Developing and evaluating a lay health worker delivered implementation intervention to decrease engagement disparities in behavioural parent training: a mixed methods study protocol

Consolidated guidance for behavioral intervention pilot and feasibility studies

BACKGROUND

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

METHODS

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of a well-known PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

RESULTS

A total of 496 authors were invited to take part in the three-round Delphi survey (round 1, N = 46; round 2, N = 24; round 3, N = 22). A set of twenty considerations, broadly categorized into six themes (intervention design, study design, conduct of trial, implementation of intervention, statistical analysis, and reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

CONCLUSION

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

The deinstitutionalization of children and adolescents in El Salvador's child protection system

BACKGROUND

In 2010, El Salvador introduced legislation aimed at reforming the country's Child Protective System (CPS), with a focus on promoting deinstitutionalization.

OBJECTIVE

The study aim was to explore the impact of deinstitutionalization on the Salvadoran CPS.

PARTICIPANTS AND SETTING

The study was conducted in El Salvador, granting authors unique access to key informants with extensive experience in the country's CPS. Unlike the United States, which is divided into states, El Salvador is divided into departments, and CPS providers were recruited from all 14 departments. Focus groups were facilitated in the East, West, and Central zones to ensure representation from all regions.

METHODS

Qualitative semi-structured interviews (n = 26) were conducted in June/July of 2019, which were then followed by focus groups (n = 4) in August 2019. The analysis of the data employed a combination of deductive and inductive thematic coding methods.

RESULTS

CPS providers offered valuable insights, categorized into five main themes: (1) Strengths of El Salvador's CPS, (2) Deinstitutionalization policy encompassing socioenvironmental contextual factors, (3) Challenges in the deinstitutionalization process, including insufficient follow-up on deinstitutionalized children, (4) Recommendations from participants, highlighting the importance of enhancing stakeholder coordination/collaboration, and (5) The necessity for a paradigm shift, emphasizing the need to redefine the social contract on protecting children from child maltreatment.

CONCLUSIONS

The Salvadoran CPS requires substantial systemic changes. Encouragingly, key informants have demonstrated a commitment to reform not only the deinstitutionalization process but also the broader CPS system in El Salvador including case management and quality of care in institutional settings.

Expert Perspectives on Pilot and Feasibility Studies: A Delphi Study and Consolidation of Considerations for Behavioral Interventions

Background

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

Methods

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of well-know PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

Results

A total of 496 authors were invited to take part in the Delphi survey, 50 (10.1%) of which completed all three rounds, representing 60 (37.3%) of the 161 identified PFS-related guidelines, checklists, frameworks, and recommendations. A set of twenty considerations, broadly categorized into six themes (Intervention Design, Study Design, Conduct of Trial, Implementation of Intervention, Statistical Analysis and Reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

Conclusion

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Effective training practices for non-specialist providers to promote high-quality mental health intervention delivery: A narrative review with four case studies from Kenya, Ethiopia, and the United States

Mental health needs and disparities are widespread and have been exacerbated by the COVID-19 pandemic, with the greatest burden being on marginalized individuals worldwide. The World Health Organization developed the Mental Health Gap Action Programme to address growing global mental health needs by promoting task sharing in the delivery of psychosocial and psychological interventions. However, little is known about the training needed for non-specialists to deliver these interventions with high levels of competence and fidelity. This article provides a brief conceptual overview of the evidence concerning the training of non-specialists carrying out task-sharing psychosocial and psychological interventions while utilizing illustrative case studies from Kenya, Ethiopia, and the United States to highlight findings from the literature. In this article, the authors discuss the importance of tailoring training to the skills and needs of the non-specialist providers and their roles in the delivery of an intervention. This narrative review with four case studies advocates for training that recognizes the expertise that non-specialist providers bring to intervention delivery, including how they promote culturally responsive care within their communities.

Male Caregivers and Engagement in a Family Strengthening Program for Child Disruptive Behavior Disorders

Awareness and interest in involving male caregivers in child mental health treatment has grown, especially for youth with disruptive behavior disorders like oppositional defiant disorder (ODD). The purpose of this study was to examine the relationship between male caregiver involvement and treatment engagement for child ODD. Children (n = 122) ages 7-11 and their caregivers participated in the 4 Rs 2 Ss Strengthening Families Program for child-onset ODD. Families were compared based on male caregiver presence. Families with a male caregiver were significantly more resourced with respect to income, educational status, and food security. Additionally, they were over three times less likely to drop out of the program than those without a male caregiver. The presence of a male caregiver was associated with increased resources and higher rates of engagement in services than single, female-headed families. Future research is needed to discern the underlying mechanisms of this association.

Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

The Impact of Parent Child Interaction Therapy on Temper Tantrums in Pre-school

Temper tantrum behavior is a child's emotional behavior which is shown by explosive anger and some parents consider this behavior to be bad behavior. Temper tantrums can occur in children aged 3-6 years or more. This literature review aims to determine the impact of PCIT (Parent Child Interaction Therapy) on temper tantrums in preschool. In finding this literature review used four databases (ProQuest, Scopus, Pubmed, and Sains Direct) for the design of the study used cross sectional, True Experimental, Observational and Systematic Reviews published in the last five years. The protocol and evaluation of the literature review used the PRISMA checklist to determine the selection of studies that were found and adapted to the objectives of the literature review. The results of literature review analysis of several parents in group and individual PCIT reported that the application of parent-child-based interventions was proven to be effective and has the potential to bring significant and lasting changes in increasing positive behavior in children with external behavior problems. The frequency of problematic child relationship behavior significantly decreased with increasing age of the child.  In addition, assessing both positive and negative child relationship behavior could assist parents in understanding the relevance of different aspects for the development of parent-child relationships.

Lay Health Workers Engaging Latino Fathers: A qualitative study

Behavioral Parent Training programs (BPTs) are evidence-based interventions that have been shown to be effective when implemented in various contexts and with different racial/ethnic minority families. Despite evidence showing their effectiveness within the Latinx community, disparities in access to BPTs still persist. In addition, fathers continue to show low rates of attendance and engagement despite evidence suggesting positive outcomes for the youth and family when fathers are involved in BPT treatment. Lay health workers (LHWs), community members without specialized metal health training that often live in the communities they serve, have been identified as engagement specialists that are uniquely positioned to reduce racial/ethnic disparities in access to services. The current study utilized a qualitative approach to examine this workforce's perspectives on engaging Latino fathers in parenting services in children's mental health. Qualitative themes revealed that LHWs have generally positive attitudes towards engaging Latino fathers in parenting interventions (i.e., benefits to parent-child relationship) despite experiencing barriers to engagement (e.g., culturally defined gender roles, fathers being less likely to ask for help). Themes also elucidate various engagement strategies that LHWs use to engage fathers in treatment (e.g., adapting treatment setting). Considerations for future LHW trainings and workforce development are discussed with a focus on how to incorporate cultural values in the use of father-engagement strategies.

A Preliminary Analysis of Parent-Child Interaction Therapy Plus Natural Helper Support to Increase Treatment Access and Engagement for Low-Income Families of Color

Disparities in care for low-income children of color call for innovative culturally and linguistically responsive solutions to better engage marginalized populations in evidence-based interventions. In partnership with a community organization, the addition of natural helper support as an adjunct to Parent-Child Interaction Therapy (PCIT+NH) was examined as a strategy to increase recruitment, engagement, and retention in PCIT for families historically unreached by a university-based clinic. Natural helpers provided home-based skills practice and support for forty-two families whose parents were more racially and linguistically diverse and had lower income and lower caregiver education than the typical population served by the same program (i.e., program population). Families who received PCIT+NH had comparable or higher rates of engagement and improvements in clinical outcomes (i.e., decreased child externalizing and internalizing behaviors, increased child compliance, decreased caregiver stress, increased caregiver parenting skills) relative to the program population. Furthermore, higher doses of natural helper support were associated with higher rates on most measures of treatment engagement (i.e., treatment completion, completion of the Child Directed Interaction phase of treatment, PCIT sessions, homework in the Parent Directed Interaction phase of treatment), with the exception of homework in the Child Directed Interaction phase of treatment and overall session attendance rate. Next steps for testing the treatment engagement and clinical outcome effects of the PCIT+NH model are discussed.

