Choosing strategies that work from the start: A mixed methods study to understand effective development of community-academic partnerships

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

BACKGROUND

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

OBJECTIVES

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

METHODS

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

RESULTS

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

CONCLUSION

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

TRIAL REGISTRATION

NCT05551728 in Clinical Trial Registry (https://clinicaltrials.gov).

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

Background

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

Objectives

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

Methods

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

Results

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

Conclusion

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

Understanding collaborative implementation between community and academic partners in a complex intervention: a qualitative descriptive study

BACKGROUND

Community-academic partnerships (CAPs) can improve the relevance, sustainability, and uptake of new innovations within the community. However, little is known about what topics CAPs focus on and how their discussions and decisions impact implementation at ground level. The objectives of this study were to better understand the activities and learnings from implementation of a complex health intervention by a CAP at the planner/decision-maker level, and how that compared to experiences implementing the program at local sites.

METHODS

The intervention, Health TAPESTRY, was implemented by a nine-partner CAP including academic, charitable organizations, and primary care practices. Meeting minutes were analyzed using qualitative description, latent content analysis, and a member check with key implementors. An open-answer survey about the best and worst elements of the program was completed by clients and health care providers and analyzed using thematic analysis.

RESULTS

In total, 128 meeting minutes were analyzed, 278 providers and clients completed the survey, and six people participated in the member check. Prominent topics of discussion categories from the meeting minutes were: primary care sites, volunteer coordination, volunteer experience, internal and external connections, and sustainability and scalability. Clients liked that they learned new things and gained awareness of community programs, but did not like the volunteer visit length. Clinicians liked the regular interprofessional team meetings but found the program time-consuming.

CONCLUSIONS

An important learning was about who had "voice" at the planner/decision-maker level: many of the topics discussed in meeting minutes were not identified as issues or lasting impacts by clients or providers; this may be due to differing roles and needs, but may also identify a gap. Overall, we identified three phases that could serve as a guide for other CAPs: Phase (1) recruitment, financial support, and data ownership; Phase (2) considerations for modifications and adaptations; Phase (3) active input and reflection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

When Higher Education Meets Sustainable Development of Rural Areas: Lessons Learned from a Community–University Partnership

Sustainable development in mountain areas faces numerous socioenvironmental and economic challenges that public institutions have sought to address for decades. The EU is increasingly demanding Higher Education Institutions be more socially relevant and responsible in addressing the needs of these often-underserved communities. To this end, one central principle of the Erasmus+ Project 2014–2020, also consolidated by the Programme 2021–2027, has been to enhance the development, transfer, and implementation of innovative practices fostering social engagement at the local and international levels. The paper describes a case study developed in the “Socially Engaged Universities—(SEU)” project, co-funded by the Erasmus+ Programme 2014–2020, which aimed to strengthen the cooperation between universities and local communities. A local foundation and the University of Parma co-piloted a project to strengthen the short supply chains of a group of farmers in the Italian Appennines. The partnership identified factors that fostered and hampered the effectiveness of community–university partnerships. We propose some final recommendations to ensure that sustainable rural development fully leverages university resources. This includes higher education teaching and research programmes tailored toward the needs of the local community.

Preliminary effectiveness of the ACT SMART implementation toolkit: facilitating evidence-based practice implementation in community-based autism organizations

Background: Evidence-based practice (EBP) use is varied in autism spectrum disorder community-based organizations (ASD-CBOs) in the United States. Aim: The ACT SMART Implementation Toolkit-a multi-faceted implementation strategy guiding teams through implementation phases-was pilot tested to assess its preliminary effectiveness in increasing EBP use within ASD-CBOs. Method: Six ASD-CBOs participated, and five completed all Toolkit phases. Supervisors and direct providers completed an agency assessment pre- and post-pilot reporting their use of the selected EBP. Results: Effect sizes, examining meaningful changes in reported EBP utilization from pre- to post-pilot, found small effect sizes for supervisor-reported, supervisor-report of direct provider's use, and for direct provider-reported EBP use. Conclusions: Results indicate an increase in reported EBP use post-pilot and signal potential effectiveness of the ACT SMART Toolkit to yield provider-reported behavioral changes. This is the first multi-faceted implementation strategy designed specifically for ASD-CBOs, and findings support its facilitation of EBP uptake to improve community care for autistic individuals.

