Protocol for a statewide randomized controlled trial to compare three training models for implementing an evidence-based treatment

Therapist Participation in a Learning Collaborative on Trauma-Focused Cognitive Behavioral Therapy: Impact of COVID-related Stressors and Challenges

The rise in mental health problems during the COVID-19 pandemic amplified the need to improve access to evidence-based treatments (EBT) and necessitated changes in treatment delivery and training of mental health providers (MHPs). There is limited information on how the pandemic may have impacted MHPs' participation in training and treatment delivery. This study included 269 MHPs who participated in a Learning Collaborative (LC) focused on an EBT. Qualitative interviews conducted with 15 MHPs who participated in the LC during the pandemic identified facilitators and barriers to training participation and EBT delivery that included social support, technology challenges, and difficulty completing cases following the transition to telehealth. Quantitative results showed that MHPs in the peri-COVID cohorts completed significantly fewer cases and fewer consultation calls compared to those prior to the pandemic. Findings suggest that providing support to train MHPs and promote EBT delivery may be beneficial during times of heightened stress.

Applying the Theoretical Domains Framework to Develop an Intervention to 'Re-implement' Parent-Child Interaction Therapy (PCIT)

Parent-Child Interaction Therapy (PCIT) is an empirically supported treatment for childhood conduct problems, with increasing numbers of clinicians being trained in Aotearoa/New Zealand. However, ensuring sustained delivery of effective treatments by trained clinicians in routine care environments is notoriously challenging. The aims of this qualitative study were to (1) systematically examine and prioritise PCIT implementation barriers and facilitators, and (2) develop a well specified and theory-driven 're-implementation' intervention to support already-trained clinicians to resume or increase their implementation of PCIT. To triangulate and refine existing understanding of PCIT implementation determinants from an earlier cross-sectional survey, we integrated previously unanalysed qualitative survey data (54 respondents; response rate 60%) with qualitative data from six new focus groups with 15 PCIT-trained clinicians and managers in Aotearoa/New Zealand. We deductively coded data, using a directed content analysis process and the Theoretical Domains Framework, resulting in the identification of salient theoretical domains and belief statements within these. We then used the Theory and Techniques Tool to identify behaviour change techniques, possible intervention components, and their hypothesised mechanisms of action. Eight of the 14 theoretical domains were identified as influential on PCIT-trained clinician implementation behaviour (Knowledge; Social/Professional Role and Identity; Beliefs about Capabilities; Beliefs about Consequences; Memory, Attention and Decision Processes; Environmental Context and Resources; Social Influences; Emotion). Two of these appeared to be particularly salient: (1) 'Environmental Context and Resources', specifically lacking suitable PCIT equipment, with (lack of) access to a well-equipped clinic room appearing to influence implementation behaviour in several ways. (2) 'Social/Professional Role and Identity', with beliefs relating to a perception that colleagues view time-out as harmful to children, concerns that internationally-developed PCIT is not suitable for non-Māori clinicians to deliver to Indigenous Māori families, and clinicians feeling obligated yet isolated in their advocacy for PCIT delivery. In conclusion, where initial implementation has stalled or languished, re-implementation may be possible, and makes good sense, both fiscally and practically. This study suggests that re-implementation of PCIT in Aotearoa/New Zealand may be facilitated by intervention components such as ensuring access to a colleague or co-worker who is supportive of PCIT delivery, access to suitable equipment (particularly a time-out room), and targeted additional training for clinicians relating to the safety of time-out for children. The feasibility and acceptability of these intervention components will be tested in a future clinical trial.

A Statewide Randomized Controlled Trial to Compare Three Models for Implementing Parent Child Interaction Therapy

OBJECTIVE

This study (NIMH RO1 MH095750; ClinicalTrials.gov Identifier: NCT02543359) evaluated the effectiveness of three training models to implement a well-established evidence-based treatment, Parent-Child Interaction Therapy (PCIT).

METHOD

Fifty licensed outpatient clinics, including 100 clinicians, 50 supervisors, and 50 administrators were randomized to one of three training conditions: 1) Learning Collaborative (LC), 2) Cascading Model (CM) or 3) Distance Education (DE). Data to assess training and implementation outcomes were collected at 4 time points coinciding with the training period: baseline, 6- (mid), 12- (post), and 24-months (1-year follow-up).

