-delivered home assessment and modification reduced falls in this population of community-dwelling participants aged ≥ 65 years deemed at risk of falling. The intervention was more expensive and less effective than usual care, and therefore it does not provide a cost-effective alternative to usual care.

FUTURE WORK

An evaluation of falls prevention advice in a higher-risk population, perhaps those previously hospitalised for a fall, or given by other professional staff could be justified.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22202133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 46. See the NIHR Journals Library website for further project information.

The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity-Building Scale-Up Trial: Study Design and Protocol

BACKGROUND

Depression is a leading cause of death and disability worldwide, including in low- and middle-income countries (LMICs). Depression often coexists with chronic medical conditions and is associated with worse clinical outcomes. This confluence has led to calls to integrate mental health treatment with chronic disease care systems in LMICs. This article describes the rationale and protocol for a trial comparing the clinical effectiveness and cost-effectiveness of two different intervention packages to implement evidence-based antidepressant management and psychotherapy into chronic noncommunicable disease (NCD) clinics in Malawi.

METHODS

Using constrained randomization, the Sub-Saharan Africa Regional Partnership (SHARP) for mental health capacity building will assign five Malawian NCD clinics to a basic implementation strategy via an internal coordinator, a provider within the chronic care clinic who champions depression services by providing training, supervision, operations, and reporting. Another five clinics will be assigned to depression services implementation via an internal coordinator along with an external quality assurance committee, which will provide a quarterly audit of intervention component delivery with feedback to providers and the health management team.

RESULTS

The authors will compare key implementation outcomes (fidelity to intervention), clinical effectiveness outcomes (patient health), and cost-effectiveness and will assess characteristics of clinics that may influence uptake and fidelity.

NEXT STEPS

This trial will provide key information to guide the Malawi Ministry of Health in scaling up depression management in existing NCD settings. The SHARP trial is anticipated to substantially contribute to enhancing both mental health treatment and implementation science research capacity in Malawi and the wider region.

Implementation support for contingency management: preferences of opioid treatment program leaders and staff

BACKGROUND

Contingency management (CM), a behavioral intervention that provides incentives for achieving treatment goals, is an evidence-based adjunct to medication to treat opioid use disorder. Unfortunately, many front-line treatment providers do not utilize CM, likely due to contextual barriers that limit effective training and ongoing support for evidence-based practices. This study applied user-informed approaches to adapt a multi-level implementation strategy called the Science to Service Laboratory (SSL) to support CM implementation.

METHODS

Leaders and treatment providers working in community-based opioid treatment programs (OTPs; N = 43) completed qualitative interviews inquiring about their preferences for training and support implementation strategies (didactic training, performance feedback, and external facilitation). Our team coded interviews using a reflexive team approach to identify common a priori and emergent themes.

RESULTS

Leaders and providers expressed a preference for brief training that included case examples and research data, along with experiential learning strategies. They reported a desire for performance feedback from internal supervisors, patients, and clinical experts. Providers and leaders had mixed feelings about audio-recording sessions but were open to the use of rating sheets to evaluate CM performance. Finally, participants desired both on-call and regularly scheduled external facilitation to support their continued use of CM.

CONCLUSIONS

This study provides an exemplar of a user-informed approach to adapt the SSL implementation support strategies for CM scale-up in community OTPs. Study findings highlight the need for user-informed approaches to training, performance feedback, and facilitation to support sustained CM use in this setting.

Making Implementation Last: The Impact of Training Design on the Sustainability of an Evidence-Based Treatment in a Randomized Controlled Trial

Although advances have been made in facilitating the implementation of evidence-based treatments, little is known about the most effective way to sustain their use over time. The current study examined the sustainability of one evidence-based treatment, Parent-Child Interaction Therapy (PCIT), following a statewide implementation trial testing three training methods: Cascading Model, Learning Collaborative, and Distance Education. Participants included 100 clinicians and 50 administrators from 50 organizations across Pennsylvania. Clinicians and administrators reported on sustainability at 24-months, as measured by the number of clients receiving PCIT and the continued use of the PCIT protocol. Multi-level path analysis was utilized to examine the role of training on sustainability. Clinicians and administrators reported high levels of sustainability at 24-months. Clinicians in the Cascading Model reported greater average PCIT caseloads at 24-months, whereas clinicians in the Learning Collaborative reported greater full use of the PCIT protocol at 24-months. Attending consultation calls was associated with delivering PCIT to fewer families. Implications for the sustainable delivery of PCIT beyond the training year as well as for the broader field of implementation science are discussed.

A systematic review of evidence-based practice implementation in drug and alcohol settings: applying the consolidated framework for implementation research framework

Background

There is a paucity of translational research programmes to improve implementation of evidence-based care in drug and alcohol settings. This systematic review aimed to provide a synthesis and evaluation of the effectiveness of implementation programmes of treatment for patients with drug and alcohol problems using the Consolidated Framework for Implementation Research (CFIR).

Methods

A comprehensive systematic review was conducted using five online databases (from inception onwards). Eligible studies included clinical trials and observational studies evaluating strategies used to implement evidence-based psychosocial treatments for alcohol and substance use disorders. Extracted data were qualitatively synthesised for common themes according to the CFIR. Primary outcomes included the implementation, service system or clinical practice. Risk of bias of individual studies was appraised using appropriate tools. A protocol was registered with (PROSPERO) (CRD42019123812) and published previously (Louie et al. Systematic 9:2020).

