Inside help: An integrative review of champions in healthcare-related implementation

Implementation of a digital diary in the intensive care unit; understanding the facilitators and barriers: A qualitative exploration

BACKGROUND

In the recent years, digital intensive care unit (ICU) diaries have emerged as more advantageous than paper diaries. Despite the advantages of digital diaries, the successful implementation and maintenance of this digital intervention present significant challenges in clinical practice. Therefore, understanding the facilitators and barriers among stakeholders influencing this process becomes imperative for devising a tailored strategy to integrate digital diaries effectively within ICU settings.

AIM/OBJECTIVE

The aim of this study was to explore facilitators and barriers for implementation of a digital ICU diary from the perspectives of ICU professionals, ICU survivors, and their relatives.

METHODS

A qualitative design was used, incorporating focus-group interviews with professionals from four Dutch ICUs, along with individual interviews with ICU survivors and relatives. The study spanned from October 2022 to April 2023. Data analysis utilised a mixed inductive-deductive approach, particularly through directed content analysis. The Consolidated Framework for Implementation Research 2.0 guided both data collection and analysis processes.

FINDINGS

We conducted five focus-group interviews among ICU professionals (n = 32) and 10 individual or dual interviews involving five ICU survivors and nine relatives. Key facilitators for implementing a digital diary according to ICU professionals encompassed a user-friendly interface accessible independent of time and place, with a seamless login process requiring minimal steps, comprehensive training covering all aspects of its use, and feedback from the experiences of both patients and relatives. Barriers for ICU professionals included many steps required to access the digital diary, as well as resistance to (co)writing diary entries. In contrast, professionals' involvement in writing diary entries was highly appreciated among ICU survivors and relatives. An ambiguous factor arose regarding sharing the digital diary with others; both ICU survivors and relatives found it valuable, yet it also raised privacy concerns.

CONCLUSIONS

This study offers insights into the most important factors influencing the implementation of a digital ICU diary. Strikingly, some factors serve as both barriers and facilitators. When developing the implementation strategy, the identified facilitators can be used to overcome the barriers faced by ICU professionals, ICU survivors, and their relatives in adopting a digital diary.

A Statewide Physician Champion Initiative to Prevent Diabetes: Lessons Learned from North Carolina

The North Carolina Medical Society (NCMS) and American Medical Association (AMA) collaborated to support diabetes prevention efforts in North Carolina (NC) with a physician champion initiative focused on tracking and increasing referrals to the National Diabetes Prevention Program (DPP). Three focus areas to effectively engage and utilize physician champions included: (1) self-adoption within their practice, (2) engagement and outreach with other healthcare leaders, and (3) influence to peers and colleagues. Six NC physician champions were selected to support the work from January 2020 to January 2023. This resulted in increased outreach to physicians about Diabetes Free NC, increased materials/education for physicians on prediabetes identification and management, and 1943 referrals to the National DPP. This work can be further translated and applied to other states to aid prevention efforts. Physician champions' expertise coupled with adequate resources can allow them to play a key role in chronic disease prevention and management.

Implementation of a Cancer Rehabilitation Navigation Program: a qualitative analysis of implementation determinants and strategies

BACKGROUND

Cancer rehabilitation navigation (CRNav) is a care delivery model that expedites identification and management of symptom-related functional morbidity for individuals undergoing cancer treatment. A CRNav program is unique in that it embeds a cancer rehabilitation professional in the cancer center for patient screening and assessment. The implementation of CRNav programs has not been studied and doing so could facilitate greater uptake of these programs.

METHODS

Using implementation science frameworks, we conducted a qualitative, post-implementation analysis of a CRNav program that was implemented in 2019. Semi-structured, 1:1 interviews were guided by the Consolidated Framework for Implementation Research (CFIR) and a combination of deductive and inductive analyses, using a priori established codes, was used to assess the implementation context, and identify emergent themes of barriers and facilitators to implementation. Participant described implementation strategies were characterized and defined using the Expert Consensus Recommendations for Implementing Change (ERIC) taxonomy.

RESULTS

Eleven stakeholders including physicians, administrators, clinical staff, and patients, involved with program development and the implementation effort, participated in interviews. Predominant barriers to implementation included developing the program infrastructure, and lack of awareness of rehabilitation services among oncology professionals, predominant facilitators of implementation included; physical co-location of the navigator in the cancer center, individual characteristics of the navigator, and unique characteristics of the program. Strategies described that supported implementation included developing stakeholder interrelationships, evaluating and iteratively adapting the program, creating infrastructure, training and education, and supporting clinicians.

CONCLUSION

This analysis uses implementation science to methodically analyze and characterize factors that may contribute to successful implementation of a CRNav program. These findings could be used alongside a prospective context-specific analysis to tailor future implementation efforts.

IMPLICATIONS FOR CANCER SURVIVORS

Implementing a CRNav program expedites a patient's direct contact with a rehabilitation provider complementing the cancer care delivery team, and providing an additive and often missing service.

Nurses' engagement in advance care planning practices: A descriptive cross-sectional study

AIMS

To describe and compare nurses' awareness of, attitudes toward, and participation in advance care planning, as well as related facilitators and challenges, in four types of healthcare settings.

DESIGN

A cross-sectional descriptive study.

METHODS

Four hundred and ninety-eight registered nurses from tertiary, secondary and primary healthcare institutions, along with long-term care centres in South Korea, participated in an investigator-developed online survey. The collected data were analysed using descriptive statistics, chi-squared test, one-way ANOVA, and binary logistic regression.

RESULTS

Participants were on average 30.6 ± 7.3 years old, mostly female (95.4%), employed as staff nurses (95.4%), held bachelor's degrees or higher (84.1%), and had worked for less than 5 years at their current institutions (69.7%). Overall, 49% of the participants were familiar with advance care planning. While most participants supported nurse involvement in advance care planning with patients and surrogates, fewer were willing to engage or recommend it. Less than half were actively engaged in advance care planning practices. A notable challenge was the lack of time due to excessive workload. Compared to those from tertiary healthcare institutions, participants from secondary and primary healthcare institutions and long-term care centres were less likely to be aware of advance care planning. Participants from secondary and primary healthcare institutions had lower odds of checking for the presence of advance directives and the physician orders for life-sustaining treatment.

CONCLUSION

Nurses demonstrated low awareness and participation in advance care planning. Nurses' insufficient time and competency to conduct advance care planning in their practice should be addressed.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Educational programs, initiatives (e.g. guidelines, position statements) and legal and policy-level efforts (e.g. nurse staffing, role clarification, reimbursement) are crucial to incorporate advance care planning into routine nursing practice.

IMPACT

What problem did the study address? Nurses play an important role in advance care planning; however, limited is understood about their readiness and involvement in such practices. What were the main findings? Nurses' awareness of advance care planning practices and their participation in such practices is low across care settings. Although nurses have a positive attitude toward advance care planning, there are challenges (e.g. insufficient time to conduct advance care planning discussions and lack of relevant knowledge and skills) that impede their participation in practice. Where and on whom will the research have an impact? This study may serve as a foundation for nursing societies in countries, where advance care planning is emerging, to discuss strategies to increase nurses' competency in advance care planning and promote their participation in the practice.

REPORTING METHOD

The STROBE checklist was followed.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

What works in implementing shared medical appointments for patients with diabetes in primary care to enhance reach: a qualitative comparative analysis from the Invested in Diabetes study

BACKGROUND

Diabetes is a serious public health problem affecting 37.3 million Americans. Diabetes shared medical appointments (SMAs) are an effective strategy for providing diabetes self-management support and education in primary care. However, practices delivering SMAs experience implementation challenges. This analysis examined conditions associated with successful practice implementation of diabetes SMAs in the context of participation in a pragmatic trial.

METHODS

Mixed methods study using qualitative and quantitative data collected from interviews, observations, surveys, and practice-reported data, guided by the practical, robust implementation and sustainability model (PRISM). Data were analyzed using qualitative comparative analysis (QCA). Successful implementation was defined as meeting patient recruitment targets (Reach) during the study period. Participants were clinicians and staff members from 22 primary care practices in Colorado and Missouri, USA.

RESULTS

The first necessary condition identified from the QCA was the presence of additional resources for patients with diabetes in the practice. Within practices that had these additional resources, we found that a sufficiency condition was the presence of an effective key person to make things happen with the SMAs. A second QCA was conducted to determine conditions underlying the presence of the effective key person (often performing functions of an implementation champion), which revealed factors including low or managed employee turnover, a strong baseline practice culture, and previous experience delivering SMAs.

CONCLUSIONS

Identification of key factors necessary and sufficient for implementation of new care processes is important to enhance patient access to evidence-based interventions. This study suggests that practice features and resources have important implications for implementation of diabetes SMAs. There may be opportunities to support practices with SMA implementation by enabling the presence of skilled implementation champions.

TRIAL REGISTRATION

Registered at clinicaltrials.gov under trial ID NCT03590041, registered on July 18, 2018.