RESULTS

Multi-level hierarchical linear growth modeling was used to examine changes over time in training outcomes. Results indicate that clinicians in CM were more likely to complete training, reported high levels of training satisfaction and better learning experiences compared to the other training conditions. However, supervisors in the LC condition reported greater learning experiences, higher levels of knowledge, understanding of treatment, and satisfaction compared to supervisors in other conditions. Although clinicians and supervisors in the DE condition did not outperform their counterparts on any outcomes, their performance was comparable to both LC and CM in terms of PCIT use, supervisor perceived acceptability, feasibility, system support, and clinician satisfaction.

CONCLUSIONS

Through the use of a randomized controlled design and community implementation, this study contributes to the current understanding of the impact of training design on implementation of PCIT. Results also indicate that although in-person training methods may produce more positive clinician and supervisor outcomes, training is not a one-size-fits-all model, with DE producing comparable results on some variables.

Therapists' Perceived Competence in Delivering Trauma-Focused Cognitive Behavioral Therapy During Statewide Learning Collaboratives

The learning collaborative (LC), a multi-component training and implementation model, is one promising approach to address the need for increased availability of trauma-focused evidence-based practices. The current study used data from four cohorts of a statewide LC on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to 1) evaluate pre- to post-LC changes in therapists' perceived competence in delivering TF-CBT and 2) explore therapist and contextual factors related to therapists' perceived TF-CBT competence. Therapists (N = 237) completed pre- and post-LC measures of practice information, interprofessional collaboration, organizational climate, and TF-CBT knowledge, perceived competence, and use. Findings indicated therapists' perceived TF-CBT competence significantly increased, pre- to post-LC (d = 1.31), with greater use of trauma-focused practices at pre-training and more TF-CBT training cases completed predicting greater pre- to post-LC gains in perceived TF-CBT competence. These findings highlight the need to assist therapists in identifying and completing training cases to promote competence and implementation.

The Dissemination of Parent-Child Interaction Therapy in West Virginia during the Opioid Epidemic and COVID-19 Pandemic: A Qualitative Study

The devastating impact of the opioid crisis on children and families in West Virginia was compounded by the COVID-19 pandemic and brought to light the critical need for greater mental health services and providers in the state. Parent-Child Interaction Therapy (PCIT) is an evidence-based treatment for child externalizing symptoms that teaches parents positive and appropriate strategies to manage child behaviors. The current qualitative study details barriers and facilitators to disseminating and implementing PCIT with opioid-impacted families across West Virginia during the COVID-19 pandemic. Therapists (n = 34) who participated in PCIT training and consultation through a State Opioid Response grant were asked to provide data about their experiences with PCIT training, consultation, and implementation. Almost all therapists (91%) reported barriers to telehealth PCIT (e.g., poor internet connection, unpredictability of sessions). Nearly half of therapists' cases (45%) were impacted directly by parental substance use. Qualitative findings about the impact of telehealth and opioid use on PCIT implementation are presented. The dissemination and implementation of PCIT in a state greatly impacted by poor telehealth capacity and the opioid epidemic differed from the implementation of PCIT training and treatment delivery in other states, highlighting the critical importance of exploring implementation factors in rural settings.

Bringing Parent-Child Interaction Therapy to South Africa: Barriers and Facilitators and Overall Feasibility-First Steps to Implementation

There is a large assessment and treatment gap in child and adolescent mental health services, prominently so in low- and middle-income countries, where 90% of the world's children live. There is an urgent need to find evidence-based interventions that can be implemented successfully in these low-resource contexts. This pre-pilot study aimed to explore the barriers and facilitators to implementation as well as overall feasibility of Parent-Child Interaction Therapy (PCIT) in South Africa. A reflective and consensus building workshop was used to gather South African PCIT therapist (N = 4) perspectives on barriers, facilitators, and next steps to implementation in that country. Caregiver participants (N = 7) receiving the intervention in South Africa for the first time were also recruited to gather information on overall feasibility. Facilitators for implementation, including its strong evidence base, manualisation, and training model were described. Barriers relating to sustainability and scalability were highlighted. Largely positive views on acceptability from caregiver participants also indicated the promise of PCIT as an intervention in South Africa. Pilot data on the efficacy of the treatment for participating families are a next step. These initial results are positive, though research on how implementation factors contribute to the longer-term successful dissemination of PCIT in complex, heterogeneous low-resource settings is required.