Results

Of the 2965 references identified, twenty studies were included in this review. Implementation research has employed a wide range of strategies to train clinicians in a few key evidence-based approaches to treatment. Implementation strategies were informed by a range of theories, with only two studies using an implementation framework (Baer et al. J Substance Abuse Treatment 37:191-202, 2009) used Context-Tailored Training and Helseth et al. J Substance Abuse Treatment 95:26-34, 2018) used the CFIR). Thirty of the 36 subdomains of the CFIR were evaluated by included studies, but the majority were concerned with the Characteristics of Individuals domain (75%), with less than half measuring Intervention Characteristics (45%) and Inner Setting constructs (25%), and only one study measuring the Outer Setting and Process domains. The most common primary outcome was the effectiveness of implementation strategies on treatment fidelity. Although several studies found clinician characteristics influenced the implementation outcome (40%) and many obtained clinical outcomes (40%), only five studies measured service system outcomes and only four studies evaluated the implementation.

Conclusions

While research has begun to accumulate in domains such as Characteristics of Individuals and Intervention Characteristics (e.g. education, beliefs and attitudes and organisational openness to new techniques), this review has identified significant gaps in the remaining CFIR domains including organisational factors, external forces and factors related to the process of the implementation itself. Findings of the review highlight important areas for future research and the utility of applying comprehensive implementation frameworks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01090-7.

Virtual Standardized Patients vs Academic Training for Learning Motivational Interviewing Skills in the US Department of Veterans Affairs and the US Military: A Randomized Trial

IMPORTANCE

Despite the need for effective and scalable training in motivational interviewing (MI) that includes posttraining coaching and feedback, limited evidence exists regarding the effectiveness of using virtual (computerized) standardized patients (VSPs) in such training.

OBJECTIVE

To evaluate the efficacy of training with a VSP on the acquisition and maintenance of MI skills compared with traditional academic study.

DESIGN, SETTING, AND PARTICIPANTS

This study was a 2-group, parallel-training randomized trial of 120 volunteer health care professionals recruited from a Department of Veterans Affairs and Department of Defense medical facility. Motivational interviewing skill was coded by external experts blinded to training group and skill assessment time points. Data were collected from October 17, 2016, to August 12, 2019.

INTERVENTIONS

After a computer course on MI, participants trained during two 45-minute sessions separated by 3 months. The 2 randomized training conditions included a branching storyline VSP, which provided MI skill rehearsal with immediate and summative feedback, and a control condition, which included academic study of content from the computerized MI course.

MAIN OUTCOMES AND MEASURES

Measurement of MI skill was based on recorded conversations with human standardized patients, assessed using the Motivational Interviewing Treatment Integrity 4.2.1 coding system, measured at baseline, after training, and after additional training in the randomized condition 3 months later.

RESULTS

A total of 120 volunteers (83 [69%] women), with a mean (SD) of 13.6 (10.3) years of health care experience, participated in the study; 61 were randomized to receive the intervention, and 59 were randomized to the control group. Those assigned to VSP training had significantly greater posttraining improvement in technical global scores (0.23; 95% CI, 0.03-0.44; P = .02), relational global scores (0.57; 95% CI, 0.33-0.81; P = .001), and the reflection-to-question ratio (0.23; 95% CI, 0.15-0.31; P = .001). Differences were maintained after the 3-month additional training session, with more improvements achieved after the 3-month training for the VSP trainees on the reflection-to- question ratio (0.15; 95% CI, 0.07-0.24; P = .001).

CONCLUSIONS AND RELEVANCE

This randomized trial demonstrated a successful transfer of training from a VSP to human standardized patients. The VSP MI skill outcomes were better than those achieved with academic study and were maintained over time. Virtual standardized patients have the potential to facilitate dissemination of MI and may be useful for training in other evidence-based skills and treatments.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04558060.

The process of skills training: A content analysis of evidence-based addiction therapies

OVERVIEW

This work builds on previous efforts to delineate cross-cutting factors of evidence-based therapies. In this report, we target a single therapeutic factor-skills training for addictive behavior change-and we operationalize this factor in a manner that will aid clinical training and quality control. Specifically, we identify principles, which we defined as broader understandings on the part of the therapist that must be kept in mind when implementing a specific therapeutic practice. We define a practice as discrete action step or specific type of intervention that the therapist uses when addressing skills training content with clients.

METHOD

We conducted a literature review and qualitative content analysis of 30 source documents (i.e., therapy manuals, literature reviews, and government issued practice guidelines) and videos (i.e., therapy demonstration videos). We performed analysis of source materials in NVIVO.

RESULTS

We identified 10 principles and 30 therapeutic practices. Together, the principles suggest that skills training in evidence-based addiction therapies can be characterized as a client-centered approach to teaching and behavioral practice. The identified practices fell into four function themes: 1) client-centered goal-setting, 2) building client self-efficacy, 3) engaging in teaching, and 4) engaging in practice.

CONCLUSIONS

When the identified principles and practices are combined, they can inform a fidelity-based approach to behavioral skills training that is applicable to a wide range of alcohol or other drug (AOD) content topics, therapeutic modalities, and implementation settings. We discuss future implications regarding standardized training and fidelity assessment.