School Nurse Leadership and the Implementation of School-Based Support for LGBTQ+ Students

In 2021, the National Association of School Nurses published an updated position statement affirming the unique position of school nurses to support the health and well-being of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) students who are faced with a variety of health disparities rooted in experiences of stigma, discrimination, and bias. The 5-year cluster randomized controlled trial "Reducing LGBTQ+ Adolescent Suicide" leveraged school nurses as leaders to facilitate the uptake of six evidence-informed, LGBTQ-supportive practices in New Mexico high schools. We analyzed 5 years of interview data from 24 school nurses in 13 intervention schools to examine what factors impacted their ability to serve as an effective leader for this initiative. Several factors including job characteristics, leadership and organizational skills, relationships and reputation, and personal commitments emerged from analysis. Contextual factors, such as working in urban or rural school, and the size of the school also influenced nurses' leadership.

Clinician Champions' Influence on Social Needs Screening Volumes in Pediatric Practices

Health systems face barriers implementing routine screening for social needs. We assessed the impact of "clinician champions" on social needs screening. Screening data were assessed at 11 pediatric primary care practices in Bronx, NY, between April 2018 and August 2021. Three intervention practices had clinician champions; 8 control practices did not. The Wald chi-square tests and Poisson regressions evaluated the relationship between screening and introduction of clinician champions. The introduction of a clinician champion was a significant predictor of screening (P < .001). Within a practice, screening after the introduction of a clinician champion was higher than before the introduction (P < .001). The rate of screening for practices with a clinician champion was 2.8 times higher per month than for practices without a clinician champion. Furthermore, practices with clinician champions had higher rates of screening during the pandemic. In summary, the presence of clinician champions increased social needs screening rates in pediatric primary care practices.

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BACKGROUND

Despite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis.

METHODS

Using National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).

RESULTS

Five of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship.

CONCLUSION

Hospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship.

LEVEL OF EVIDENCE

Level V.

Implementing the Brøset Violence Checklist in the ED

ABSTRACT

The emerging field of implementation science (IS) facilitates the sustainment of evidence-based practice in clinical care. This article, the second in a series on applying IS, describes how a nurse-led IS team at a multisite health system implemented the Brøset Violence Checklist-a validated, evidence-based tool to predict a patient's potential to become violent-in the system's adult EDs, with the aim of decreasing the rate of violence against staff. The authors discuss how they leveraged IS concepts, methods, and tools to achieve this goal.

An Approach to Enhancing Medication Treatment for Opioid Use Disorder in the HEALing Communities Study

The HEALing (Helping to End Addiction Long-term) Communities Study (HCS) aims to test the effectiveness of the Communities That HEAL intervention in decreasing opioid overdose deaths in 67 communities across four U.S. states. This intervention enlists a collaborative team of researchers, academic experts, and community coalitions to select and implement interventions from a menu of evidence-based practices, including medications for opioid use disorder (MOUD). The HCS's New York team developed an integrated network systems (INS) approach with a mapping tool to coach coalitions in the selection of strategies to enhance medication treatment. With the INS approach, community coalitions develop a map of service delivery venues in their local county to better engage people with medication treatment wherever this need arises. The map is structured around core services that can provide maintenance MOUD and satellite services, which include all settings where people with opioid use disorder are encountered and can be identified, possibly given medication, and referred to core programs for ongoing MOUD care. This article describes the rationale for the INS mapping tool, with a discussion framed by the consolidated framework for implementation research, and provides a case example of its application.

Using implementation science to promote the use of the fascia iliaca blocks in hip fracture care

PURPOSE

There is variable and suboptimal use of fascia iliaca compartment nerve blocks (FICBs) in hip fracture care. Our objective was to use an evidence-based and theory-informed implementation science approach to analyze barriers and facilitators to timely administration of FICB and select evidence-based interventions to enhance uptake.

METHODS

We conducted a qualitative study at a single centre using semistructured interviews and site observations. We interviewed 35 stakeholders including health care providers, managers, patients, and caregivers. We mapped barriers and facilitators to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). We compared the rate and timeliness of FICB administration before and after evidence-based implementation strategies were applied.

RESULTS

The study identified 18 barriers and 11 facilitators within seven themes of influences of FICB use: interpersonal relationships between health care professionals; clinician knowledge and skills related to FICB; roles, responsibilities, and processes for delivering FICB; perceptions on using FICB for pain; patient and caregiver perceptions on using FICB for pain; communication of hip fracture care between departments; and resources for delivering FICBs. We mapped the behaviour change domains to eight implementation strategies: restructure the environment, create and distribute educational materials, prepare patients to be active participants, perform audits and give feedback, use local opinion leaders, use champions, train staff on FICB procedures, and mandate change. We observed an increase in the rates of FICBs administered (48% vs 65%) and a decrease in the median time to administration (1.63 vs 0.81 days).

CONCLUSION

Our study explains why FICBs are underused and shows that the TDF and CFIR provide a framework to identify barriers and facilitators to FICB implementation. The mapped implementation strategies can guide institutions to improve use of FICB in hip fracture care.

User-Centered Framework for Implementation of Technology (UFIT): Development of an Integrated Framework for Designing Clinical Decision Support Tools Packaged With Tailored Implementation Strategies

BACKGROUND

Electronic health record-based clinical decision support (CDS) tools can facilitate the adoption of evidence into practice. Yet, the impact of CDS beyond single-site implementation is often limited by dissemination and implementation barriers related to site- and user-specific variation in workflows and behaviors. The translation of evidence-based CDS from initial development to implementation in heterogeneous environments requires a framework that assures careful balancing of fidelity to core functional elements with adaptations to ensure compatibility with new contexts.

OBJECTIVE

This study aims to develop and apply a framework to guide tailoring and implementing CDS across diverse clinical settings.

METHODS

In preparation for a multisite trial implementing CDS for pediatric overweight or obesity in primary care, we developed the User-Centered Framework for Implementation of Technology (UFIT), a framework that integrates principles from user-centered design (UCD), human factors/ergonomics theories, and implementation science to guide both CDS adaptation and tailoring of related implementation strategies. Our transdisciplinary study team conducted semistructured interviews with pediatric primary care clinicians and a diverse group of stakeholders from 3 health systems in the northeastern, midwestern, and southeastern United States to inform and apply the framework for our formative evaluation.

RESULTS

We conducted 41 qualitative interviews with primary care clinicians (n=21) and other stakeholders (n=20). Our workflow analysis found 3 primary ways in which clinicians interact with the electronic health record during primary care well-child visits identifying opportunities for decision support. Additionally, we identified differences in practice patterns across contexts necessitating a multiprong design approach to support a variety of workflows, user needs, preferences, and implementation strategies.

CONCLUSIONS

UFIT integrates theories and guidance from UCD, human factors/ergonomics, and implementation science to promote fit with local contexts for optimal outcomes. The components of UFIT were used to guide the development of Improving Pediatric Obesity Practice Using Prompts, an integrated package comprising CDS for obesity or overweight treatment with tailored implementation strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05627011; https://clinicaltrials.gov/study/NCT05627011.

Identifying effective vaccine champions: Findings from a national survey of primary care professionals

BACKGROUND

Vaccine champions are common in primary care, but little is known about which champions are effective.

METHODS

In 2022, we surveyed 2,144 US primary care professionals (PCPs) who reported working with vaccine champions. Respondents rated the champion with whom they worked most closely on their effectiveness at improving vaccination rates.

RESULTS

About half (49 %) of PCPs perceived their closest champion as highly effective. PCPs perceived advanced practice providers and nursing staff as highly effective somewhat more often than physicians (52 % and 58 % vs 43 %, p <.001). Other correlates of perceived effectiveness included being a formally appointed versus informal champion, working extremely versus less closely with PCPs, and using a high (4-5) versus low (0-1) number of implementation strategies to improve vaccination rates (all p <.001).

CONCLUSIONS

Results suggest vaccine champions may benefit from having formal roles and opportunities to work closely with colleagues to improve vaccination rates using multiple strategies.

Allied Health Clinicians' Uptake of Evidence in Stroke Rehabilitation: A Systematic Review of Determinants Targeted in Implementation Studies

OBJECTIVE

This study aimed to determine whether targeting specific implementation determinants is associated with allied health clinicians' uptake of evidence when implemented within stroke rehabilitation settings.

DATA SOURCES

7 key databases were searched to identify articles published between 1990 and 2022 for inclusion. Reference lists of relevant articles were hand searched.

STUDY SELECTION

Studies were independently screened by 2 authors and included if the implementation intervention targeted allied health clinical practice in any stroke rehabilitation context and reported at least 1 quantitative measure of evidence uptake. Thirty studies met inclusion criteria.

DATA EXTRACTION

Data were independently extracted by the first and second author. Implementation outcomes for each study were categorized as either mostly successful, partially successful, or not successful based on the degree of evidence uptake achieved. Determinants targeted were categorized using the Consolidated Framework for Implementation Research (CFIR).

DATA SYNTHESIS

Patterns between the degree of evidence uptake and determinants targeted across studies were analyzed by the first and second authors in 1 of 3 groups: A (pre-post statistical analysis), B (pre-post descriptive analysis), or C (post-only descriptive analysis). Patterns between evidence uptake and determinants targeted were first identified within groups A and B, with group C consulted to support findings. All studies categorized as "mostly successful" targeted facilitation in combination with establishing face-to-face networks and communication strategies. Conversely, no studies rated "not successful" targeted either of these determinants. Studies rated "partially successful" targeted either 1, but seldom both, of these determinants.

CONCLUSIONS

This review has provided descriptive evidence of determinants which may be important to target for allied health clinicians' uptake of evidence within stroke rehabilitation settings.