Clinician adoption of Parent-Child Interaction Therapy: A systematic review of implementation interventions

Background

Parent-Child Interaction Therapy (PCIT) is a parent training intervention for childhood conduct problems, distinctive in its use of live clinician coaching of the parent-child dyad via a one-way mirror and discrete earpiece. However, despite a compelling evidence base, uptake of evidence-based parent training programmes such as PCIT by clinicians in routine care settings remains poor. This systematic review aimed to identify and synthesise implementation interventions that have sought to increase clinician adoption of PCIT in usual care settings.

Methods

We searched MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), CINAHL (EBSCO), Science Citation Index and Social Sciences Citation Index, and Web of Science Core Collection from inception to October 2020. Articles were included if they tested (by way of randomised controlled trials, controlled clinical trials, interrupted time series and controlled before and after trials) implementation interventions across any and all of the patient, clinician, clinic, system or policy domains. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data - summarising implementation intervention components according to items from the Template for Intervention Description and Replication (TIDieR) checklist ( Hoffmann et al., 2014).

Results

Of the 769 articles identified once duplicates were removed, 13 papers relating to three studies met the inclusion criteria - all were quantitative or mixed-methods examinations of the effectiveness of different PCIT clinician training or training-related consultation methods. A narrative description of interventions was provided, as quantitative synthesis was not possible.

Conclusions

Research attention has to date been focussed on the establishment of an evidence-base for PCIT's effectiveness, with relatively little attention to the dissemination, implementation and sustainment of this treatment. Those studies that do exist have focused on training methods and training-related expert consultation. Research attention could usefully turn to both adoption and sustainment of this effective treatment in usual care settings.

Plain language summary

In this review, we aimed to summarise what is already known about how to implement PCIT in community settings after clinicians have received training in the approach. While research relating to the implementation of other parent training programmes is interesting and informative, implementation efforts are most effective when tailored to a specific programme in a specific context. As such, it was important to review published studies relating to PCIT specifically. We identified three relevant studies, one of which is yet to publish its main implementation findings. The three studies have focused on how best to train clinicians in PCIT, including how best to provide post-training support from expert trainers. We concluded that a fruitful line for future research would be to focus on the post-training period, particularly how best to support clinicians to adopt and sustain PCIT in their practice.

Systematic review registration

The study was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 01/10/2020 (CRD42020207118).

How do Lay Health Worker Engage Caregivers? A Qualitative Study to Enhance Equity in Evidence-Based Parenting Programs

Engaging caregivers in their children's mental health treatment is critical for delivering high quality, evidence-based care, particularly for young children with externalizing behaviors. Lay health workers (LHWs), including peer providers and promotoras de salud, have been identified as important workforces in addressing structural and stigma-related barriers to engagement in mental health services. Importantly, research has suggested that LHWs may be integral in efforts to address engagement disparities in evidence-based behavioral parent training programs (BPTs) for Latinx caregivers. The purpose of the study was to understand how different LHW workforces engage caregivers within their usual services, in order to inform strategies that improve access to and engagement in BPTs. Qualitative interviews were conducted with two different LHW workforces: volunteer LHWs (i.e., promotoras de salud) (n = 14), who were part of a community-embedded network, and paid LHWs (i.e., parent support partners, home visitors) (n = 9) embedded within children's mental health agencies. Participants were predominately Latinx (79%) and female (96%). Qualitative analyses revealed three primary themes related to engagement strategies used by LHWs to address barriers to care: 1.) Building Trust, 2.) Empowerment, 3.) Increasing Access. Although the majority of themes and sub-themes were consistent across the two LHW workforces, agency-embedded LHWs often discussed having the means to provide resources through their organizations, whereas community-embedded LHWs discussed acting as a bridge to services by providing information and conducting outreach. Findings have implications for partnering with different workforces of LHWs to increase equity in access to BPTs.