Cost and cost-effectiveness of three strategies for implementing motivational interviewing for substance misuse on medical inpatient units

BACKGROUND

This study conducted cost and cost-effectiveness analyses of three strategies for implementing motivational interviewing for substance misuse on general medical inpatient units: workshop, apprenticeship, and consult.

METHODS

The economic analyses were conducted prospectively alongside a type 3 hybrid effectiveness-implementation randomized trial comprising 38 medical providers, 1173 inpatients, and four consultation-liaison motivational interviewing experts. The trial took place in a university affiliated teaching hospital in New Haven, CT, USA. After completing a 1-day workshop on motivational interviewing, providers were randomized to conditions. The primary outcome measure was the number of study-eligible patients who received a motivational interview. The economic analyses included the costs of both start-up and on-going activities in each condition. Incremental cost-effectiveness ratios were used to determine cost effectiveness. Results are presented from the healthcare provider (i.e., hospital) perspective in 2018 US dollars.

RESULTS

The total cost per patient receiving a motivational interview averaged $804.53, $606.52, and $185.65 for workshop, apprenticeship, and consult, respectively. Workshop and apprenticeship were extended dominated by the combination of consult and doing nothing. Doing nothing is cost effective when the willingness-to-pay for an additional patient receiving a motivational interview is less than $185.65, and consult is cost-effective when the willingness-to-pay for an additional patient receiving a motivational interview is greater than $185.65.

CONCLUSIONS

Given that typical reimbursements for brief intervention services for substance misuse are $35-$65, none of the three implementation strategies is likely to be economically viable from the healthcare provider perspective.

Therapist training in evidence-based interventions for mental health: A systematic review of training approaches and outcomes

A lack of effective therapist training is a major barrier to evidence-based intervention (EBI) delivery in the community. Systematic reviews published nearly a decade ago suggested that traditional EBI training leads to higher knowledge but not more EBI use, indicating that more work is needed to optimize EBI training and implementation. This systematic review synthesizes the training literature published since 2010 to evaluate how different training models (workshop, workshop with consultation, online training, train-the-trainer, and intensive training) affect therapists' knowledge, beliefs, and behaviors. Results and limitations for each approach are discussed. Findings show that training has advanced beyond provision of manuals and brief workshops; more intensive training models show promise for changing therapist behavior. However, methodological issues persist, limiting conclusions and pointing to important areas for future research.

Effectiveness of training methods for delivery of evidence-based psychotherapies: a systematic review

BACKGROUND

Extensive efforts have been made to train mental health providers in evidence-based psychotherapies (EBPs); there is increasing attention focused on the methods through which providers are trained to deliver EBPs. Evaluating EBP training methods is an important step in determining which methods are most effective in increasing provider skill and improving client outcomes.

METHODS

We searched MEDLINE (Ovid) and PsycINFO for randomized controlled trials published from 1990 through June 2019 that evaluated EBP training methods to determine the effectiveness of EBP training modalities on implementation (provider and cost) and client outcomes. Eligible studies (N = 28) were evaluated for risk of bias, and the overall strength of evidence was assessed for each outcome. Data was extracted by a single investigator and confirmed by a second; risk of bias and strength of evidence were independently rated by two investigators and determined by consensus.

RESULTS

Overall, EBP training improved short-term provider satisfaction, EBP knowledge, and adherence compared to no training or self-study of training materials (low to moderate strength of evidence). Training in an EBP did not increase treatment adoption compared to no training or self-study. No specific active EBP training modality was found to consistently increase provider EBP knowledge, skill acquisition/adherence, competence, adoption, or satisfaction compared to another active training modality. Findings were mixed regarding the additive benefit of post-training consultation on these outcomes. No studies evaluated changes in provider outcomes with regards to training costs and few studies reported on client outcomes.

LIMITATIONS

The majority of included studies had a moderate risk of bias and strength of evidence for the outcomes of interest was generally low or insufficient. Few studies reported effect sizes. The ability to identify the most effective EBP training methods was limited by low strength of evidence for the outcomes of interest and substantial heterogeneity among studies.

CONCLUSIONS

EBP training may have increased short-term provider satisfaction, EBP knowledge, and adherence though not adoption. Evidence was insufficient on training costs and client outcomes. Future research is needed on EBP training methods, implementation, sustainability, client outcomes, and costs to ensure efforts to train providers in EBPs are effective, efficient, and durable.

TRIAL REGISTRATION

The protocol for this review is registered in PROSPERO (CRD42018093381).

Assessing competence in health professionals' use of motivational interviewing: A systematic review of training and supervision tools

OBJECTIVE

To conduct a systematic review of instruments for assessing the competency of therapists in motivational interviewing (MI) for training purposes.

METHODS

A search of Medline, Emcare, CINAHL, Scopus, Proquest, and Web of Science databases yielded 20,313 articles, of which 105 were included in the review. Data were summarised in terms of the instruments' development, adherence to MI principles, administration characteristics, psychometric properties, advantages, and disadvantages.