The role of champions in the implementation of technology in healthcare services: a systematic mixed studies review

BACKGROUND

Champions play a critical role in implementing technology within healthcare services. While prior studies have explored the presence and characteristics of champions, this review delves into the experiences of healthcare personnel holding champion roles, as well as the experiences of healthcare personnel interacting with them. By synthesizing existing knowledge, this review aims to inform decisions regarding the inclusion of champions as a strategy in technology implementation and guide healthcare personnel in these roles.

METHODS

A systematic mixed studies review, covering qualitative, quantitative, or mixed designs, was conducted from September 2022 to March 2023. The search spanned Medline, Embase, CINAHL, and Scopus, focusing on studies published from 2012 onwards. The review centered on health personnel serving as champions in technology implementation within healthcare services. Quality assessments utilized the Mixed Methods Appraisal Tool (MMAT).

RESULTS

From 1629 screened studies, 23 were included. The champion role was often examined within the broader context of technology implementation. Limited studies explicitly explored experiences related to the champion role from both champions' and health personnel's perspectives. Champions emerged as promoters of technology, supporting its adoption. Success factors included anchoring and selection processes, champions' expertise, and effective role performance.

DISCUSSION

The specific tasks and responsibilities assigned to champions differed across reviewed studies, highlighting that the role of champion is a broad one, dependent on the technology being implemented and the site implementing it. Findings indicated a correlation between champion experiences and organizational characteristics. The role's firm anchoring within the organization is crucial. Limited evidence suggests that volunteering, hiring newly graduated health personnel, and having multiple champions can facilitate technology implementation. Existing studies predominantly focused on client health records and hospitals, emphasizing the need for broader research across healthcare services.

CONCLUSIONS

With a clear mandate, dedicated time, and proper training, health personnel in champion roles can significantly contribute professional, technological, and personal competencies to facilitate technology adoption within healthcare services. The review finds that the concept of champions is a broad one and finds varied definitions of the champion role concept. This underscores the importance of describing organizational characteristics, and highlights areas for future research to enhance technology implementation strategies in different healthcare settings with support of a champion.

Clinician perspectives of the implementation of an early intervention service for eating disorders in England: a mixed method study

BACKGROUND

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has been shown to reduce the wait for care and improve clinical outcomes in initial evaluations. These findings led to the national scaling of FREED in England. To support this scaling, we conducted a mixed method evaluation of the perceptions and experiences of clinicians in the early phases of scaling. The Normalisation Process Theory (NPT) was used as a conceptual lens to understand if and how FREED becomes embedded in routine practice.

METHODS

The convergent mixed method evaluation included 21 semi-structured interviews with clinicians from early adopter sites and 211 surveys administered to clinicians before, immediately after and 3 months after the FREED training. The interview guide and survey included questions evaluating attitudes towards early intervention for eating disorders (EDs) and NPT mechanisms. Interview data were analysed using an inductive thematic analysis. The NPT was applied to the inductively derived themes to evaluate if and how NPT domains impacted the implementation. Survey data were analysed using multilevel growth models.

RESULTS

Six themes and 15 subthemes captured barriers and facilitators to implementation at the patient, clinician, service, intervention, implementation and wider system levels. These interacted with the NPT mechanisms to facilitate or hinder the embedding of FREED. Overall, clinicians were enthusiastic and positive towards early intervention for EDs and FREED, largely because of the expectation of improved patient outcomes. This was a considerable driver in the uptake and implementation of FREED. Clinicians also had reservations about capacity and the potential impact on other patients, which, at times, was a barrier for its use. The FREED training led to significant improvements in positive attitudes and NPT mechanisms that were largely maintained at the 3-month follow-up. However, negative attitudes did not significantly improve following training.

CONCLUSIONS

Positive attitudes towards early intervention for EDs increased enthusiasm and engagement with the model. Features of the model and its implementation were effective at developing adopter commitment and capabilities. However, there were aspects of the model and its implementation which require attention in the future (e.g., capacity and the potential impact on the wider service).

Implementation of Physical Therapist Services for Men Undergoing Radical Prostatectomy: An Administrative Case Report

OBJECTIVE

Prostate cancer is the most commonly diagnosed cancer among men in the USA, and radical prostatectomy (RP) is the primary surgical treatment option. With an increasing number of men undergoing RP and surviving prostate cancer, clinical management strategies have broadened to improve the preoperative and postoperative patient experience and minimize treatment-related functional consequences. Urinary incontinence is a predictable functional consequence of RP. Recent reviews recommend preoperative and postoperative physical therapist services as the standard of care for men undergoing RP to decrease the severity of urinary incontinence and improve patients' quality of life. Despite compelling evidence, the routine provision of physical therapist services preoperatively and postoperatively for men undergoing RP is limited. The purpose of this case report is to describe the implementation of preoperative and postoperative physical therapist services for men undergoing RP in a US health care system using the knowledge-to-action process and the Consolidated Framework for Implementation Research frameworks.

CASE DESCRIPTION

The implementation process included 4 steps: (1) development of a preoperative and postoperative physical therapist services program; (2) identification of barriers and enablers for implementation; (3) implementation of the program; and (4) evaluation of the effectiveness of the implemented program.

RESULTS

Outcomes from the implementation of a physical therapist services program for men undergoing RP included lower urinary incontinence rates, improved patient satisfaction, and increased physical therapist utilization.

CONCLUSION

This case report documents the implementation of physical therapist services for men undergoing RP. The use of implementation frameworks enabled the identification of unique enablers, barriers, and strategies for the implementation of physical therapist services for men undergoing RP.

IMPACT

Implementing preoperative and postoperative physical therapist services for men undergoing RP improves patient outcomes. The implementation process and outcomes can be considered by other health care systems when developing preoperative and postoperative physical therapist services for men undergoing RP.

Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial

BACKGROUND

Although evidence-based treatments for depression in low-resource settings are established, implementation strategies to scale up these treatments remain poorly defined. We aimed to compare two implementation strategies in achieving high-quality integration of depression care into chronic medical care and improving mental health outcomes in patients with hypertension and diabetes.

METHODS

We conducted a parallel, cluster-randomised, controlled, implementation trial in ten health facilities across Malawi. Facilities were randomised (1:1) by covariate-constrained randomisation to either an internal champion alone (ie, basic strategy group) or an internal champion plus external supervision with audit and feedback (ie, enhanced strategy group). Champions integrated a three-element, evidence-based intervention into clinical care: universal depression screening; peer-delivered psychosocial counselling; and algorithm-guided, non-specialist antidepressant management. External supervision involved structured facility visits by Ministry officials and clinical experts to assess quality of care and provide supportive feedback approximately every 4 months. Eligible participants were adults (aged 18-65 years) seeking hypertension and diabetes care with signs of depression (Patient Health Questionnaire-9 score ≥5). Primary implementation outcomes were depression screening fidelity, treatment initiation fidelity, and follow-up treatment fidelity over the first 3 months of treatment, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03711786, and is complete.

FINDINGS

Five (50%) facilities were randomised to the basic strategy and five (50%) to the enhanced strategy. Between Oct 1, 2019, and Nov 30, 2021, in the basic group, 587 patients were assessed for eligibility, of whom 301 were enrolled; in the enhanced group, 539 patients were assessed, of whom 288 were enrolled. All clinics integrated the evidence-based intervention and were included in the analyses. Of 60 774 screening-eligible visits, screening fidelity was moderate (58% in the enhanced group vs 53% in the basic group; probability difference 5% [95% CI -38% to 47%]; p=0·84) and treatment initiation fidelity was high (99% vs 98%; 0% [-3% to 3%]; p=0·89) in both groups. However, treatment follow-up fidelity was substantially higher in the enhanced group than in the basic group (82% vs 20%; 62% [36% to 89%]; p=0·0020). Depression remission was higher in the enhanced group than in the basic group (55% vs 36%; 19% [3% to 34%]; p=0·045). Serious adverse events were nine deaths (five in the basic group and four in the enhanced group) and 26 hospitalisations (20 in the basic group and six in the enhanced group); none were treatment-related.

INTERPRETATION

The enhanced implementation strategy led to an increase in fidelity in providers' follow-up treatment actions and in rates of depression remission, consistent with the literature that follow-up decisions are crucial to improving depression outcomes in integrated care models. These findings suggest that external supervision combined with an internal champion could offer an important advance in integrating depression treatment into general medical care in low-resource settings.

FUNDING

The National Institute of Mental Health.

ICU Care Team's Perception of Clinical Research in the ICU: A Cross-Sectional Study

OBJECTIVES

Adequate recruitment is essential for successful clinical research. ICU nurses play a crucial role in identifying eligible patients, introducing research teams, facilitating informed consent, and caring for enrolled patients. However, a larger group of multidisciplinary healthcare professionals (the ICU care team) is equally important in promoting clinical research participation.To describe the ICU care team's experiences in ongoing clinical research, identifying perceived barriers and enablers to their participation, and apply a behavior framework to enhance research engagement.

DESIGN

Cross-sectional survey study.

SETTING

Four adult ICUs and one PICU between June 2021 and March 2023.

SUBJECTS

We recruited nurses, physicians, nurse practitioners, allied health professionals, and unit clerks.