Advancing implementation frameworks with a mixed methods case study in child behavioral health

Despite a growing policy push for the provision of services based on evidence, evidence-based treatments for children and youth with mental health challenges have poor uptake, yielding limited benefit. With a view to improving implementation in child behavioral health, we investigated a complementary implementation approach informed by three implementation frameworks in the context of implementing motivational interviewing in four child and youth behavioral health agencies: the Active Implementation Frameworks (AIF) (process), the Consolidated Framework for Implementation Research (factors), and the Implementation Outcomes Framework (evaluation). The study design was mixed methods with embedded interrupted time series and motivational interviewing (MI) fidelity was the primary outcome. Focus groups and field notes informed perspectives on the implementation approach, and a questionnaire explored the salience of Consolidated Framework for Implementation Research (CFIR) factors. Findings validate the process guidance provided by the AIF and highlight CIFR factors related to implementation success. Novel CFIR factors, not elsewhere reported in the literature, are identified that could potentially extend the framework if validated in future research. Introducing fidelity measurement in practice proved challenging and was not sustained beyond the study. A complementary implementation approach was successful in implementing MI in child behavioral health agencies. In contrast with the typical train and hope approach to implementation, practice change did not occur immediately post-training but emerged over a 7 month period of consultation and practice following a discrete interactive training period. The saliency of CFIR constructs aligned with findings from studies conducted in other contexts, demonstrating external validity and highlighting common factors that can focus planning and measurement.

Family-based treatment for children and adolescents with eating disorders: a mixed-methods evaluation of a blended evidence-based implementation approach

In this study, we evaluated a blended implementation approach with teams learning to provide family-based treatment (FBT) to adolescents with eating disorders. Four sites participated in a sequential mixed method pre-post study to evaluate the implementation of FBT in their clinical settings. The implementation approach included: (a) preparatory site visits; (b) the establishment of implementation teams; (c) a training workshop; (d) monthly clinical consultation; (e) monthly implementation consultation; and (f) fidelity assessment. Quantitative measures examining attitudes toward evidence-based practice, organizational learning environment and organizational readiness for change, as well as, individual readiness for change were delivered pre- and postimplementation. Correlational analyses were used to examine associations between baseline variables and therapist fidelity to FBT. Fundamental qualitative description guided the sampling and data collection for the qualitative interviews performed at the conclusion of the study. Seventeen individuals participated in this study (nine therapists, four medical practitioners, and four administrators). The predetermined threshold of implementation success of 80% fidelity in every FBT session was achieved by only one therapist. However, mean fidelity scores were similar to those reported in other studies. Participant attitudes, readiness, and self-efficacy were not associated with fidelity and did not change significantly from pre- to postimplementation. In qualitative interviews, all participants reported that the implementation intervention was helpful in adopting FBT. Our blended implementation approach was well received by participants. A larger trial is needed to determine which implementation factors predict FBT fidelity and impact patient outcomes.

Translating and Implementing Evidence-Based Mental Health Services in Child Welfare

Children in the child welfare system with mental health difficulties seldom receive evidence-based treatment (EBT) despite the abundance of validated interventions that exist. This manuscript describes two projects aimed at increasing access to EBTs. The first is a completed field trial of an adapted parent-child interaction therapy intervention with foster-parent child dyads. New findings are presented from variable- and person-centered analyses of impact on diverse symptom profiles. The second is an ongoing statewide initiative that is increasing access to multiple EBTs while navigating implementation barriers. Lessons learned for bridging gaps between children's mental health research, services, and policy are discussed.

Sustainment of Trauma-Focused and Evidence-Based Practices Following Learning Collaborative Implementation

Given the need to develop and validate effective implementation models that lead to sustainable improvements, we prospectively examined changes in attitudes, behaviors, and perceived organizational support during and after statewide Community-Based Learning Collaboratives (CBLCs) promoting trauma-focused evidence-based practices (EBPs). Participants (N = 857; i.e., 492 clinicians, 218 brokers, and 139 senior leaders) from 10 CBLCs completed surveys pre- and post-CBLC; a subsample (n = 146) completed a follow-up survey approximately two years post-CBLC. Results indicated (a) medium, sustained increases in clinician-reported use of trauma-focused EBPs, (b) medium to large, sustained increases in perceived organizational support for trauma-focused EBPs, and (c) trivial to small, sustained increases in perceived organizational support for EBPs broadly. In contrast, clinician-reported overall attitudes towards EBPs decreased to a trivial degree pre- to post-CBLC, but then increased to a small, statistically significant degree from post-CBLC to follow-up. Notably, the degree of perceived improvements in organizational support for general and trauma-focused EBPs varied by professional role. Findings suggest the CBLC implementation strategies may both increase and sustain provider practices and organizational support towards EBPs, particularly those EBPs a CBLC explicitly targets.

