An audience research study to disseminate evidence about comprehensive state mental health parity legislation to US State policymakers: protocol

Designing for dissemination among public health and clinical practitioners in the USA

Introduction

The slow adoption of evidence-based interventions reflects gaps in effective dissemination of research evidence. Existing studies examining designing for dissemination (D4D), a process that ensures interventions and implementation strategies consider adopters' contexts, have focused primarily on researchers, with limited perspectives of practitioners. To address these gaps, this study examined D4D practice among public health and clinical practitioners in the USA.

Methods

We conducted a cross-sectional study among public health and primary care practitioners in April to June 2022 (analyzed in July 2022 to December 2022). Both groups were recruited through national-level rosters. The survey was informed by previous D4D studies and pretested using cognitive interviewing.

Results

Among 577 respondents, 45% were public health and 55% primary care practitioners, with an overall survey response rate of 5.5%. The most commonly ranked sources of research evidence were email announcements for public health practitioners (43.7%) and reading academic journals for clinical practitioners (37.9%). Practitioners used research findings to promote health equity (67%) and evaluate programs/services (66%). A higher proportion of clinical compared to public health practitioners strongly agreed/agreed that within their work setting they had adequate financial resources (36% vs. 23%, p < 0.001) and adequate staffing (36% vs. 24%, p = 0.001) to implement research findings. Only 20% of all practitioners reported having a designated individual or team responsible for finding and disseminating research evidence.

Conclusions

Addressing both individual and modifiable barriers, including organizational capacity to access and use research evidence, may better align the efforts of researchers with priorities and resources of practitioners.

Four very basic ways to think about policy in implementation science

BACKGROUND

Policy is receiving increasing attention in the field of implementation science. However, there remains a lack of clear, concise guidance about how policy can be conceptualized in implementation science research. Building on Curran's article "Implementation science made too simple"-which defines "the thing" as the intervention, practice, or innovation in need of implementation support-we offer a typology of four very basic ways to conceptualize policy in implementation science research. We provide examples of studies that have conceptualized policy in these different ways and connect aspects of the typology to established frameworks in the field. The typology simplifies and refines related typologies in the field. Four very basic ways to think about policy in implementation science research. 1) Policy as something to adopt: an evidence-supported policy proposal is conceptualized as "the thing" and the goal of research is to understand how policymaking processes can be modified to increase adoption, and thus reach, of the evidence-supported policy. Policy-focused dissemination research is well-suited to achieve this goal. 2) Policy as something to implement: a policy, evidence-supported or not, is conceptualized as "the thing" and the goal of research is to generate knowledge about how policy rollout (or policy de-implementation) can be optimized to maximize benefits for population health and health equity. Policy-focused implementation research is well-suited to achieve this goal. 3) Policy as context to understand: an evidence-supported intervention is "the thing" and policies are conceptualized as a fixed determinant of implementation outcomes. The goal of research is to understand the mechanisms through which policies affect implementation of the evidence-supported intervention. 4) Policy as strategy to use: an evidence-supported intervention is "the thing" and policy is conceptualized as a strategy to affect implementation outcomes. The goal of research is to understand, and ideally test, how policy strategies affect implementation outcomes related to the evidence-supported intervention.

CONCLUSION

Policy can be conceptualized in multiple, non-mutually exclusive ways in implementation science. Clear conceptualizations of these distinctions are important to advancing the field of policy-focused implementation science and promoting the integration of policy into the field more broadly.

A policy implementation study of earmarked taxes for mental health services: study protocol

BACKGROUND

Insufficient funding is frequently identified as a critical barrier to the implementation and sustainment of evidence-based practices (EBPs). Thus, increasing access to funding is recognized as an implementation strategy. Policies that create earmarked taxes-defined as taxes for which revenue can only be spent on specific activities-are an increasingly common mental health financing strategy that could improve the reach of EBPs. This project's specific aims are to (1) identify all jurisdictions in the USA that have implemented earmarked taxes for mental health and catalogue information about tax design; (2) characterize experiences implementing earmarked taxes among local (e.g., county, city) mental health agency leaders and other government and community organization officials and assess their perceptions of the acceptability and feasibility of different types of policy implementation strategies; and (3) develop a framework to guide effect earmarked tax designs, inform the selection of implementation strategies, and disseminate the framework to policy audiences.

METHODS

The project uses the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to inform data collection about the determinants and processes of tax implementation and Leeman's typology of implementation strategies to examine the acceptability and feasibility strategies which could support earmarked tax policy implementation. A legal mapping will be conducted to achieve aim 1. To achieve aim 2, a survey will be conducted of 300 local mental health agency leaders and other government and community organization officials involved with the implementation of earmarked taxes for mental health. The survey will be followed by approximately 50 interviews with these officials. To achieve aim 3, quantitative and qualitative data will be integrated through a systematic framework development and dissemination process.