MEASUREMENT AND MAIN RESULTS

We developed and validated a cross-sectional survey based on the Capability, Opportunity, Motivation, Behavior model. This survey included: 1) demographic questions (n = 7); 2) research experience questions (n = 6), 3) capability questions (n = 8); 4) opportunity questions (n = 11); 5) and motivation questions (n = 13).A total of 172 ICU care team members completed the survey. Results showed differences in capabilities, opportunities, and motivations among ICU care team members. For example, fellow/attending physicians and nurse practitioners reported higher confidence in discussing research with patients/families, while registered nurses and allied health professionals expressed less confidence.

CONCLUSIONS

ICU care team members face multiple barriers that impact their involvement with the conduct of ICU research. To effectively engage healthcare professionals in this process, it is essential to address their capabilities (research knowledge and skills to communicate research with patients/families), create opportunities (collaboration/communication with research team, discuss research during multidisciplinary rounds), and motivate them (recognize their help and share the results of the research being conducted at their site) to improve ICU care team engagement in the conduct of ICU research.

Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluation

BACKGROUND

Depression is a major contributor to morbidity and mortality in sub-Saharan Africa. Due to low system capacity, three in four patients with depression in sub-Saharan Africa go untreated. Despite this, little attention has been paid to the cost-effectiveness of implementation strategies to scale up evidence-based depression treatment in the region. In this study, we investigate the cost-effectiveness of two different implementation strategies to integrate the Friendship Bench approach and measurement-based care in non-communicable disease clinics in Malawi.

METHODS

The two implementation strategies tested in this study are part of a trial, in which ten clinics were randomly assigned (1:1) to a basic implementation package consisting of an internal coordinator acting as a champion (IC-only group) or to an enhanced package that complemented the basic package with quarterly external supervision, and audit and feedback of intervention delivery (IC + ES group). We included material costs, training costs, costs related to project-wide meetings, transportation and medication costs, time costs related to internal champion activities and depression screening or treatment, and costs of external supervision visits if applicable. Outcomes included the number of patients screened with the patient health questionnaire 2 (PHQ-2), cases of remitted depression at 3 and 12 months, and disability-adjusted life-years (DALYs) averted. We compared the cost-effectiveness of both packages to the status quo (ie, no intervention) using a micro-costing-informed decision-tree model.

FINDINGS

Relative to the status quo, IC + ES would be on average US$10 387 ($1349-$17 365) more expensive than IC-only but more effective in achieving remission and averting DALYs. The cost per additional remission would also be lower with IC + ES than IC-only at 3 months ($119 vs $223) and 12 months ($210 for IC + ES; IC-only dominated by the status quo at 12 months). Neither package would be cost-effective under the willingness-to-pay threshold of $65 per DALY averted currently used by the Malawian Ministry of Health. However, the IC + ES package would be cost-effective in relation to the commonly used threshold of three times per-capita gross domestic product per DALY averted.

INTERPRETATION

Investing in supporting champions might be an appropriate use of resources. Although not currently cost-effective by Malawian willingness-to-pay standards compared with the status quo, the IC + ES package would probably be a cost-effective way to build mental health-care capacity in resource-constrained settings in which decision makers use higher willingness-to-pay thresholds.

FUNDING

National Institute of Mental Health.

Enhancing Impact: A Call to Action for Equitable Implementation Science

Despite investments in evidence-based interventions and Implementation Science, most evidence-based interventions are not widely or routinely adopted, delivered, or sustained in many real-world community and healthcare settings. This gap is even greater in settings and populations experiencing numerous social and structural barriers to health, with important implications for persistent patterns in health inequities. In this Viewpoint, as part of a Special Issue on Advancing the Adaptability of Chronic Disease Prevention and Management through Implementation Science, we outline seven calls to action for the field of Implementation Science, with the goal of encouraging researchers, practitioners, and funders to be more intentional and accountable in applying Implementation Science to have greater impact on promoting health equity. Calls to action include (1) enhance public health, community, and multi-sectoral partnerships to promote health equity and equitable implementation; (2) revisit and build the evidence base needed to promote health equity and impact at multiple levels; (3) prioritize focus on policy development, dissemination, and implementation; (4) be agile and responsive in application of Implementation Science frameworks, processes, and methods; (5) identify and redefine meaningful metrics for equity and impact; (6) disseminate scientific evidence and research to a diverse range of partners and potential beneficiaries; and (7) extend focus on de-implementation, mis-implementation, and sustainability which are central to enhancing health equity. Additionally, we outline why a focus on prevention and public health is essential to making progress towards health equity in Implementation Science, summarize important advancements that the field has made towards making equity more foundational, and pose important research questions to enhance equitable impact of work in this area.

"FREED instils a bit of hope in the eating disorder community… that things can change.": an investigation of clinician views on implementation facilitators and challenges from the rapid scaling of the First Episode Rapid Early Intervention for Eating Disorders programme

Introduction

First Episode Rapid Early Intervention for Eating Disorders (FREED) is the leading eating disorder (ED) early intervention model for young people. Research has shown that it reduces the duration of untreated illness, improves clinical outcomes, and has cost savings. However, less is known about the experience of implementing FREED. This study aimed to investigate the views and experiences of adopting, implementing, and sustaining FREED from the perspective of clinical staff.

Methods

Seven focus groups were conducted involving 26 clinicians. Thematic analysis was used, with the Non-Adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability (The NASSS framework) framework being applied to organise subthemes and determine facilitators and barriers. The NASSS framework was also used to rate the complexity of themes as either simple (straightforward, predictable, few components), complicated (multiple interrelating components), or complex (dynamic, unpredictable, not easily divisible into constituent components).

Results

There were 16 subthemes identified under seven broader themes representing each domain of the NASSS framework. Key barriers and areas of complexity included factors related to EDs as an illness (e.g., high acuity and prevalence), and organisational complexity (e.g., staffing shortages, lack of managerial/team support). Key facilitators included positive clinician/adopter attitudes, a supportive national network, and the ability for FREED to be flexible/adaptable over time.

Conclusion

The FREED model appears to be desirable to clinical staff. Wider team and managerial support was perceived to be particularly important to its successful implementation, as were the national network and supervision. Key areas of complexity include staffing issues and high ED acuity/prevalence. These barriers to implementation need to be managed and investment continued to expand and improve early intervention for EDs further.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals

BACKGROUND

Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care.

METHODS

In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates."

RESULTS

Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001).

CONCLUSIONS

Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life

BACKGROUND

Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention.

METHODS

Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed.

RESULTS

Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level.

CONCLUSIONS

An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).

Development of a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers: A multi-method study

BACKGROUND

Delirium is a common yet challenging condition in older hospitalized patients, associated with various adverse outcomes. Environmental factors, such as room changes, may contribute to the development or severity of delirium. Most previous research has focused on preventing and reducing this condition by addressing risk factors and facilitating reorientation during hospital stay.

OBJECTIVE

We aimed to systematically develop a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers during and after these procedures. The intervention combines stakeholder and expert opinions, evidence, and theory. This article provides guidance and inspiration to research groups in developing complex interventions according to the recommendations in the Medical Research Council framework for complex interventions.

DESIGN AND METHODS

A stepwise multi-method study was conducted. The preparation phase included analysis of the context and current practice via focus groups. Based on these results, an expert workshop was organized, followed by a Delphi survey. Finally, the intervention was modeled and a program theory was developed, including a logic model.

RESULTS

A complex intervention was developed in an iterative process, involving healthcare professionals, delirium experts, researchers, as well as caregiver and patient representatives. The key intervention component is an 8-point-program, which provides caregivers with recommendations for preventing delirium during the transition phase and in the post-discharge period. Information materials (flyers, handbook, videos, posters, defined "Dos and Don'ts", discharge checklist), training for healthcare professionals, and status analyses are used as implementation strategies. In addition, roles were established for gatekeepers to act as leaders, and champions to serve as knowledge multipliers and trainers for the multi-professional team in the hospitals.

CONCLUSIONS

This study serves as an example of how to develop a complex intervention. In an additional step, the intervention and implementation strategies will be investigated for feasibility and acceptability in a pilot study with an accompanying process evaluation.

TWEETABLE ABSTRACT

Delirium prevention can benefit from optimizing discharge and transfer processes and involving caregivers of older patients in these procedures.

STUDY REGISTRATION

DRKS00017828, German Register of Clinical Studies, date of registration 17.09.2019.

Barriers to and facilitators of successful implementation of a palliative approach to care in primary care practices: a mixed methods study

OBJECTIVE

Integrating a palliative approach to care into primary care is an emerging evidence-based practice. Despite the evidence, this type of care has not been widely adopted into primary care settings. The objective of this study was to examine the barriers to and facilitators of successful implementation of a palliative approach to care in primary care practices by applying an implementation science framework.

DESIGN

This convergent mixed methods study analysed semistructured interviews and expression of interest forms to evaluate the implementation of a protocol, linked to implementation strategies, for a palliative approach to care called Early Palliation through Integrated Care (EPIC) in three primary care practices. This study assessed barriers to and facilitators of implementation of EPIC and was guided by the Consolidated Framework for Implementation Research (CFIR). A framework analysis approach was used during the study to determine the applicability of CFIR constructs and domains.

SETTING

Primary care practices in Canada. Interviews were conducted between September 2020 and November 2021.

PARTICIPANTS

10 individuals were interviewed, who were involved in implementing EPIC. Three individuals from each practice were reinterviewed to clarify emerging themes.