Saving a seat at the table for community members: co-creating an attachment-based intervention for low-income Latin parent-youth dyads using a promotor/a model

Evidence for the effectiveness of attachment-based interventions in improving youth’s socioemotional health increases each year, yet potential for scalability of existing programs is limited. Available programs may have lower acceptability within low-income immigrant communities. Co-designing and implementing interventions with trained community workers (Promotors) offers an appealing solution to multiple challenges, but community workers must have high investment in the program for this to be a workable solution. This study examines the experiences of promotors involved in the co-creation and delivery of an attachmentbased intervention program for low-income Latinx youth (ages 8 to 17) and their mothers. Promotors (N=8) completed surveys, reporting on the experiences of each therapy group in terms of group dynamic (e.g., promotors’ connectedness to each group, perceived program relevance). Following the completion of the intervention study, promotors participated in interviews in which they described their experiences in co-creating the intervention, delivering the intervention to the community, and their recommendations for improving the intervention. Overall, promotors perceived group dynamics as positive, though the mother groups were evaluated as significantly higher in quality (e.g., lower conflict) than the youth groups. Interviews revealed that promotors enjoyed the cocreation process and identified important areas for improvements for the intervention (incorporation of more visuals, creation of agelimited groups, reducing number of youth sessions) and evaluation (reduction in length, modification of language). Integrating input from promotors in the process of co-creating and implementing an intervention can benefit every member of the community from the program participants to the providers themselves.

"Todo Se Hace de Corazón:" An Examination of Role and Identity Among Latina Promotoras de Salud

Promotoras de salud are community health workers that mostly help the underserved members of Latinx communities. They seek to reduce health disparities through community engagement and work that is voluntary or mostly unpaid. While there is evidence that promotoras aid in prevention, follow-up care, and treatment adherence, little is known about promotoras themselves, specifically, the impact that fulfilling their roles has on their views of themselves and their service identities. Fourteen Spanish-speaking, Latina promotoras were interviewed individually about their experiences and their motivation for the role. Four themes emerged from the content analysis of the participant responses: "Uno Nace Siendo Promotora:" One is Born Being a Promotora, "Poner Esa Semillita:" To Plant a Seed by Sharing Knowledge, "Es un Regalo Ser Promotora:" It is a Gift to be a Promotora, and "Se Hace por Amor pero también Hay Necesidad:" A Labor of Love but there are Needs too. The findings show that assuming and enacting the promotora role had positive benefits, both personal and professional, despite the often-limited recognition they received. The findings have multiple implications for the development of health and prevention programs, particularly for those that involve promotoras de salud.

Therapist Experiences and Attitudes About Implementing Internet-Delivered Parent-Child Interaction Therapy During COVID-19

It has been widely recognized that access to mental health treatment is imperative to address current and long-term stressors for children and parents during COVID-19. Internet-delivered Parent-Child Interaction Therapy (iPCIT, previously referred to as I-PCIT) is a strong model for remote service delivery during social distancing restrictions due to its empirical base. However, this treatment modality was not widely implemented before COVID-19, likely due to barriers to providing telehealth services. This mixed methods study conducted a follow-up survey to gather therapist experiences (N = 223) in delivering iPCIT during COVID-19, including qualitative data on the benefits and challenges to delivering iPCIT. The vast majority of therapists (82%) indicated that they transitioned to deliver PCIT via telehealth in response to COVID-19. PCIT caseloads decreased slightly from the first survey to the COVID-19 follow-up survey, but the racial and ethnic composition of caseloads were not significantly different between the two surveys. Of the 183 therapists who transitioned to deliver PCIT via telehealth, 82% expressed interest in continuing to provide iPCIT following the COVID-19 pandemic. Reported benefits of iPCIT included decreased barriers to access and the ability to practice skills within the naturalistic home environment. Challenges to iPCIT were primarily issues with technology as well as other logistical barriers, which could limit engagement for some families. Findings from this study may be beneficial in improving future implementation of iPCIT during and post-COVID-19.

Future Directions in Lay Health Worker Involvement in Children's Mental Health Services in the U.S

Nearly half of children meeting criteria for a mental health disorder in the United States (U.S.) do not receive the treatment they need. Unfortunately, lack of access to and engagement in mental health services can be seen at even higher rates for historically marginalized groups, including low-income, racial, and ethnic minority youth. Lay Health Workers (LHWs) represent a valuable workforce that has been identified as a promising solution to address mental health disparities. LHWs are individuals without formal mental health training who oftentimes share lived experiences with the communities that they serve. A growing body of research has supported the mobilization of LHWs to address service disparities around the globe; however, challenges persist in how to scale-up and sustain LHW models of care, with specific barriers in the U.S. In this paper, we describe LHWs' different roles and involvement in the mental health field as well as the current state of the literature around LHW implementation. We integrate the RE-AIM Framework with a conceptual model of how LHWs address disparities to outline future directions in research and practice to enhance equity in the reach, effectiveness, adoption, implementation, and maintenance of LHW models of care and evidence-based practices for historically marginalized communities within the U.S.

The FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare

BACKGROUND

Implementation strategies are necessary to ensure that evidence-based practices are successfully incorporated into routine clinical practice. Such strategies, however, are frequently modified to fit local populations, settings, and contexts. While such modifications can be crucial to implementation success, the literature on documenting and evaluating them is virtually nonexistent. In this paper, we therefore describe the development of a new framework for documenting modifications to implementation strategies.

DISCUSSION

We employed a multifaceted approach to developing the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS), incorporating multiple stakeholder perspectives. Development steps included presentations of initial versions of the FRAME-IS to solicit structured feedback from individual implementation scientists ("think-aloud" exercises) and larger, international groups of researchers. The FRAME-IS includes core and supplementary modules to document modifications to implementation strategies: what is modified, the nature of the modification (including the relationship to core elements or functions), the primary goal and rationale for the modification, timing of the modification, participants in the modification decision-making process, and how widespread the modification is. We provide an example of application of the FRAME-IS to an implementation project and provide guidance on how it may be used in future work.

CONCLUSION

Increasing attention is being given to modifications to evidence-based practices, but little work has investigated modifications to the implementation strategies used to implement such practices. To fill this gap, the FRAME-IS is meant to be a flexible, practical tool for documenting modifications to implementation strategies. Its use may help illuminate the pivotal processes and mechanisms by which implementation strategies exert their effects.

Caregiver Attendance as a Quality Indicator in the Implementation of Multiple Evidence-Based Practices for Children

OBJECTIVE

This study investigated a quality indicator for children's mental health, caregiver attendance in youth psychotherapy sessions, within a system-driven implementation of multiple evidence-based practices (EBPs) in children's community mental health services.

METHOD

Administrative claims from nine fiscal years were analyzed to characterize and predict caregiver attendance. Data included characteristics of therapists (n = 8,626), youth clients (n = 134,368), sessions (e.g., individual, family), and the EBP delivered. Clients were primarily Latinx (63%), male (54%) and mean age was 11; they presented with a range of mental health problems. Three-level mixed models were conducted to examine the association between therapist, youth, service, EBP characteristics and caregiver attendance.

RESULTS

Caregivers attended, on average, 46.0% of sessions per client for the full sample and 59.6% of sessions for clients who were clinically indicated, based on age and presenting problem, to receive caregiver-focused treatment. Following initial EBP implementation, the proportion of caregiver attendance in sessions increased over time. Caregivers attended a higher proportion of youth psychotherapy sessions when clients were younger, had an externalizing disorder, were non-Hispanic White, and were male. Further, higher proportions of caregiver attendance occurred when services were delivered in a clinic setting (compared with school and other settings), by bilingual therapists, and the EBP prescribed caregiver attendance in all sessions.

CONCLUSIONS

Overall, the patterns of caregiver attendance appear consistent with evidence-informed practice parameters of client presenting problem and age. Yet, several improvement targets emerged such as client racial/ethnic background and service setting. Potential reasons for these disparities are discussed.

Leveraging implementation science to reduce inequities in Children's mental health care: highlights from a multidisciplinary international colloquium

BACKGROUND AND PURPOSE

Access to evidence-based mental health care for children is an international priority. However, there are significant challenges to advancing this public health priority in an efficient and equitable manner. The purpose of this international colloquium was to convene a multidisciplinary group of health researchers to build an agenda for addressing disparities in mental health care access and treatment for children and families through collaboration among scholars from the United States and Europe engaged in innovative implementation science and mental health services research.

KEY HIGHLIGHTS

Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, presentations related to inner, outer, and bridging context factors that impact the accessibility and quality of mental health evidence-based practices (EBPs) for children and families. Three common topics emerged from the presentations and discussions from colloquium participants, which included: 1) the impact of inner and outer context factors that limit accessibility to EBPs across countries, 2) strategies to adapt EBPs to improve their fit in different settings, 3) the potential for implementation science to address emerging clinical and public health concerns.

IMPLICATIONS

The common topics discussed underscored that disparities in access to evidence-based mental health care are prevalent across countries. Opportunities for cross-country and cross-discipline learnings and collaborations can help drive solutions to address these inequities, which relate to the availability of a trained and culturally appropriate workforce, insurance reimbursement policies, and designing interventions and implementation strategies to support sustained use of evidence-based practices.