RESULTS

Twelve instruments were identified. Tools tended to be better at covering simpler MI techniques. Differences in administration burden allow users to choose between briefer but cheaper and more detailed yet costly tools. Psychometric testing was often limited, and even if more extensive, the quality was often inconsistent. Although each tool tended to have relatively unique advantages (e.g. use of client ratings), they shared common disadvantages (e.g. lack of psychometric testing).

CONCLUSION

A number of tools can be used to assess MI competency, each with their own strengths but notable weaknesses that should be considered by potential users.

PRACTICE IMPLICATIONS

There is a need to further test existing tools before creating new ones, due to the repetition of the same limitations. Standardised guidelines should also be created to ensure each tool meets the same quality standards.

Implementing Parent-Teen Motivational Interviewing + Behavior Therapy for ADHD in Community Mental Health

Despite the promise of psychosocial interventions for adolescent Attention Deficit Hyperactivity Disorder (ADHD), there are no studies that examine their implementation in community mental health contexts. In this study, we evaluate the implementation of community-based Supporting Teens' Autonomy Daily (STAND), a parent-teen Motivational Interviewing + Behavior Therapy intervention for adolescents with ADHD. Adolescents with ADHD (N = 225), who were clients at four community mental health agencies, received treatment from 82 therapists. There was double randomization of adolescents and therapists to STAND or Usual Care (UC). Nearly all therapists randomized to STAND completed the training and regularly attended supervision, rating STAND as acceptable and lower burden than UC practices. In the STAND group, MI competence and implementation were lower than in university trials (benchmark range, 19.5% for reflection to question ratio to 83.1% for technical globals). MI integrity in the STAND group was significantly higher than UC across most MITI indices. Content fidelity was adequate in STAND's engagement and skills phases (76.4-85.0%), but not its planning phase (24.4%). Therapists commonly neglected weekly review of goals and home practice and deviated from manualized pace and sequencing of therapy tasks. Learning MI was more challenging for bilingual therapists and therapists with more years of experience. STAND was delivered with higher integrity in earlier sessions and office-based sessions. Discussion identifies future directions for exporting adolescent ADHD interventions to community settings. Patient outcome data for this trial is presented elsewhere. Trial Registration: NCT02694939 www.clinicaltrials.gov .

Training Models for Implementing Evidence-Based Psychological Treatment: A Cluster-Randomized Trial in College Counseling Centers

IMPORTANCE

Progress has been made in establishing evidence-based treatments for psychiatric disorders, but these are not often delivered in routine settings. A scalable solution for training clinicians in evidence-based treatments is needed.

OBJECTIVE

To compare 2 methods of training college (university) counseling center therapists to treat psychiatric disorders using interpersonal psychotherapy. The hypothesis was that the train-the-trainer condition would demonstrate superior implementation outcomes vs the expert condition. Moderating factors were also explored.

DESIGN, SETTING, AND PARTICIPANTS

This cluster-randomized trial was conducted from October 2012 to December 2017 in 24 college counseling centers across the United States. Therapist participants were recruited from enrolled centers, and student patients with symptoms of depression and eating disorders were recruited by therapists. Data were analyzed from 184 enrolled therapists.

INTERVENTIONS

Counseling centers were randomized to the expert condition, which involved a workshop and 12 months of follow-up consultation, or the train-the-trainer condition, in which a staff member from the counseling center was coached to train other staff members.

MAIN OUTCOMES AND MEASURES

The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, as assessed via audio recordings of therapy sessions. Therapist knowledge of interpersonal psychotherapy was a secondary outcome.

RESULT

A total of 184 therapists (mean [SD] age, 41.9 [10.6] years; 140 female [76.1%]; 142 white [77.2%]) were included. Both the train-the-trainer-condition and expert-condition groups showed significant within-group improvement for adherence to interpersonal psychotherapy (change: 0.233 [95% CI, 0.192-0.274] and 0.190 [0.145-0.235], respectively; both P < .001), with large effect sizes (1.64 [95% CI, 1.35-1.93] and 1.34 [95% CI, 1.02-1.66], respectively) and no significant difference between conditions. Both groups also showed significant within-group improvement in interpersonal therapy competence (change: 0.179 [95% CI, 0.132-0.226] and 0.106 [0.059-0.153], respectively; both P < .001), with a large effect size for the train-the-trainer condition (1.16 [95% CI, 0.85-1.46]; P < .001) and a significant difference between groups favoring the train-the-trainer condition (effect size, 0.47 [95% CI, 0.05-0.89]; P = .03). Knowledge of interpersonal psychotherapy improved significantly within both groups (effect sizes: train-the-trainer, 0.64 [95% CI, 0.28-0.99]; P = .005; expert, 0.69 [95% CI, 0.38-1.01]; P < .001), with no significant difference between groups. The significant moderating factors were job satisfaction for adherence (b, 0.120 [95% CI, 0.001-0.24]; P = .048) and competence (b, 0.133 [95% CI, 0.001-0.27]; P = .048), and frequency of clinical supervision for competence (b, 0.05 [95% CI, 0.004-0.09]; P = .03).

CONCLUSIONS AND RELEVANCE

Results demonstrate that the train-the-trainer model produced training outcomes comparable with the expert model for adherence and was superior on competence. Given its potential capability to train more therapists over time, it has the potential to facilitate widespread dissemination of evidence-based treatments.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02079142.