RESULTS

Overall, there were implementation barriers at multiple levels that caused some practices to struggle. However, barriers were mitigated when practices had the following facilitators: (1) a high level of intra-practice collaboration, (2) established practices with organisational structures that enhanced communications, (3) effective leveraging of EPIC project supports to transition care, (4) perceptions that EPIC was an opportunity to make a long-term change in their approach to care as opposed to a limited term project and (5) strong practice champions.

CONCLUSIONS

Future implementation work should consider assessing facilitators identified in our results to better gauge primary care pre-implementation readiness. In addition, providing primary care practices with support to help offset the additional work of implementing innovations and networking opportunities where they can share strategies may improve implementation success.

Using intervention mapping to develop an implementation strategy to improve timely uptake of streamlined birth-dose vaccines in the Democratic Republic of the Congo

Despite the policy recommendation and effectiveness of administering the hepatitis B birth-dose vaccine (HepB-BD) to newborns to prevent mother-to-child hepatitis B transmission, timely uptake remains an issue. Countries adopting the HepB-BD to their national immunization schedule report programmatic challenges to administering the vaccine within the recommended 24-hour window after delivery. Further, while the World Health Organization recommends streamlining three birth-dose vaccines (HepB-BD, BCG, and OPV0), scarce Sub-Saharan(SSA)-based literature reports on a streamlined and timely approach to birth-dose vaccines. As more SSA countries adopt the new birth-dose vaccine to their immunization schedules, a systematically developed implementation strategy-Vaccination of Newborns-Innovative Strategies to Hasten Birth-Dose vaccines' delivery (VANISH-BD)-will facilitate the adoption and implementation of timely birth-dose vaccine uptake. In this paper, we describe the development of the implementation strategy using intervention mapping, an evidence-based and theory-driven approach. We report on the development of our intervention, beginning with the needs assessment based in Kinshasa Province, Democratic Republic of the Congo (DRC), informing step 1 of intervention mapping. The intervention is contextually relevant, locally produced, sustainable, and designed to improve timely birth-dose vaccine uptake in the DRC. We intend to inform future implementers about improving timely and streamlined birth-dose vaccine uptake and for VANISH-BD to be adapted for similar contexts.

Exploring Factors for Implementation of EPAs in Pediatric Subspecialty Fellowships: A Qualitative Study of Program Directors

OBJECTIVE

To understand fellowship program directors' (FPDs) perspectives on facilitators and barriers to using entrustable professional activities (EPAs) in pediatric subspecialty training.

METHODS

We performed a qualitative study of FPDs, balancing subspecialty, program size, geographic region and current uses of EPAs. A study coordinator conducted 1-on-1 interviews using a semistructured approach to explore EPA use or nonuse and factors supporting or preventing their use. Investigators independently coded transcribed interviews using an inductive approach and the constant comparative method. Group discussion informed code structure development and refinement. Iterative data collection and analysis continued until theoretical sufficiency was achieved, yielding a thematic analysis.

RESULTS

Twenty-eight FPDs representing 11 pediatric subspecialties were interviewed, of whom 16 (57%) reported current EPA use. Five major themes emerged: (1) facilitators including the intuitive nature and simple wording of EPAs; (2) barriers such as workload burden and lack of a regulatory requirement; (2) variable knowledge and training surrounding EPAs, leading to differing levels of understanding; (3) limited current use of EPAs, even among self-reported users; and (4) complementary nature of EPAs and milestones. FPDs acknowledged the differing strengths of both EPAs and milestones but sought additional knowledge about the value added by EPAs for assessing trainees, including the impact on outcomes.

CONCLUSIONS

Identified themes can inform effective and meaningful EPA implementation strategies: Supporting and educating FPDs, ongoing assessment of the value of EPAs in training, and practical integration with current workflow. Generating additional data and engaging stakeholders is critical for successful implementation for the pediatric subspecialties.

Utilization of whole health services among veterans with spinal cord injuries and disorders (SCI/D): Early insights from the VA SCI/D system of care

CONTEXT/OBJECTIVE

Our objective was to describe early participation in Whole Health programs across the Veterans Health Administration (VHA) Spinal Cord Injuries and Disorders (SCI/D) System of Care.

DESIGN

Retrospective analysis of VHA administrative data.

SETTING

The VHA SCI/D System of Care.

PARTICIPANTS

Veterans with SCI/D included in the FY2019 cumulative VHA SCI/D Registry cohort with living status during FY2017, FY2018, and FY2019.

INTERVENTIONS

N/A.

OUTCOME MEASURES

We assessed the number of encounters and unique Veterans with SCI/D, and the percent of Veterans with SCI/D, who utilized each Whole Health (WH) program available in VA.

RESULTS

Utilization of WH Pathway and well-being Programs increased from 62 encounters to 1703 encounters between FY2017 and FY2019 (representing 0.09% to 3.13% of Veterans with SCI/D). Utilization of chiropractic care rose from 130 encounters to 418 encounters during the same time period. Similarly, utilization of complementary and integrative health programs increased from 886 encounters to 2655 encounters (representing 1.09% to 3.11% of Veterans; FY2017 to 2019). We also report utilization of specific WH programs.

CONCLUSION

Participation in WH services has been increasing among Veterans with SCI/D who receive health care from the VHA SCI/D System of Care. However, utilization among Veterans with SCI/D remains low overall, and targeted efforts to increase WH program reach are needed. Additional information about the relative effectiveness of different strategies to support WH implementation is also needed, to ensure strategies likely to have the most impact are prioritized.

Selection of criteria for a telemedicine framework for designing, implementing, monitoring and evaluating telemedicine interventions: Validation using a modified Delphi process

Objectives

The call to scale up telemedicine services globally as part of the digital health transformation lacks an agreed-upon set of constructs to guide the implementation process. A lack of guidance hinders the development, consolidation, sustainability and optimisation of telemedicine services. The study aims to reach consensus among telemedicine experts on a set of implementation constructs to be developed into an evidence-based support tool.

Methods

A modified Delphi study was conducted to evaluate a set of evidence-informed telemedicine implementation constructs comprising cores, domains and items. The study evaluated the constructs consisting of five cores: Assessment of the Current Situation, Development of a Telemedicine Strategy, Development of Organisational Changes, Development of a Telemedicine Service, and Monitoring, Evaluation and Optimisation of Telemedicine Implementation; seven domains: Individual Readiness, Organisational Readiness, Clinical, Economic, Technological and Infrastructure, Regulation, and Monitoring, Evaluation and Optimisation; divided into 53 items. Global telemedicine specialists (n = 247) were invited to participate and evaluate 58 questions. Consensus was set at ≥70%.

Results

Forty-five experts completed the survey. Consensus was reached on 78% of the constructs evaluated. Regarding the core constructs, Monitoring, Evaluation and Optimisation of Telemedicine Implementation was determined to be the most important one, and Development of a Telemedicine Strategy the least. As for the domains, the Clinical one had the highest level of consensus, and the Economic one had the lowest.

Conclusions

This research advances the field of telemedicine, providing expert consensus on a set of implementation constructs. The findings also highlight considerable divergence in expert opinion on the constructs of reimbursement and incentive mechanisms, resistance to change, and telemedicine champions. The lack of agreement on these constructs warrants attention and may partly explain the barriers that telemedicine services continue to face in the implementation process.

A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes

OBJECTIVES

To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention.

DESIGN

Mixed-methods process evaluation study.

SETTING AND PARTICIPANTS

Physicians, nursing staff, client council members, and residents of Dutch NHs.

METHODS

We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members.

RESULTS

Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture.

CONCLUSIONS AND IMPLICATIONS

Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.

Clinician Perceptions on Using Decision Tools to Support Prediction-Based Shared Decision Making for Lung Cancer Screening

Background

Considering a patient's full risk factor profile can promote personalized shared decision making (SDM). One way to accomplish this is through encounter tools that incorporate prediction models, but little is known about clinicians' perceptions of the feasibility of using these tools in practice. We examined how clinicians react to using one such encounter tool for personalizing SDM about lung cancer screening (LCS).

Design

We conducted a qualitative study based on field notes from academic detailing visits during a multisite quality improvement program. The detailer engaged one-on-one with 96 primary care clinicians across multiple Veterans Affairs sites (7 medical centers and 6 outlying clinics) to get feedback on 1) the rationale for prediction-based LCS and 2) how to use the DecisionPrecision (DP) encounter tool with eligible patients to personalize LCS discussions.

Results

Thematic content analysis from detailing visit data identified 6 categories of clinician willingness to use the DP tool to personalize SDM for LCS (adoption potential), varying from "Enthusiastic Potential Adopter" (n = 18) to "Definite Non-Adopter" (n = 16). Many clinicians (n = 52) articulated how they found the concept of prediction-based SDM highly appealing. However, to varying degrees, nearly all clinicians identified challenges to incorporating such an approach in routine practice.

Limitations

The results are based on the clinician's initial reactions rather than longitudinal experience.

Conclusions

While many primary care clinicians saw real value in using prediction to personalize LCS decisions, more support is needed to overcome barriers to using encounter tools in practice. Based on these findings, we propose several strategies that may facilitate the adoption of prediction-based SDM in contexts such as LCS.

Highlights

Encounter tools that incorporate prediction models promote personalized shared decision making (SDM), but little is known about clinicians' perceptions of the feasibility of using these tools in practice.We examined how clinicians react to using one such encounter tool for personalizing SDM about lung cancer screening (LCS).While many clinicians found the concept of prediction-based SDM highly appealing, nearly all clinicians identified challenges to incorporating such an approach in routine practice.We propose several strategies to overcome adoption barriers and facilitate the use of prediction-based SDM in contexts such as LCS.