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

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

When Do Therapists Stop Using Evidence-Based Practices? Findings from a Mixed Method Study on System-Driven Implementation of Multiple EBPs for Children

Therapist discontinuation of delivering an evidence-based practice (EBP) is a critical outcome in the community implementation of EBPs. This mixed methods study examined factors associated with therapist discontinuation within a large reimbursement-driven implementation of multiple EBPs in public children's mental health services. The study integrated quantitative survey data from 748 therapists across 65 agencies, and qualitative interviews from a subset of 79 therapists across 14 agencies. Therapists adopted, on average, 2.41 EBPs (SD = 1.05, range = 1-5), and nearly half (n = 355, 47.5%) reported discontinuing at least one EBP. Multi-level models were used to predict the binary outcome of discontinuation, and qualitative analyses were used to expand upon quantitative findings. Quantitative models revealed that therapist factors, including fewer direct service hours per week, a greater number of EBPs adopted, higher emotional exhaustion, and more negative attitudes toward EBPs in general were associated with discontinuation. In addition, EBP-specific factors including more negative perceptions of the particular EBP and lower self-efficacy for delivering the specific EBP predicted discontinuation. Themes from interview responses highlighted the importance of fit of the EBP with the agency's client base, as well as therapist perceptions of adequate EBP training supports, and the alignment of an EBP with therapists' professional goals. Together, the findings suggest the need for strategic sustainment planning interventions that target EBP fit (i.e., fit between adopted EBPs and agency target population, fit between EBP and therapist preferences and career goals) and support therapist self-efficacy in delivering EBPs.

Train-to-Sustain: Predictors of Sustainment in a Large-Scale Implementation of Parent-Child Interaction Therapy

Sustainment of evidence-based practices is necessary to ensure their public health impact. The current study examined predictors of sustainment of Parent-Child Interaction Therapy (PCIT) within a large-scale system-driven implementation effort in Los Angeles County. Data were drawn from PCIT training data and county administrative claims between January 2013 and March 2018. Participants included 241 therapists from 61 programs. Two sustainment outcomes were examined at the therapist- and program-levels: 1) PCIT claim volume and 2) PCIT claim discontinuation (discontinuation of claims during study period; survival time of claiming in months). Predictors included therapist- and program-level caseload, training, and workforce characteristics. On average, therapists and programs continued claiming to PCIT for 17.7 and 32.3 months, respectively. Across the sustainment outcomes, there were both shared and unshared significant predictors. For therapists, case-mix fit (higher proportions of young child clients with externalizing disorders) and participation in additional PCIT training activities significantly predicted claims volume. Furthermore, additional training activity participation was associated with lower likelihood of therapist PCIT claim discontinuation in the follow-up period. Programs with therapists eligible to be internal trainers were significantly less likely to discontinue PCIT claiming. Findings suggest that PCIT sustainment may be facilitated by implementation strategies including targeted outreach to ensure eligible families in therapist caseloads, facilitating therapist engagement in advanced trainings, and building internal infrastructure through train-the-trainer programs.

Changes in Community Clinicians' Attitudes and Competence following a Transdiagnostic Cognitive Behavioral Therapy Training

Background

Although the literature suggest that attitudes toward evidence-based practices (EBPs) are associated with provider use of EBPs, less is known about the association between attitudes and how competently EBPs are delivered. This study examined how initial attitudes and competence relate to improvements in attitudes and competence following EBP training.

Methods

Program evaluation data was collected during implementation of an EBP in a large community mental health network. Clinicians (N=891) received intensive training in cognitive behavioral therapy followed by six months of consultation. Attitudes were assessed using the Evidence-Based Practice Attitude Scale, and competence was assessed using the Cognitive Therapy Rating Scale. Data were analyzed by fitting three latent change score models to examine the relationship between changes in attitudes and competence across the training and within its two phases (workshop phase, consultation phase).