Assessing the effectiveness of training models for national scale-up of an evidence-based nutrition and physical activity intervention: a group randomized trial

BACKGROUND

There is a great need to identify implementation strategies to successfully scale-up public health interventions in order to achieve their intended population impact. The Out-of-school Nutrition and Physical Activity group-randomized trial previously demonstrated improvements in children's vigorous physical activity and the healthfulness of foods and beverages consumed. This implementation study aimed to assess the effects and costs of two training models to scale-up this evidence-based intervention.

METHODS

A 3-arm group-randomized trial was conducted to compare effectiveness of in-person and online training models for scaling up the intervention compared to controls. One-third of sites were randomized to the in-person train-the-trainer model: local YMCA facilitators attended a training session and then conducted three learning collaborative meetings and technical assistance. One-third were assigned to the online model, consisting of self-paced monthly learning modules, videos, quizzes, and facilitated discussion boards. Remaining sites served as controls. Fifty-three afterschool sites from three YMCA Associations in different regions of the country completed baseline and follow-up observations using a validated tool of afterschool nutrition and physical activity practices. We used multivariable regression models, accounting for clustering of observations, to assess intervention effects on an aggregate afterschool practice primary outcome, and conducted secondary analyses of nine intervention goals (e.g. serving water). Cost data were collected to determine the resources to implement each training model.

RESULTS

Changes in the primary outcome indicate that, on average, sites in the in-person arm achieved 0.44 additional goals compared to controls (95%CI 0.02, 0.86, p = 0.04). Increases in the number of additional goals achieved in sites in the online arm were not significantly greater than control sites (+ 0.28, 95% CI -0.18, 0.73, p = 0.24). Goal-specific improvements were observed for increasing water offered in the in-person arm and fruits and vegetables offered in the online arm. The cost per person trained was $678 for the in-person training model and $336 for the on-line training model.

CONCLUSIONS

This pilot trial presents promising findings on implementation strategies for scale-up. It validated the in-person training model as an effective approach. The less expensive online training may be a useful option for geographically disbursed sites where in-person training is challenging.

TRIAL REGISTRATION

Although this study does not report the results of a health care intervention on human subjects, it is a randomized trial and was therefore retrospectively registered in ClinicalTrials.gov on July 4, 2019 in accordance with the BMC guidelines to ensure the complete publication of all results (NCT04009304).

Implementing Motivational Interviewing for Substance Misuse on Medical Inpatient Units: a Randomized Controlled Trial

BACKGROUND

General medical hospitals provide care for a disproportionate share of patients who misuse substances. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance misuse.

OBJECTIVE

To determine the effectiveness of three strategies for implementing motivational interviewing for substance misuse with general medical inpatients.

DESIGN

Type 3 hybrid effectiveness-implementation randomized controlled trial (Clinical Trials.gov: NCT01825057).

PARTICIPANTS

Thirty-eight providers (physicians, physician assistants, nurses) from 13 general medical inpatient services, and 1173 of their patients admitted to an academically affiliated acute care hospital.

INTERVENTIONS

Implementation strategies included (1) a continuing medical education workshop on detection of substance misuse and provision of a motivational interview; (2) workshop plus bedside supervision (apprenticeship condition); and (3) a workshop plus ability to place a medical order for an interview from a consultation-liaison service (consult condition).

MAIN MEASURES

Primary outcomes were the percentage of study-eligible patients who received an interview for substance misuse and the integrity (adherence, competence) of the interviews. The secondary outcome was the percent of patient statements within the interviews that indicated motivation for reducing substance misuse.

KEY RESULTS

20.5% of patients in the consult condition received an interview, compared to 0.8% (Hedge's g = 1.49) and 3.0% (Hedge's g = 1.26) in the respective workshop only and apprenticeship conditions (p < 0.001). Motivational interviews in the consult condition were performed with more fundamental motivational interviewing adherence and competence than the other conditions. Most statements made by patients during the interviews favored reducing substance misuse, with no differences between conditions.

CONCLUSIONS

Providers' ability to place an order to have experts from the consultation-liaison service deliver a motivational interview was a more effective implementation strategy than a workshop or apprenticeship method for ensuring motivational interviewing is available to medical inpatients who misuse substances.

TRIAL REGISTRY

NCT01825057.

Barriers and consultation needs regarding implementation of evidence-based treatment in community agencies

There is growing recognition of the gap between research and practice in mental health settings, and community agencies now face significant pressure from multiple stakeholders to engage in evidence-based practices. Unfortunately, little is known about the barriers that exist among agencies involved in formal implementation efforts or their perceptions about how implementation experts can best support change. This study reports the results of a survey of 263 individuals across 32 agencies involved in a state-wide effort to increase access to an evidence-based trauma-focused treatment for children. Quantitative and qualitative results identified lack of time and secondary trauma as significant barriers to implementation and areas in which agencies desired consultation and support. Qualitative responses further suggested the importance of addressing client/structural barriers, staff turnover, and continued intervention training. Findings inform the development of a structured consultation process for community agencies focused on addressing the multiple barriers that can interfere with implementation of evidence-based treatment.