Why it is hard to use PROMs and PREMs in routine health and care

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) show the results of healthcare activities as rated by patients and others. Patients or their proxies record feedback using questionnaires. These can enhance quality for all and tailored care for individuals. This paper describes obstacles that inhibit widespread use of PROMs and PREMs and some potential solutions.Implementation is a prerequisite for any innovation to succeed. Health and care services are complex and people need to be engaged at every level. Most people are cautious about proven innovations such as PROMs and PREMs but champions and leaders can help them engage. The NASSS framework (reasons for Non-adoption, Abandonment and failure to Scale up, Spread or Sustain digital health innovations) helps indicate that implementation is complex why it may be resisted.The Plan-Do-Study-Act (PDSA) approach aids implementation and helps ensure that everyone knows who should do what, when, where, how and why. Noise is an under-appreciated problem, especially when tracking patients over time such as before and after treatment. Interoperability of PROMs and PREMs with electronic health records should use Fast Health Interoperability Resources and internationally accepted coding schemes such as SNOMED CT and LOINC.Most projects need multiple measures to meet the needs of everyone involved. Measure selection should focus on their relevance, ease of use, and response rates.If these problems are avoided or mitigated, PROMs and PREMs can help deliver better patient outcomes, patient experience, staff satisfaction and health equity.

Early Insights into Implementation of Universal Screening, Brief Intervention, and Referral to Treatment for Perinatal Substance Use

OBJECTIVES

Perinatal substance use is a growing concern across the United States. Universal screening, brief intervention, and referral to treatment (SBIRT) is one systems-level approach to addressing perinatal substance use. The objective of this study is to assess early efforts to implement SBIRT in an outpatient obstetric clinic.

METHODS

The research team implemented universal screening with the 5 P's screening tool. Providers then engaged patients in a brief intervention and referred to a care manager who then worked with patients via tele-health to connect patients with needed services. Feasibility was measured through the collection of aggregate data describing frequency of universal screening and referral to treatment. The implementation team met bi-weekly to reflect on implementation barriers and facilitators.

RESULTS

In the first year of implementation, 48.5% of patients receiving care in the clinic completed the 5 P's screener at least once during the perinatal period. Screening occurred in a little over a quarter (26.5%) of eligible visits. Of the 463 patients that completed the 5 P's at least once during the perinatal period, 195 (42%) unique patients screened positive (answered yes to at least one question).

CONCLUSIONS FOR PRACTICE

Early implementation efforts suggest this approach is feasible in this obstetric setting. Similar implementation studies should consider implementing universal screening for substance use and perinatal mood and anxiety disorders simultaneously; guide efforts using an implementation framework; invest resources in more intensive training and ongoing coaching for providers; and adopt strategies to track frequency and fidelity of brief intervention.

Reducing Ileostomy Readmissions: Using Implementation Science to Evaluate the Adoption of a Quality Improvement Initiative

BACKGROUND

Translating empirical evidence into clinical practice remains challenging. Prevention of morbidity from new ileostomies may serve as an example. Despite evidence demonstrating improvements in electrolyte levels, kidney function markers, and hospital readmissions, widespread adoption of oral rehydration solutions among patients with new ileostomies has not occurred. The causes of low uptake are unknown and likely multifactorial.

OBJECTIVE

We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance implementation science framework to identify barriers and facilitators in the adoption of a quality improvement initiative aimed at decreasing emergency department visits and hospital readmissions because of dehydration among patients with new ileostomies using oral rehydration solutions.

DESIGN

Qualitative interviews were conducted with stakeholders based on the domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

SETTINGS

Participating community and academic hospitals across Michigan (n = 12).

PATIENTS

Convenience sampling was used to recruit 25 key stakeholders, including wound, ostomy, and continence nurses; registered nurses; nurse practitioners; nurse managers; colorectal surgeons; surgery residents; physician assistants; and data abstractors (1-4 participants per site).

MAIN OUTCOME MEASURES

Through qualitative content analysis, we located, analyzed, and identified patterns using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

RESULTS

We identified the following factors to increase the adoption of quality improvement initiatives at the provider level: 1) selection and coaching of champions, 2) broadening of multidisciplinary teams, 3) performing structured patient follow-up, and 4) addressing long-term sustainability concerns regarding cost and equity.

LIMITATIONS

Limited to high-volume ileostomy surgery hospitals, did not include in-person site visits to each hospital before and after implementation, and did not consider the hospital- and patient-level factors that impact the widespread adoption of quality improvement initiatives.

CONCLUSIONS

Integrating implementation science frameworks to rigorously study quality improvement initiatives may reveal the determinants of the widespread adoption of evidence-based practices.

REDUCCIN DE REINGRESOS POR ILEOSTOMA USO DE LA CIENCIA DE LA IMPLEMENTACIN PARA EVALUAR LA ADOPCIN DE UNA INICIATIVA DE MEJORA DE LA CALIDAD

ANTECEDENTES:Traducir la evidencia empírica a la práctica clínica sigue siendo un desafío. La prevención de la morbilidad por nuevas ileostomías puede servir como ejemplo. A pesar de la evidencia que demuestra mejoras en los niveles de electrolitos, marcadores de función renal y reingresos hospitalarios, no se ha producido una adopción generalizada de soluciones de rehidratación oral entre pacientes con nuevas ileostomías. Las causas de la baja captación son desconocidas y probablemente multifactoriales.OBJETIVO:Empleamos Alcance, Eficacia, Adopción, Implementación y Mantenimiento, un marco de las ciencias de implementación, para identificar barreras y facilitadores en la adopción de una iniciativa de mejora de la calidad destinada a disminuir las visitas al departamento de emergencias y los reingresos hospitalarios debido a la deshidratación entre los pacientes con nuevos ileostomías utilizando soluciones de rehidratación oral.DISEÑO:Se realizaron entrevistas cualitativas con las partes interesadas basadas en los dominios del marco de Alcance, Efectividad, Adopción, Implementación y Mantenimiento.CONFIGURACIÓN:Hospitales académicos y comunitarios participantes a través de Michigan (n = 12).PARTICIPANTES:Se utilizó un muestreo por conveniencia para reclutar a 25 partes interesadas clave, incluyendo enfermeras de heridas, ostomía y continencia; enfermeras registradas; enfermeras practicantes; gerentes de enfermera; cirujanos colorrectales; residentes de cirugía; asistentes médicos; y extractores de datos (1-4 participantes por sitio).PRINCIPALES MEDIDAS DE RESULTADO:A través del análisis de contenido cualitativo, localizamos, analizamos e identificamos patrones utilizando el marco de Alcance, Eficacia, Adopción, Implementación y Mantenimiento.RESULTADOS:Identificamos los siguientes factores para aumentar la adopción de iniciativas de mejora de la calidad a nivel de proveedores: 1) selección y entrenamiento de campeones, 2) ampliación de equipos multidisciplinarios, 3) seguimiento estructurado de pacientes y 4) abordaje a largo plazo. preocupaciones de sostenibilidad con respecto al costo y la equidad.LIMITACIONES:Limitado a hospitales de cirugía de ileostomía de alto volumen, incapaz de realizar visitas en persona a cada hospital antes y después de la implementación, no considera los factores a nivel del hospital y del paciente que afectan la adopción generalizada de iniciativas de mejora de la calidad.CONCLUSIONES:La integración de marcos científicos de implementación para estudiar rigurosamente las iniciativas de mejora de la calidad puede revelar los determinantes de la adopción generalizada de prácticas basadas en la evidencia. (Traducción-Dr. Aurian Garcia Gonzalez ).

Developing a Comprehensive Adolescent and Young Adult Cancer Program: Lessons Learned from 7 Years of Growth and Progress

Purpose: Every year, nearly 100,000 adolescents and young adults (15-39 years, AYAs) are diagnosed with cancer in the United States and many have unmet physical, psychosocial, and practical needs during and after cancer treatment. In response to demands for improved cancer care delivery for this population, specialized AYA cancer programs have emerged across the country. However, cancer centers face multilevel barriers to developing and implementing AYA cancer programs and would benefit from more robust guidance on how to approach AYA program development. Methods: To contribute to this guidance, we describe the development of an AYA cancer program at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center. Results: We summarize the evolution of UNC's AYA Cancer Program since it was established in 2015, offering pragmatic strategies for developing, implementing, and sustaining AYA cancer programs. Conclusion: The development of the UNC AYA Cancer Program since 2015 has generated many lessons learned that we hope may be informative to other cancer centers seeking to build specialized services for AYAs.

Designing and testing social media campaign messages to promote COVID-19 vaccine confidence among rural adults: A community-engaged approach featuring rural community leader and clinician testimonials

Despite the growing availability of effective COVID-19 vaccines in rural communities in the United States, widespread vaccine hesitancy delays COVID-19 vaccine coverage in rural communities and threatens to worsen pre-pandemic rural-urban disparities in other vaccination rates, including influenza and routine pediatric immunizations. Therefore, there is an urgent need to develop communication-based interventions to improve vaccine confidence in rural America. This study demonstrates the efficacy of a community-engaged approach to developing social media campaign messages in promoting COVID-19 vaccine uptake and pro-vaccine social diffusion among rural adults. Using a community-engaged approach, we developed social media campaign videos varying in (a) featured messengers (clinicians versus community leaders) and (b) the presence of personal testimonials. We conducted a national online experiment (N = 1,364 rural adults) in spring 2022. We found that videos featuring clinicians serving rural communities and their testimonials increased (a) vaccination intentions in the unvaccinated group (4-point scale, b = 0.23, p =.015) and (b) intention to discuss the messages with others (4-point scale, b = 0.14, p =.037), share the message (4-point scale, b = 0.15, p =.026), and promote the vaccines to others (9-point scale, b = 0.48, p =.013). Results suggest that vaccine promotional social media campaigns targeting rural populations can benefit from including clinician testimonials.