Results

Latent change models identified significant improvement in attitudes (Ms _latent change≥1.03, SEs≤ 0.18, zs≥6.55, ps< .001) and competence (Ms _{latent change} ≥14.16, SEs≤3.10, zs≥2.82, ps<.001) across the full training and in each phase. Higher pre-workshop attitudes predicted significantly greater change in competence in the workshop and across training (bs≥1.62, SEs≤0.90, z≥1.09, p<.04, β≥0.10); however, contrary to our hypothesis, post-workshop attitudes did not significantly predict change in competence in consultation (b=1.62, SE=0.86, z=1.87, p=.06, β=0.09). Change in attitudes and change in competence in the training period and within the two phases were not significantly correlated.

Conclusions

Results indicate that pre-training attitudes about EBPs present a target for implementation interventions, given their relation to changes in both attitudes and competence throughout training. Following participation in in itial training workshops, other factors such as subjective norms, implementation culture, or system-level policy shifts may be more predictive of change in competence through consultation.

An evaluation of an intervention designed to help inactive adults become more active with a peer mentoring component: a protocol for a cluster randomised feasibility trial of the Move for Life programme

Background

There is overwhelming evidence to support the promotion of physical activity in adults in terms of benefits to well-being, physical and mental health. Physical activity guidelines suggest that adults should accumulate at least 150 min of moderate to vigorous physical activity per week. In Ireland, the majority of adults do not achieve these guidelines, with costs to health and economy. ‘Move for Life’ (MFL) employs behavioural change techniques delivered by an instructor and peer mentor, using a train-the-trainer (cascade) model. This study will conduct a feasibility cluster randomised controlled trial of the MFL intervention for modifying physical activity behaviours in inactive adults aged 45 years and older.

Methods

The trial is set in eight Local Sports Partnership (LSP) hubs that have structured physical activity programmes. The hubs are the units of randomisation (clusters), and individuals are the units of analysis (participants). Eligible participants will contact one of the hubs, with each hub running four physical activity programmes. Each programme requires between 12–15 inactive adults, resulting in 48–60 participants per hub. Allowing for 20% dropout rate, an additional 96 people will be recruited giving a maximum sample of 576. The hub will be randomised: true control, usual programme or MFL intervention. The true control group will be given information about physical activity but will not be included in a programme for the duration of the trial; the intervention will involve the instructor training one (or more) of the participants to be a peer mentor using an educational toolkit; and usual care groups will have physical activity classes delivered as normal. Baseline data will collect physical activity measures and follow-up measurements will be obtained at 3 and 6 months. All participants will be asked to wear a device for measuring activity on the thigh (activPAL) for 7 days before commencing the programme and at 3 and 6 months. The primary objective of the study is to investigate if it is feasible to deliver the intervention and collect data on moderate to vigorous physical activity (MVPA) on all participants, thereby providing valuable information to guide sample size calculation for a future, more definitive trial.

Trial registration number

ISRCTN11235176

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0473-y) contains supplementary material, which is available to authorized users.

Associations Among Job Role, Training Type, and Staff Turnover in a Large-Scale Implementation Initiative

Staff turnover is problematic for behavioral health agencies implementing evidence-based practices (EBPs), which are costly and time-consuming. The current study examined the association between EBP training methods and turnover and explored predictors of turnover for different types of staff. Participants (100 clinicians, 50 supervisors, 50 administrators) were randomized to one of three training conditions for an EBP. Results indicated low annual rates of turnover for clinicians, supervisors, and administrators. However, contrary to hypothesis, no statistically significant differences were found in rates of turnover across training conditions. Partially consistent with prior research, organizational climate was a significant predictor of supervisor and administrator turnover at 24 months, but was not a significant predictor of clinician turnover. Implications and future directions for research are discussed.