Motivational interviewing training of substance use treatment professionals: A systematic review

Background: Through evaluations of training programs, systematic reviews, and meta-analyses, advances in identifying best practices for disseminating motivational interviewing (MI) have emerged. To advance this work further, inclusion of thorough descriptions of the following is needed in research publications: study (design, trainee characteristics, setting characteristics), training and coaching methods (if applicable), trainer qualifications, and evaluation of MI skills. Methods: The purpose of this study was to systematically evaluate the research on MI training of substance use treatment professionals for the inclusion of such descriptions. Twenty-five studies were reviewed using a scoring rubric developed by the authors. Results: Just over two thirds of the studies (68%) were randomized controlled trials of MI training. The majority of studies provided information about (a) trainee characteristics (professional background = 76%, education = 60%, experience = 56%); (b) setting characteristics (80%); (c) training methods (format = 96%, length = 92%); (d) coaching (76%); and (e) evaluation of MI skills (92%). Conclusion: Findings suggest advancements in MI training studies since previous reviews, especially in regards to the inclusion of feedback and coaching. However, this review also found that inconsistencies in methods and reporting of training characteristics, as well as limited follow-up assessment of trainees' skill, continue to limit knowledge of effective training methods.

From training to practice: the impact of ENGAGE, Ireland's national men's health training programme

Ireland's National Men's Health Policy recommended developing training programmes tailored to the needs of those working in health and allied health professionals and ENGAGE was developed to meet that recommendation. This study evaluated the impact of ENGAGE on frontline service providers' self-reported knowledge, skills, capacity and practice up to 5-months post training. Between 2012 and 2015, ENGAGE Trainers (n = 57) delivered 62 1-day training programmes to 810 participants. This study was conducted on a subset of those training days (n = 26) and participants. Quantitative methodologies were used to collect pre (n = 295), post (n = 295) and 5-month post (n = 128) training questionnaire data. Overall, participants were highly satisfied with the training immediately post training (8.60 ± 1.60 out of 10) and at 5-month follow up (8.06 ± 1.43 out of 10). Participants' self-reported level of knowledge, skill and capacity in identifying priorities, engaging men and influencing practice beyond their own organisation increased immediately following training (P < 0.001) and, with the exception of improving capacity to engage men and influencing practice beyond their organisation, these improvements were sustained at 5-month post training (P < 0.001). The vast majority of service providers (93.4%) reported that ENGAGE had impacted their work practice up to 5-month post training. The findings suggest that ENGAGE has succeeded in improving service providers' capacity to engage and work with men; improving gender competency in the delivery of health and health related services may increase the utilisation of such services by men and thereby improve health outcomes for men.

A New Community-Based Model for Training in Evidence-Based Psychotherapy Practice

It is critical that evidence-based practices (EBP's) be provided to patients. Efforts to train clinicians in the community in EBP's, however, has been hindered by a lack of resources and rigid and resource intensive models of training. We describe efforts to overcome these barriers in a large scale community-based training program for Interpersonal Psychotherapy implemented with over 1400 clinicians in Los Angeles working within the Los Angeles County Department of Mental Health public system of care. The program, described in detail, is a potential template for training for community-based clinicians in evidence-based psychotherapy practices.

The impact of motivational interviewing on self-perceived burden in patients receiving therapeutic plasma exchange

BACKGROUND

Autoimmune disorders and neurodegenerative disorders take a physical and emotional toll on patients that undergo therapeutic plasma exchange (TPE) treatments. Previous literature has shown that these patients may feel a greater sense of self-burden. Motivational Interviewing (MI) is a technique used in various settings that has the potential to decrease feelings of self-burden. MI for patients who receive TPE has not been tested. The purpose of this study was to examine the impact of MI in patients with a neurodegenerative diagnosis (eg, transverse myelitis, myasthenia gravis, multiple sclerosis, and chronic inflammatory demyelinating polyneuropathy) that are undergoing TPE treatments.

METHODS

This was a prospective, non-randomized, longitudinal study of the impact of MI with patients at high risk of sense of self-burden who underwent apheresis treatments. Consented patients underwent three to six MI sessions with a trained clinician. Patients completed a self-report baseline and post-test of self-perceived burden.

RESULTS

Thirty participants consented to the study; 27 were included in the analysis. The Self-Perceived Burden Scale scores were significantly higher at baseline (m = 26.2) when compared to scores post MI sessions (m = 21.48, P < .05). The number of MI sessions (3, 4, 5, 6 sessions) did not significantly impact the outcome score (r²  = 0.001; P = .901).

CONCLUSION

MI is a straightforward technique that is feasible and shown to be effective to be used by bedside clinicians while working with patients who receive TPE to decrease levels of self-perceived burden.

Training models for implementing evidence-based psychological treatment for college mental health: A cluster randomized trial study protocol

Mental disorders often emerge in adolescence and young adulthood, and these disorders can have lasting effects on students' health, social functioning, and education. Although evidence-based treatments have been established for many mental disorders, few community therapists use such treatments. What is needed is a practical, economically feasible means of training clinicians to implement evidence-based treatments suitable for widespread use. This cluster randomized trial will randomize 26 college counseling centers to one of two implementation strategies for training counselors to use interpersonal psychotherapy (IPT), an evidence-based treatment for depression and eating disorders: 1) an external expert consultation model comprising a workshop, therapy manual, and expert follow-up consultation (n = 13); or 2) a train-the-trainer model in which a staff member from the counseling center is coached to train other staff members to implement IPT (n = 13). The primary outcome is therapist adherence to IPT, with secondary outcomes of therapist competence in IPT and client outcomes for depression and eating disorders. Therapist and organizational characteristics will be explored as potential moderators and mediators of implementation outcomes. Implementation costs for each of the training methods will also be assessed. The present study involves partnering with college counseling centers to determine the most effective method to implement IPT for depression and eating disorders in these settings. The results of this study will inform future large-scale dissemination of clinical interventions to mental health service providers by providing evidence for the selection of training methods when an agency chooses to adopt new interventions.