Champion and audit and feedback strategy fidelity and their relationship to depression intervention fidelity: A mixed method study

Background

Globally, mental health disorders rank as the greatest cause of disability. Low and middle-income countries (LMICs) hold a disproportionate share of the mental health burden, especially as it pertains to depression. Depression is highly prevalent among those with non-communicable diseases (NCDs), creating a barrier to successful treatment. While some treatments have proven efficacy in LMIC settings, wide dissemination is challenged by multiple factors, leading researchers to call for implementation strategies to overcome barriers to care provision. However, implementation strategies are often not well defined or documented, challenging the interpretation of study results and the uptake and replication of strategies in practice settings. Assessing implementation strategy fidelity (ISF), or the extent to which a strategy was implemented as designed, overcomes these challenges. This study assessed fidelity of two implementation strategies (a 'basic' champion strategy and an 'enhanced' champion + audit and feedback strategy) to improve the integration of a depression intervention, measurement based care (MBC), at 10 NCD clinics in Malawi. The primary goal of this study was to assess the relationship between the implementation strategies and MBC fidelity using a mixed methods approach.

Methods

We developed a theory-informed mixed methods fidelity assessment that first combined an implementation strategy specification technique with a fidelity framework. We then created corresponding fidelity indicators to strategy components. Clinical process data and one-on-one in-depth interviews with 45 staff members at 6 clinics were utilized as data sources. Our final analysis used descriptive statistics, reflexive-thematic analysis (RTA), data merging, and triangulation to examine the relationship between ISF and MBC intervention fidelity.

Results

Our mixed methods analysis revealed how ISF may moderate the relationship between the strategies and MBC fidelity. Leadership engagement and implementation climate were critical for clinics to overcome implementation barriers and preserve implementation strategy and MBC fidelity. Descriptive statistics determined champion strategy fidelity to range from 61 to 93% across the 10 clinics. Fidelity to the audit and feedback strategy ranged from 82 to 91% across the 5 clinics assigned to that condition. MBC fidelity ranged from 54 to 95% across all clinics. Although correlations between ISF and MBC fidelity were not statistically significant due to the sample of 10 clinics, associations were in the expected direction and of moderate effect size. A coefficient for shared depression screening among clinicians had greater face validity compared to depression screening coverage and functioned as a proximal indicator of implementation strategy success.

Conclusion

Fidelity to the basic and enhanced strategies varied by site and were influenced by leadership engagement and implementation climate. Champion strategies may benefit from the addition of leadership strategies to help address implementation barriers outside the purview of champions. ISF may moderate the relationship between strategies and implementation outcomes.

"The project did not come to us with a solution": Perspectives of research teams on implementing a study about electronic health record-embedded individualized pain plans for emergency department treatment of vaso-occlusive episodes in adults with sickle cell disease

BACKGROUND

This study aimed to capture the implementation process of the ALIGN Study, (An individualized Pain Plan with Patient and Provider Access for Emergency Department care of Sickle Cell Disease). ALIGN aimed to embed Individualized Pain Plans in the electronic health record (E-IPP) and provide access to the plan for both adult patients with sickle cell disease (SCD) and emergency department providers when a person with SCD comes to the emergency department in vaso-occlusive crises.

METHODS

Semi-structured interviews were conducted with research teams from the 8 participating sites from the ALIGN study. Seventeen participants (principal investigators and study coordinators) shared their perspectives about the implementation of ALIGN in their sites. Data were analyzed in three phases using open coding steps adapted from grounded theory and qualitative content analysis.

RESULTS

A total of seven overarching themes were identified: (1) the E-IPP structure (location and upkeep) and collaboration with the informatics team, (2) the role of ED champion, (3) the role of research coordinators, (4) research team communication, and communication between research team and clinical team, (5) challenges with the study protocol, (6) provider feedback: addressing over-utilizers, patient mistrust, and the positive feedback about the intervention, and (7) COVID-19 and its effects on study implementation.

CONCLUSIONS

Findings from this study contribute to learning how to implement E-IPPs for adult patients with SCD in ED. The study findings highlight the importance of early engagement with different team members, a champion from the emergency department, study coordinators with different skills and enhancement of communication and trust among team members. Further recommendations are outlined for hospitals aiming to implement E-IPP for patients with SCD in ED.

Bereaved Families Views on the Death of Loved Ones Due to COVID 19: An Integrative Review

Families encounter some issues after the death of their loved one due to COVID-19. Therefore, this study aimed to explore the family's views on the death of their loved one due to COVID-19. This integrative review was conducted from May to Jan 2021. We searched PubMed, Google Scholar, Scopus, Web of Science, CINHAL, Magiran, and SID databases. Fifteen studies met the inclusion criteria. The results were classified into two categories, including before and after death. The issues raised before the death of the loved ones include no visit and absence at death time, fear of being infected with the COVID-19, death anxiety, failure to perform religious rites at death, and psychological problems. The after-death issues were related to funeral, burial, rituals, prolonged grieving, maladaptation, loneliness, and repeated mourning. Therefore, health policymakers should provide support before and after the death of loved ones for families.

Exploring the roles and functions of champions within community-based interventions to support older adults with chronic conditions: A scoping review protocol

BACKGROUND

Health care solutions are needed to meet the need of an ageing population. Health care champions are people who endorse the adoption of new initiatives being implemented within health care settings. Although the role of champions has been cited as key to the success of numerous community-based interventions implemented to improve the care of older adults with chronic conditions, no synthesis of their implementation experiences have been conducted. We report on a scoping review protocol that will be applied to collect evidence on the role of champions within community-based health interventions to support older adults with chronic conditions. Specifically, we will identify how the term 'champion' is used and defined (i.e., conceptualized) and identify the roles (i.e., professional background) and functions of champions (i.e., responsibilities). We will also explore how this role impacts program implementation.

METHODS

This is a scoping review protocol informed by guidelines for Scoping Reviews (PRISMA-ScR) and a six-stage scoping review methodology. Peer-review literature will be retrieved from Medline, CINAHL, PubMed, PsycInfo, Cochrane JBI and Scopus databases, using a peer-reviewed search strategy developed in collaboration with an Information Specialist. The scoping review will consider all empirical studies published in English. Two reviewers will pilot-test the screening criteria and data abstraction forms, and then independently screen the literature. Extracted data will be analyzed numerically and thematically. Self-identified champions will be consulted to refine the practice recommendations from this work.

DISCUSSION

This scoping review will broadly and systematically identify, define and expand existing knowledge on champions' impact in implementing community-based interventions to support older adults with chronic conditions. We anticipate that our results will lead to a greater understanding of the characteristics and role champions play within these interventions, which will be relevant to a wide range of knowledge users, including researchers, decision-makers, and health care providers.

Stakeholders' perception of factors influencing adoption of a pediatric weight management intervention: a qualitative study

Background

Childhood obesity is highly prevalent in the United States and disproportionately impacts communities of color and low-income populations; these disparities have worsened during the COVID-19 pandemic. Adoption of effective pediatric weight management interventions (PWMIs) that have been evaluated among low-income diverse populations is needed. The Healthy Weight Clinic PWMI, a package co-developed by the American Academy of Pediatrics and Massachusetts General Hospital, helps health centers establish multidisciplinary Healthy Weight Clinics based on previous randomized controlled trials which demonstrated effectiveness. We sought to identify the factors influencing successful adoption of this PWMI and understand adaptations needed prior to implementation in new sites.

Methods

We interviewed 20 stakeholders, 10 from two health centers in Mississippi where the Healthy Weight Clinic PWMI will be piloted (pre-implementation sites) and 10 from health centers that have previously implemented it (sites in maintenance stages). Separate interview guides informed by the Consolidated Framework for Implementation Research (CFIR) were developed for the pre-implementation sites and those in maintenance stages, including questions related to adaptations of the PWMI in response to the COVID-19 pandemic. Qualitative data analysis was conducted using directed content analysis based on CFIR constructs. Adaptations in response to the pandemic were categorized using Framework for Reporting Adaptations and Modifications-Expanded (FRAME).

Results

In pre-implementation sites, an inner setting facilitator mentioned was a positive learning climate. Characteristics of individuals that can facilitate adoption include staff willingness to learn, valuing evidence-based care for childhood obesity, and culturally and weight-sensitive staff. In terms of patient needs and resources (outer setting), social drivers of health are barriers to adoption, but creative solutions were suggested to mitigate these. Other facilitators related to the intervention included its multidisciplinary model and adaptability. Similar themes were elicited from sites in maintenance stages; adaptations brought on by the pandemic, such as telehealth visits and content modification to align with distancing guidelines and the effects of social isolation were also described.