Statewide implementation of child trauma-focused practices using the community-based learning collaborative model

A significant number of youth in the United States experience traumatic events that substantially increase the risk of physical and behavioral health problems across the life span. This public health concern warrants concerted efforts to promote trauma-informed, evidence-based practices that facilitate recovery. Although youth-focused trauma-specific treatments exist, determining effective ways to disseminate and implement these services-so that they are available, accessible, and sustainable-poses an ongoing challenge. This paper describes a comprehensive model for such implementation, the community-based learning collaborative (CBLC), developed as part of Project BEST, a four-phase statewide initiative to promote trauma-focused practices. The CBLC augments the learning collaborative model by including clinical and nonclinical (i.e., broker) professionals from multiple service organizations within a targeted community. CBLCs aim to build capacity for sustained implementation of trauma-focused practices by promoting interprofessional collaboration among those involved in the coordination and provision of these services. This paper describes the iterative development of the CBLC by examining participant completion data across the three completed phases of Project BEST (N = 13 CBLCs; 1,190 participants). Additionally, data from Project BEST's third phase (N = 6 CBLCs; 639 participants) were used to evaluate changes in the frequency of specific practices, pre- to post-CBLC, and post-CBLC perceived utility of CBLC components. High participant completion rates, significant increases in reported trauma-focused practices, and positive ratings of the CBLC's utility provisionally support the feasibility and efficacy of the model's final iteration. Implications for implementation and CBLC improvements are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Implementing Evidence-Based Interventions With Community-Dwelling Older Adults: A Scoping Review

OBJECTIVE

With the rapid growth of the community-dwelling older adult population, evidence-based occupational therapy interventions targeting older clients need to be effectively implemented. However, little is understood about the factors influencing effective intervention implementation into practice.

METHOD

We performed a scoping review to explore what strategies and factors relate to the uptake of older adult interventions into practice. Concepts from implementation science literature guided our review.

RESULTS

Our review yielded 13 articles that met our search criteria. Study designs examined barriers, facilitators, and strategies related to the implementation of evidence-based older adult interventions into practice. Effective implementation strategies included training sessions, workshops, consultations, and outreach meetings.

CONCLUSION

Our findings suggest that practitioners, administrators, and researchers should adopt strategies such as workshops, consultations, fidelity vignettes, peer mentoring, and standardized training to effectively implement research into practice with older adults.

Training Community-Based Clinicians in Parent-Child Interaction Therapy: The Interaction Between Expert Consultation and Caseload

Professional psychologists are increasingly encouraged to utilize evidence-based treatments (EBTs), and therefore have a need to participate and provide the most efficient training methods for these treatments. Multicomponent trainings, which commonly include ongoing support, are more effective than brief methods such as 1-day workshops or reading treatment manuals. The present study examined the effectiveness of 1 form of ongoing support, consultation, as part of a multicomponent training protocol. Thirty-two community-based clinicians were trained in Parent-Child Interaction Therapy (PCIT) as part of a statewide implementation effort, and data were collected on clinician and implementation outcomes at pre-, mid-, and posttraining. Simple and multiple linear regression analyses were conducted to predict posttraining knowledge, skill, acceptability, and feasibility, as well as to examine clinician variables that might moderate these relations. Greater consultation call attendance significantly predicted higher posttraining skill; however, this association was qualified by a significant interaction with PCIT caseload. Implications for training guidelines are discussed.

Parent-Child Interaction Therapy: current perspectives

Parent-Child Interaction Therapy (PCIT) is an empirically supported intervention originally developed to treat disruptive behavior problems in children between the ages of 2 and 7 years. Since its creation over 40 years ago, PCIT has been studied internationally with various populations and has been found to be an effective intervention for numerous behavioral and emotional issues. This article summarizes progress in the PCIT literature over the past decade (2006-2017) and outlines future directions for this important work. Recent PCIT research related to treatment effectiveness, treatment components, adaptations for specific populations (age groups, cultural groups, military families, individuals diagnosed with specific disorders, trauma survivors, and the hearing-impaired), format changes (group and home-based), teacher-child interaction training (TCIT), intensive PCIT (I-PCIT), treatment as prevention (for externalizing problems, child maltreatment, and developmental delays), and implementation are discussed.

Behavioral Parent Training in Infancy: What About the Parent-Infant Relationship?