Implementation-as-Usual in Community-Based Organizations Providing Specialized Services to Individuals with Autism Spectrum Disorder: A Mixed Methods Study

Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental disorder. ASD community-based organizations (ASD-CBOs) underutilize or inconsistently utilize evidence-based practices (ASD-EBPs) despite numerous available EBPs to treat ASD. Nonetheless, ASD-CBOs implement changes to practices regularly. Understanding ASD-CBO's implementation-as-usual (IAU) processes may assist to develop strategies to facilitate ASD-EBP adoption, implementation and sustainment. A convergent mixed methods (quan + QUAL) design was utilized. Twenty ASD-CBO agency leaders (ALs) and 26 direct providers (DPs), from 21 ASD-CBOs, completed the Autism Model of Implementation Survey Battery, including demographic and agency IAU process questions. Surveys were analyzed through descriptive and content analyses. A subset of 10 ALs provided qualitative interview data that were analyzed using coding, consensus and comparison methods to allow for a more comprehensive understanding of the IAU process within their ASD-CBOs. Quantitative analyses and qualitative coding were merged utilizing a joint display and compared. Results suggest that the IAU process follows some phases identified in the Exploration, Preparation, Implementation, Sustainment (EPIS) framework but were conducted in an informal manner-lacking specificity, structure and consistency across and within ASD-CBOs. Moreover, data suggest adding a specific adoption decision phase to the framework. Nonetheless, most ALs felt previous implementation efforts were successful. IAU processes were explored to determine whether the implementation process may be an area for intervention to increase ASD-EBP utilization in ASD-CBOs. Developing a systematized implementation process may facilitate broader utilization of high quality ASD-EBPs within usual care settings, and ultimately improve the quality of life for individuals with ASD and their families.

Attempting Randomized Housing First Research in a Community Context: Reflections on Failure

The Housing First (HF) model of permanent supportive housing for individuals experiencing chronic homelessness has a strong evidence base that has largely been driven by researchers in the field of community psychology in partnership with community-based organizations. However, important gaps in the HF literature remain. Implementing rigorous research designs to further the evidence for HF requires immense resources to fund both the housing intervention and the research activities. In the absence of such resources, university-community partnerships may be established to integrate research within business-as-usual services and utilize existing housing units. This first person account presents a "post-mortem" exploration of an attempt to conduct a randomized trial of scattered-site and single-site approaches to HF within a community context from the perspectives of multiple stakeholders involved in the endeavor. Despite strengths of the research collaborative, the project did not come to completion due to a series of both insurmountable and avoidable barriers. Yet, the experience illuminated several potential challenges researchers and housing providers conducting work in this area may encounter, such as ever-changing homeless service system policies that may impact research and organizational procedures. Lessons learned and recommendations for preventing or overcoming systems-level barriers and potential challenges within the university-community partnership are described.

Fostering Community-Academic Partnerships to Promote Employment Opportunities for Refugees with Disabilities: Accomplishments, Dilemmas, and Deliberations

Little attention has been given to the processes and dynamics involved in community-engaged research with hard-to-reach and marginalized communities. This concept paper focuses on experiences with and lessons learned from the developmental phase of a community-engaged research project aimed at promoting the economic self-sufficiency of refugees with disabilities in Illinois. Steps taken to foster collaboration between academic researchers and community stakeholders are described, followed by the authors’ commentary on challenges encountered and how these were addressed. Several methods were used to facilitate engagement of community stakeholders. In the pre-funding stage, lead researchers identified potential community partners by networking with coalition groups and task forces focused on disability- and refugee-related issues. In the post-funding stage, relationships with partners were formalized, partners’ roles were defined, and contractual agreements were developed. An advisory board consisting of representatives from partner agencies and self-advocates with disabilities was also assembled to help guide the project goals and deliverables. Structured group and one-on-one meetings were held to sustain community partner engagement. These community engagement strategies were deemed successful. However, challenges did emerge due to conflict between community stakeholders’ preferences, and research logistics and regulatory requirements of the academic institution. Findings suggest that with careful planning, barriers to community-academic collaborations can be addressed in ways that benefit all parties. This paper offers practical strategies and a roadmap for other community-engaged research projects focusing on vulnerable and marginalized groups.