Conclusion

Understanding the factors influencing adoption of an evidence-based PWMI informs necessary adaptations and implementation strategies required to facilitate nationwide dissemination of PWMIs, with the goal of reaching the populations most at-risk.

Implementation of interprofessional quality circles on deprescribing in Swiss nursing homes: an observational study

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are still frequent among older adults in nursing homes. Deprescribing is an intervention that has been shown to be effective in reducing their use. However, the implementation of deprescribing in clinical practice has not yet been widely evaluated. The Quality Circle Deprescribing Module (QC-DeMo) intervention has been trialled through an effectiveness-implementation hybrid type 2 design. The intervention consists of a quality circle workshop session between healthcare professionals HCPs (physicians, nurses, and pharmacists) within a nursing home, in which they define a consensus to deprescribe specific PIMs classes. The aim of this study was to evaluate the implementation of the QC-DeMo intervention in nursing homes.

METHODS

This observational study focuses on the implementation part of the QC-DeMo trial. Implementation was based on the Framework for Implementation of Pharmacy Services (FISpH). Questionnaires at baseline and follow-up were used to evaluate reach, adoption, implementation effectiveness, fidelity, implementation, maintenance and the implementation strategies. Other data were collected from the QC-DeMo trial and routine data collected as part of the integrated pharmacy service where the QC-Demo trial was embedded. Implementation strategies included training of pharmacists, integration of the intervention into an existing quality circle dynamic and definition of tailored strategies to operationalise the consensus by each nursing home.

RESULTS

The QC-DeMo intervention was successfully implemented in 26 nursing homes in terms of reach, fidelity, adoption, implementation and implementation effectiveness. However, the intervention was found to be implemented with low maintenance as none of the nursing homes repeated the intervention after the trial. Implementation strategies were well received by HCPs: training was adequate according to pharmacists. Pre-existing quality circle dynamic facilitated interprofessional collaboration as involvement and support of each HCP was rated as high. HCPs recognized a specific and important role for each HCP in the deprescribing process. The most relevant tailored strategies to implement the consensus defined by each nursing home were identification of the patients by the pharmacist and a systematic review of medication's patients.

CONCLUSIONS

The implementation of a Quality Circle on Deprescribing is feasible but its maintenance in practice remains challenging. This study explores multiple implementation outcomes to better inform future implementation efforts of these types of interventions.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018.

Florida-California Cancer Health Equity Center (CaRE2) Community Scientist Research Advocacy Program

The Community Scientist Program (CSP), a model connecting researchers with community members, is effective to inform and involve the general population in health-related clinical research. Given the existing cancer disparities among Black/African American and Hispanic/Latino/a populations, more models describing how cancer-related CSPs are designed, implemented, and evaluated are needed. The Florida-California Cancer Research, Education and Engagement (CaRE2) Health Equity Center is a tri-institutional, bicoastal center created to eliminate cancer health disparities among Black/African American and Hispanic/Latino/a populations living in California and in Florida. The CaRE2 Center created a Community Scientist Research Advocacy (CSRA) training program for community members to become cancer research advocates. The CSRA program is currently a 13-week program conducted 100% virtually with all materials provided in English and Spanish for participants to learn more about prostate, lung, and pancreas cancers, ongoing research at CaRE2, and ways to share cancer research throughout their communities. Participants attend didactic lectures on cancer research during weeks 1-5. In week 4, participants join CSRA self-selected groups based on cancer-related topics of interest. Each group presents their cancer-related advocacy project developed during weeks 5-12 at the final session. In this paper, we describe the CaRE2 Health Equity Center's CSRA program, share results, and discuss opportunities for improvement in future program evaluation as well as replication of this model in other communities.

Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) in Appalachia: protocol for a group randomized, delayed intervention trial

Appalachian regions of Kentucky and Ohio are hotspots for colorectal cancer (CRC) mortality in the USA. Screening reduces CRC incidence and mortality; however, screening uptake is needed, especially in these underserved geographic areas. Implementation science offers strategies to address this challenge. The aim of the current study was to conduct multi-site, transdisciplinary research to evaluate and improve CRC screening processes using implementation science strategies. The study consists of two phases (Planning and Implementation). In the Planning Phase, a multilevel assessment of 12 health centers (HC) (one HC from each of the 12 Appalachian counties) was conducted by interviewing key informants, creating community profiles, identifying HC and community champions, and performing HC data inventories. Two designated pilot HCs chose CRC evidence-based interventions to adapt and implement at each level (i.e., patient, provider, HC, and community) with evaluation relative to two matched control HCs. During the Implementation Phase, study staff will repeat the rollout process in HC and community settings in a randomized, staggered fashion in the remaining eight counties/HCs. Evaluation will include analyses of electronic health record data and provider and county surveys. Rural HCs have been reluctant to participate in research because of concerns about capacity; however, this project should demonstrate that research does not need to be burdensome and can adapt to local needs and HC abilities. If effective, this approach could be disseminated to HC and community partners throughout Appalachia to encourage the uptake of effective interventions to reduce the burden of CRC.

Implementing Parenting Programs in Primary Care: A Framework and a Call for Action

Healthy parent-child relationships are clearly critical to healthy child development. Parenting programs develop caregivers' skills to support the health and well-being of children. Rigorous evidence has demonstrated the efficacy of these programs. Rising rates of child and youth depression, anxiety, grief, and suicide, both prior to and compounded by the COVID-19 pandemic, provide further reasons to implement parenting programs that support all parents in their essential roles. Parents can act as a buffer to stressors and support for children's well-being when they have the knowledge and skills to do so. Pediatric primary care practices are a natural setting for parenting programs, but challenges, including stigma, technology, workflow issues, and funding, have prevented their broad dissemination, implementation, and sustainability. In this article, we develop a framework for implementing parenting programs in primary care and present key considerations for selecting programs that fit the needs of parents, providers, patients, and the practice. We offer lessons from our experiences in overcoming these challenges, using the updated Consolidated Framework for Implementation Research to structure our discussion. We also provide an initial stepwise process which readers may use to plan their own parenting program implementation. Pediatric clinicians and practices can use this article and associated resources to plan, implement, and evaluate parenting programs in their practices as a strategy to help address the growing youth mental health crisis. Improving parenting behaviors can reduce the need for current or future mental health interventions by supporting optimal child development, emotional regulation, and parent-child relationships.

Multilevel Factors Associated With Participation in Group Well-Child Care

OBJECTIVE

To identify factors associated with participation in group well-child care (GWCC), wherein families share preventive health care visits.

METHODS

We extracted electronic health record data of mother-infant dyads with infants born 2013-18 at Yale New Haven Hospital and followed at the primary care center. Using chi-square analysis and multivariate logistic regression, we examined the extent to which 1) maternal/infant characteristics and recruitment timing were associated with GWCC initiation and continued engagement and 2) initiation was associated with primary care visits.

RESULTS

Of 2046 eligible mother-infant dyads, 11.6% initiated GWCC. The odds of initiation were higher among mothers with Spanish versus English primary language (odds ratio: 2.36 [95% confidence interval: 1.52-3.66]), with 1 child versus ≥ 3 children (1.58 [1.13-2.22]), and of non-Hispanic Black versus non-Hispanic White infants (2.72 [1.39-5.32]). Initiation was lower among infants born in 2016 (0.53 [0.32-0.88]) and 2018 (0.29 [0.17-0.52]) versus 2013. Among GWCC initiators with follow-up data (n = 217), continued engagement (n = 132, 60.8%) was positively associated with maternal age of 20-29 years (2.85 [1.10-7.34]) and > 30 years (3.46 [1.15-10.43]) compared with< 20 years, and mothers with 1 child versus ≥ 3 (2.28 [1.04-4.98]). GWCC initiators, versus non-initiators, had 5.06 times higher adjusted odds of attending > 9 primary care appointments in the first 18 months (95% confidence interval: 3.74-6.85).

CONCLUSIONS

As evidence builds on health and social benefits of GWCC, recruitment efforts may gain from considering multi-level socio-economic, demographic, and cultural factors associated with GWCC participation. Higher participation among systemically marginalized groups may present unique opportunities for family-based health promotion to mitigate health inequities.

Clinicians' Perspectives on Equitable Health Care Delivery in Group Well-Child Care

OBJECTIVE

To explore clinicians' perspectives about the impact of group well-child care (GWCC) on equitable health care delivery.

METHODS

In this qualitative study, we conducted semistructured interviews with clinicians engaged in GWCC recruited via purposive and snowball sampling. We first conducted a deductive content analysis using constructs from Donabedian's framework for health care quality (structure, process, and outcomes) followed by inductive thematic analysis within these constructs.

RESULTS

We completed 20 interviews with clinicians who deliver or research GWCC in 11 institutions across the United States. Four major themes around equitable health care delivery in GWCC emerged from clinicians' perspectives: 1) shifts in power dynamics (process); 2) enabling relational care, social support, and a sense of community (process, outcome); 3) centering multidisciplinary care delivery around patient and family needs (structure, process, and outcomes); and 4) unaddressed social and structural barriers limit patient and family participation.

CONCLUSIONS

Clinicians perceived that GWCC enhances equity in health care delivery by shifting hierarchies in clinical visits and promoting relational, patient, and family-centered care. However, potential opportunities exist to further address provider implicit bias in group care delivery and structural inequities at the level of the health care institution. Clinicians underscored the need to address barriers to participation so that GWCC can more fully enhance equitable health care delivery.