Behavioral parent training (BPT) and attachment interventions have demonstrated efficacy in improving outcomes for young children. Despite theoretical overlap in these approaches, the literature has evolved separately, particularly with respect to outcome measurement in BPT. We examined the impact of the Infant Behavior Program (IBP), a brief home-based adaptation of Parent-Child Interaction Therapy, on changes in attachment-based caregiving behaviors (sensitivity, warmth, and intrusiveness) at postintervention and 3- and 6-month follow-ups during a videotaped infant-led play. Sixty mother-infant dyads were randomly assigned to receive the IBP (n = 28) or standard care (n = 30). Infants were an average age of 13.52 months and predominately from ethnic or racial minority backgrounds (98%). We used bivariate correlations to examine the association between attachment-based caregiving behaviors and behaviorally based parenting do and don't skills and structural equation modeling to examine the direct effect of the IBP on attachment-based caregiving behaviors and the indirect effect of behaviorally based parenting skills on the relation between intervention group and attachment-based caregiving behaviors. Behaviorally based parenting do and don't skills were moderately correlated with attachment-based caregiving behaviors. Results demonstrated a direct effect of the IBP on warmth and sensitivity at postintervention and 3- and 6-month follow-ups. The direct effect of the IBP on warmth and sensitivity at the 3- and 6-month follow-ups was mediated by increases in parenting do skills at postintervention. Findings suggest that behaviorally based parenting skills targeted in BPT programs have a broader impact on important attachment-based caregiving behaviors during the critical developmental transition from infancy to toddlerhood.

Enrolling Family Participants in a Statewide Implementation Trial of an Evidence-Based Treatment

BACKGROUND

Community-based research with families is subject to unique challenges in recruiting and enrolling participants, particularly when researchers do not have face-to-face contact with participants.

OBJECTIVES

To identify strategies that overcome challenges associated with the recruitment and enrollment of family participants from community behavioral health settings into a research study.

METHODS

We used a case study design to describe lessons learned during the recruitment and enrollment phases of a large-scale study of the implementation of an evidence-based treatment (EBT) across the Commonwealth of Pennsylvania.

LESSONS LEARNED

Key lessons identified include the early involvement of stakeholders, engaging clinicians in the research process, establishing a research-community relationship, and using a flexible, ongoing recruitment approach.

CONCLUSIONS

In large-scale community-based research, engagement, recruitment, and enrollment strategies are particularly crucial. The strategies included in this paper are relevant to multiple disciplines involving community-based research.

Testing the Community-Based Learning Collaborative (CBLC) implementation model: a study protocol

Background

High rates of youth exposure to violence, either through direct victimization or witnessing, result in significant health/mental health consequences and high associated lifetime costs. Evidence-based treatments (EBTs), such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), can prevent and/or reduce these negative effects, yet these treatments are not standard practice for therapists working with children identified by child welfare or mental health systems as needing services. While research indicates that collaboration among child welfare and mental health services sectors improves availability and sustainment of EBTs for children, few implementation strategies designed specifically to promote and sustain inter-professional collaboration (IC) and inter-organizational relationships (IOR) have undergone empirical investigation. A potential candidate for evaluation is the Community-Based Learning Collaborative (CBLC) implementation model, an adaptation of the Learning Collaborative which includes strategies designed to develop and strengthen inter-professional relationships between brokers and providers of mental health services to promote IC and IOR and achieve sustained implementation of EBTs for children within a community.

Methods/design

This non-experimental, mixed methods study involves two phases: (1) analysis of existing prospective quantitative and qualitative quality improvement and project evaluation data collected pre and post, weekly, and monthly from 998 participants in one of seven CBLCs conducted as part of a statewide initiative; and (2) Phase 2 collection of new quantitative and qualitative (key informant interviews) data during the funded study period to evaluate changes in relations among IC, IOR, social networks and the penetration and sustainment of TF-CBT in targeted communities. Recruitment for Phase 2 is from the pool of 998 CBLC participants to achieve a targeted enrollment of n = 150. Study aims include: (1) Use existing quality improvement (weekly/monthly online surveys; pre-post surveys; interviews) and newly collected quantitative (monthly surveys) and qualitative (key informant interviews) data and social network analysis to test whether CBLC strategies are associated with penetration and sustainment of TF-CBT; and (2) Use existing quantitative quality improvement (weekly/monthly on-line surveys; pre/post surveys) and newly collected qualitative (key informant interviews) data and social network analysis to test whether CBLC strategies are associated with increased IOR and IC intensity.

Discussion

The proposed research leverages an on-going, statewide implementation initiative to generate evidence about implementation strategies needed to make trauma-focused EBTs more accessible to children. This study also provides feasibility data to inform an effectiveness trial that will utilize a time-series design to rigorously evaluate the CBLC model as a mechanism to improve access and sustained use of EBTs for children.