DISCUSSION

This exploratory policy implementation process study will build the evidence base for outer-context implementation determinants and strategies by focusing on policies that earmarked taxes for mental health services.

An Examination of Factors Affecting State Legislators' Support for Parity Laws for Different Mental Illnesses

Mental health parity legislation can improve mental health outcomes. U.S. state legislators determine whether state parity laws are adopted, making it critical to assess factors affecting policy support. This study examines the prevalence and demographic correlates of legislators' support for state parity laws for four mental illnesses- major depression disorder, post-traumatic stress disorder (PTSD), schizophrenia, and anorexia/bulimia. Using a 2017 cross-sectional survey of 475 U.S. legislators, we conducted bivariate analyses and multivariate logistic regression. Support for parity was highest for schizophrenia (57%), PTSD (55%), and major depression (53%) and lowest for anorexia/bulimia (40%). Support for parity was generally higher among females, more liberal legislators, legislators in the Northeast region of the country, and those who had previously sought treatment for mental illness. These findings highlight the importance of better disseminating evidence about anorexia/bulimia and can inform dissemination efforts about mental health parity laws to state legislators.

Quantifying implementation strategy and dissemination channel preferences and experiences for pain management in primary care: a novel implementer-reported outcome

BACKGROUND

Precision implementation science requires methods to evaluate and select implementation strategies. This study developed and evaluated a novel measure of concordance between current and preferred dissemination channels (DC) and implementation strategies (IS) to guide efforts to improve the adoption of evidence-based management strategies for chronic pain.

METHODS

We conducted a one-time electronic survey of Pennsylvania primary care practitioners (PCPs) about current vs. preferred chronic pain management DC and IS use. Survey items were selected based on preliminary data, the Model for Dissemination of Research, and the Evidence-Based Recommendations for Implementing Change taxonomy of implementation strategies. We used Cohen's kappa (κ) to assess the agreement between participant-level current and preferred DC/IS. We calculated % preferred minus % experienced for each DC/IS and assessed the equality of proportions to determine whether this difference significantly departed from zero. We categorized DC and IS based on the degree of use and preference, to evaluate alignment.

RESULTS

The current sample included 101 Pennsylvania PCPs primarily in urban (94.06%), non-academic (90.10%) settings who self-identified as mostly female (66.34%) and white (85.15%). The greatest difference between preferred and experienced DCs, or "need," was identified by participants as workshops, clinical experts, seminars, and researchers. Similarly, participants reported the greatest IS gaps as multidisciplinary chronic pain workgroups, targeted support for clinicians, and a chronic pain clinical champion. Participating PCPs had moderate DC concordance (kappa = 0.45, 95% CI = 0.38-0.52) and low IS concordance (kappa = 0.18, 95% CI = 0.13-0.23). DC and IS concordance were both greater than that expected by chance. We further identified well-aligned DC and IS, including professional organizations, briefs, and guidelines.

CONCLUSION

We identified a novel implementer-reported outcome of dissemination channel and implementation strategy concordance that allows implementation scientists to quantify the magnitude of the gap between the current and preferred experience of implementers. This quantitative measure can help with the selection and evaluation of dissemination channels and implementation strategies. Future research should leverage this measure to understand the degree to which preference concordance influences clinical outcomes and performance.

Support for COVID-19-Related Substance Use Services Policy Changes: a New York State-Wide Survey

This study aims to describe which substance use service (SUS) organizations and who within these organizations support the maintenance of policies targeted at improving substance use treatment services. An online survey assessing respondent, organizational and program demographics, and knowledge and support regarding policy changes was distributed to all certified SUS and harm reduction programs in NYS. Bivariate and latent class analyses were used to identify patterns and associations to policy choices. Across the 227 respondents, there was a support for maintaining expansion of insurance coverage, virtual behavioral health/counseling and medication initiation/maintenance visits, reductions in prior authorizations, and access to prevention/harm reduction services. Three classes of support for policies were derived: (1) high-supporters (n = 49; 21%), (2) low-supporters (n = 66; 29%), and (3) selective-supporters. Having knowledge of policy changes was associated with membership in the high-supporters class. Implications regarding the role of knowledge in behavioral health policies dissemination structures, decision-making, and long-term expansion of SUS are discussed.