Bridging the gap between physician and medical student education: using the Train the Trainer model to improve cultural competence training in the clerkship years of medical school

Cultural competence (CC) training has become a required part of medical education to create future physicians dedicated to decreasing health disparities. However, current training seems to be inadequate as research has demonstrated gaps between CC training and clinical behaviors of students. One aspect that is potentially contributing to this gap is the lack of physician education of CC. Without it being something not only taught in the classroom, but also modeled and taught in the clinical setting, CC will continue to be a theoretical concept instead of a skill set that changes the way that future physicians interact with patients and make decisions about patient care. To change this, we propose the implementation of a Train the Trainer model in which the preclinical professor in charge of CC education trains Clerkship and Residency Directors who then can train and supervise the physicians and residents in their departments on CC to better implement it into the formal and informal curriculum of clerkships.

Safe and competent opioid prescribing education: Increasing dissemination with a train-the-trainer program

BACKGROUND

Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioids to fund continuing education based on an FDA curricular Blueprint. This paper describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) train-the-trainer program and its impact on (1) disseminating the SCOPE of Pain curriculum and (2) knowledge, confidence, attitudes, and performance of the participants of trainer-led compared with expert-led meetings.

METHODS

SCOPE of Pain is a 3-hour ER/LA opioid REMS education. In addition to expert-led live statewide meetings, a 2-hour train-the-trainer (TTT) workshop was developed to increase dissemination nationally. The trainers were expected to conduct SCOPE of Pain meetings at their institutions. Participants of both the trainer-led and expert-led SCOPE of Pain programs were surveyed immediately post and 2 months post meetings to assess improvements in knowledge, confidence, attitudes, and self-reported safe opioid prescribing practices.

RESULTS

During 9 months (May 2013 to February 2014), 89 trainers were trained during 9 TTT workshops in 9 states. Over 24 months (May 2013 to April 2015), 33% of the trainers conducted at least 1 SCOPE of Pain training, with a total of 79 meetings that educated 1419 participants. The average number of meetings of those who conducted at least 1 meeting was 2.8 (range: 1-19). The participants of the trainer-led programs were significantly more likely to be practicing in rural settings than those who participated in the expert-led meetings (39% vs. 26%, P < .001). At 2 months post training, there were no significant differences in improvements in participant knowledge, confidence, attitudes, and performance between expert-led and trainer-led meetings.

CONCLUSIONS

The SCOPE of Pain TTT program holds promise as an effective dissemination strategy to increase guideline-based safe opioid prescribing knowledge, confidence, attitudes, and self-reported practices.

A Guide for Planning and Implementing Successful Mental Health Educational Programs

INTRODUCTION

Considering the global burden of mental disorders, there is a worldwide need to improve the quality of mental health care. In order to address this issue, a change in how health care professionals are trained may be essential. However, the majority of the few reports published on this field's training programs do not discuss the characteristics associated with the success or failure of these strategies. The purpose of this review was to systematically examine the literature about mental health training programs designed for health care professionals in order to identify the relevant factors associated with their effective implementation.

METHODS

The MEDLINE/PubMed, SciELO, and Virtual Health Library databases were used to search for articles published before February 2017 and reviewed by two double-blind reviewers.

RESULTS

We found 77 original papers about mental health educational programs. Many of these studies were conducted in the USA (39%), addressed depression as the main subject (34%), and applied a quasi-experimental design (52%). Effective interventions were associated with the following characteristics: the use of learner-centered and interactive methodological approaches; a curriculum based on challenges in the trainees' daily routines; the involvement of experts in the program's development; the enrollment of experienced participants; interdisciplinary group work; flexible timing; the use of e-learning resources; and optimizing the implementation of knowledge into the participants' routine work practices.

IMPLICATIONS FOR PRACTICE

These results will be helpful for planning and improving the quality of future educational programs in mental health.

Impact of Brief Intervention Workshops on Addiction Provider Knowledge, Skills, Negative Attitudes, and Interest in Implementing Evidence-Based Practices

This study evaluated the impact of Motivational Interviewing (MI) and Screening, Brief Intervention, and Referral to Treatment (SBIRT) workshops on posttraining knowledge, skills, negative attitudes, and interest in implementing evidence-based practices (EBPs). Participants ( N = 70) were primarily mental health counselor (41.4%), social workers (20.0%), substance abuse counselors (15.7%), school counselors (5.7%), and nursing professionals (4.3%) who selected the 1- or 2-day workshop for continuing education credit. Participants attended either a Basic MI training workshop (1 day) or a Basic MI training plus an advanced MI/SBIRT training workshop (2 days) to assess if exposure to two EBPs would improve training outcomes. Participants in both the 1-day and 2-day workshops reported posttraining increased perceived knowledge and skills, decreased negative attitudes toward EBPs, and increased interest in implementing EBPs from pretraining to posttraining. There were no differences between participants in the Basic MI or MI plus advanced MI/SBIRT training conditions. Implications for reducing the research-practice gap in EBPs are discussed.