Advancing health equity through a theoretically critical implementation science

While implementation science is driven by theory, most implementation science theories, models, and frameworks (TMF) do not address issues of power, inequality, and reflexivity that are pivotal to achieving health equity. Theories used in anthropology address these issues effectively and could complement prevailing implementation science theories and constructs. We propose three broad areas of theory that complement and extend existing TMF in implementation science to advance health equity. First, theories of postcoloniality and reflexivity foreground attention to the role of power in knowledge production and to the ways that researchers and interventionists may perpetuate the inequalities shaping health. Second, theories of structural violence and intersectionality can help us to better understand the unequal burden of health disparities in the population, thereby encouraging researchers to think beyond single interventions to initiate partnerships that can impact overlapping health vulnerabilities and influence the upstream causes of vulnerability. Finally, theories of policy and governance encourage us to examine the social-political forces of the "outer context" crucial for implementation and sustainability. The incorporation of critical theories could enhance implementation science and foster necessary reflexivity among implementation scientists. We contend that a theoretically critical implementation science will promote better science and, more importantly, support progress toward health equity.

Iran's Comprehensive Mental and Social Health Services (SERAJ Program): A Pilot Protocol

Objective: The Iranian Mental Health Survey (IranMHS) indicated that almost 1 in 4 people had one or more psychiatric disorders (23.6%); however, two-thirds of patients did not benefit from health interventions, many provided services were inadequate and imposed a high burden on Iranian families. Therefore, the development of a national program on providing comprehensive social and mental health services, entitled “SERAJ”, became necessary. The present study aims to develop and outline the protocol for the pilot implementation of SERAJ.

Method: This study is an action research with the collaborative mode. To compile the protocol, a broad review of the literature, interviews with experts and stakeholders, and focused group discussions were conducted.

Results: The pilot implementation should be divided into 4 phases: (1) preparing documentation and work team, (2) preparing the prerequisites for providing pilot services, (3) providing pilot services, and (4) implementation and evaluation.

Conclusion: SERAJ considered both preventive and treatment measures for mental and social health disorders and their risk factors. Moreover, the entire population can have access to primary and secondary services. Therefore, SERAJ is more comprehensive than the current situation in the country's mental health services. We suggest piloting and evaluating SERAJ in three districts of Iran.

Strategies for effective dissemination of research to United States policymakers: a systematic review

BACKGROUND

Research has the potential to influence US social policy; however, existing research in this area lacks a coherent message. The Model for Dissemination of Research provides a framework through which to synthesize lessons learned from research to date on the process of translating research to US policymakers.

METHODS

The peer-reviewed and grey literature was systematically reviewed to understand common strategies for disseminating social policy research to policymakers in the United States. We searched Academic Search Premier, PolicyFile, SocINDEX, Social Work Abstracts, and Web of Science from January 1980 through December 2019. Articles were independently reviewed and thematically analyzed by two investigators and organized using the Model for Dissemination of Research.

RESULTS

The search resulted in 5225 titles and abstracts for inclusion consideration. 303 full-text articles were reviewed with 27 meeting inclusion criteria. Common sources of research dissemination included government, academic researchers, the peer reviewed literature, and independent organizations. The most frequently disseminated research topics were health-related, and legislators and executive branch administrators were the most common target audience. Print materials and personal communication were the most common channels for disseminating research to policymakers. There was variation in dissemination channels by level of government (e.g., a more formal legislative process at the federal level compared with other levesl). Findings from this work suggest that dissemination is most effective when it starts early, galvanizes support, uses champions and brokers, considers contextual factors, is timely, relevant, and accessible, and knows the players and process.

CONCLUSIONS

Effective dissemination of research to US policymakers exists; yet, rigorous quantitative evaluation is rare. A number of cross-cutting strategies appear to enhance the translation of research evidence into policy.

REGISTRATION

Not registered.

What Is Dissemination and Implementation Science?: An Introduction and Opportunities to Advance Behavioral Medicine and Public Health Globally

There has been a well-documented gap between research (e.g., evidence-based programs, interventions, practices, policies, guidelines) and practice (e.g., what is routinely delivered in real-world community and clinical settings). Dissemination and implementation (D&I) science has emerged to address this research-to-practice gap and accelerate the speed with which translation and real-world uptake and impact occur. In recent years, there has been tremendous development in the field and a growing global interest, but much of the introductory literature has been U.S.-centric. This piece provides an introduction to D&I science and summarizes key concepts and progress of the field for a global audience, provides two case studies that highlight examples of D&I research globally, and identifies opportunities and innovations for advancing the field of D&I research globally.

Factors associated with state legislators' support for opioid use disorder parity laws

BACKGROUND

In the United States, state behavioral health parity laws play a crucial role in ensuring equitable insurance coverage and access to substance use disorder treatment and services for people that need them. State legislators have the exclusive authority to adopt these laws. The purpose of this study was to identify legislator beliefs independently associated with "strong support" for opioid use disorder (OUD) parity.