Addressing critical gaps in the treatment of eating disorders

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

Quality Improvement Curriculum for Physical Medicine and Rehabilitation Residents: A Needs Assessment

This needs assessment survey of physical medicine and rehabilitation (PM&R) program directors (PDs) from Accreditation Council for Graduate Medical Education-accredited programs aimed to (1) describe current quality improvement (QI) training, (2) characterize PDs' perceptions of their own and their faculty's QI knowledge and skill, and (3) determine PDs' opinions of optimal QI training to inform the development of a future QI curriculum. Descriptive statistics were used for data analysis. Forty-five percent of PDs (35/78) responded. All programs had QI education and required QI project participation; however, the quantity and types of learning experiences varied greatly. PDs assessed their ability as less than proficient to teach QI (67%) and lead a project (57%), and rated 60% of their faculty as having novice or advanced beginner QI skills. PDs reported 31% of graduating residents had less than competent QI skills. Almost all PDs were interested in a standardized QI curriculum.

After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing?

AIMS

Motivational interviewing (MI) is the most successfully disseminated evidence-based practice in the substance use disorder (SUD) treatment field. This systematic review considers two questions relevant to policymakers and service providers: (1) does training in MI achieve sustained practice change in clinicians delivering SUD treatment; and (2) do clinicians achieve a level of competence after training in MI that impacts upon client outcomes?

METHODS

A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, examining training outcomes for MI in the SUD treatment sector, and for clinicians working in a SUD treatment role. We determined a training method to have resulted in sustained practice change when over 75% of participants met beginning proficiency in MI spirit at a follow-up time-point.

RESULTS

Of the 20 studies identified, 15 measured training at a follow-up time-point using standard fidelity measures. The proportion of clinicians who reached beginning proficiency was either reported or calculated for 11 of these studies. Only two studies met our criterion of 75% of clinicians achieving beginning proficiency in MI spirit after training. Of the 20 studies identified, two measured client substance use outcomes with mixed results.

CONCLUSIONS

A broad range of training studies failed to achieve sustained practice change in MI according to our criteria. It is unlikely that 75% of clinicians can achieve beginning proficiency in MI spirit after training unless competency is benchmarked and monitored and training is ongoing. The impact of training on client outcomes requires future examination.

The Effectiveness and Cost of Clinical Supervision for Motivational Interviewing: A Randomized Controlled Trial

The effectiveness of a competency-based supervision approach called Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) was compared to supervision-as-usual (SAU) for increasing clinicians' motivational interviewing (MI) adherence and competence and client retention and primary substance abstinence in a multisite hybrid type 2 effectiveness-implementation randomized controlled trial. Participants were 66 clinicians and 450 clients within one of eleven outpatient substance abuse programs. An independent evaluation of audio recorded supervision sessions indicated that MIA: STEP and SAU were highly and comparably discriminable across sites. While clinicians in both supervision conditions improved their MI performance, clinician supervised with MIA: STEP, compared to those in SAU, showed significantly greater increases in the competency in which they used fundamental and advanced MI strategies when using MI across seven intakes through a 16-week follow-up. There were no retention or substance use differences among the clients seen by clinicians in MIA: STEP or SAU. MIA: STEP was substantially more expensive to deliver than SAU. Innovative alternatives to resource-intensive competency-based supervision approaches such as MIA: STEP are needed to promote the implementation of evidence-based practices.

Reducing eating disorder risk factors: A pilot effectiveness trial of a train-the-trainer approach to dissemination and implementation

OBJECTIVE

Impediments limit dissemination and implementation of evidence-based interventions (EBIs), including lack of sufficient training. One strategy to increase implementation of EBIs is the train-the-trainer (TTT) model. The Body Project is a peer-led body image program that reduces eating disorder (ED) risk factors. This study examined the effectiveness of a TTT model at reducing risk factors in Body Project participants. Specifically, this study examined whether a master trainer could train a novice trainer to train undergraduate peer leaders to administer the Body Project such that individuals who received the Body Project (i.e., participants) would evidence comparable outcomes to previous trials. We hypothesized that participants would evidence reductions in ED risk factors, with effect sizes similar to previous trials.

METHOD

Utilizing a TTT model, a master trainer trained a novice trainer to train undergraduate peer leaders to administer the Body Project to undergraduate women. Undergraduate women aged 18 years or older who received the Body Project intervention participated in the trial and completed measures at baseline, post-treatment, and five-month follow-up. Primary outcomes included body dissatisfaction, thin ideal internalization, negative affect, and ED pathology.

RESULTS

Participants demonstrated significant reductions in thin ideal internalization, ED pathology and body dissatisfaction at post-treatment and 5-month follow-up. At 5 months, using three different strategies for managing missing data, effect sizes were larger or comparable to earlier trials for 3 out of 4 variables.

DISCUSSION

Results support a TTT model for Body Project implementation and the importance of utilizing sensitivity analyses for longitudinal datasets with missing data.