METHODS

Data were from a 2017 cross-sectional, state-stratified, multi-modal survey of state legislators (N = 475). The dependent variable was "strong support" for OUD parity. Primary independent variables were beliefs about state parity laws. Bivariate analyses and mixed effects logistic regression were conducted.

RESULTS

Legislators who "strongly supported" OUD parity were significantly more likely than legislators who did not "strongly support" OUD parity to be female (64.1% vs. 46.5%, p<.001) , Democrat (76.2% vs. 29.3%, p<.001), and have liberal, compared to conservative, ideology (85.6% vs. 27.1%, p<.001). After adjusting for legislator demographics and state-level covariates, beliefs such as agreeing that state parity laws do not increase health insurance premium costs (aOR=6.77, p<.01) and that substance use disorder treatments can be effective (aOR=5.00, p<.001) remained associated with "strong support" for OUD parity. These state legislators' beliefs were more strongly associated with "strong support" for OUD parity than political party, ideology, and other demographic and state-level characteristics.

CONCLUSIONS

Dissemination materials and communication strategies to cultivate support for OUD parity laws among state legislators should focus on the fiscal impacts of parity laws and the effectiveness of substance use disorder treatments.

State mental health agency officials' preferences for and sources of behavioral health research

State mental health agencies (SMHAs) are integral to public behavioral health service systems. As such, senior-level officials within SMHAs are important targets for advocacy and dissemination of behavioral health research findings. Evidence-informed decision making in SMHAs can potentially be enhanced by developing summaries of behavioral health research (e.g., policy briefs) that reflect SMHA officials' information preferences, but knowledge about these preferences is lacking. An exploratory study was conducted with the aims of characterizing senior-level SMHA officials' preferences for behavioral health research and describing where they turn for this research when making policy decisions. A cross-sectional, web-based survey of senior-level SMHA officials (1 per state) was conducted in March-May 2017 (n = 43, response rate = 84%). The features of behavioral health research that SMHA officials identified as "very important" most frequently were research being relevant to state residents (93.0%), providing data on cost-effectiveness (86.0%) and budget impact (81.4%), and being presented concisely (81.0%). The primary sources that SMHA officials turned to for behavioral research when making policy decisions were professional organizations (79.1%), SMHA agency staff (60.5%), and university researchers (55.8%). Compared with state legislators' responses to the same survey questions, results suggest that senior-level SMHA officials and legislators have similar preferences for behavioral health research but turn to different sources for this research. Advocates and researchers who seek to promote evidence-informed decision making in SMHAs should consider developing policy briefs that are concise, provide state-level prevalence data about behavioral conditions, and contain economic evaluation data, and they should disseminate these materials to multiple sources. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

State Legislators' Support for Behavioral Health Parity Laws: The Influence of Mutable and Fixed Factors at Multiple Levels

Policy Points When communicating with state legislators, advocates for state behavioral health parity laws should emphasize that the laws do not increase insurance premiums. Legislators' opinions about the impacts of state behavioral health parity laws and the effectiveness of behavioral health treatment have more influence on support for the laws than do their political party affiliation or state-level contextual factors. Reducing legislators' stigma toward people with mental illness could increase their support for state behavioral health parity laws CONTEXT: Comprehensive state behavioral health parity legislation (C-SBHPL) is an evidence-based policy that improves access and adherence to behavioral health treatments. However, adoption of C-SBHPL by state legislators is low. Little is known about how C-SBHPL evidence might be most effectively disseminated to legislators or how legislators' fixed characteristics (eg, ideology), mutable characteristics (eg, beliefs about the policy's impact), and state-level contextual factors might influence their support for behavioral health policies. The purpose of our study is (1) to describe the associations between legislators' fixed and mutable characteristics, state-level contextual factors, and support for C-SBHPL; and (2) to identify the mutable characteristics of legislators independently associated with C-SBHPL support.

METHODS

We conducted a multimodal (post mail, email, telephone) survey of US state legislators in 2017 (N = 475). The dependent variable was strong support for C-SBHPL, and the independent variables included legislators' fixed and mutable characteristics and state-level contextual factors. We conducted multivariable, multilevel (legislator, state) logistic regression.

FINDINGS

Thirty-nine percent of the legislators strongly supported C-SBHPL. After adjustment, the strongest predictors of C-SBHPL support were beliefs that C-SBHPL increases access to behavioral health treatments (aOR = 5.85; 95% CI = 2.41, 14.20) and does not increase insurance premiums (aOR = 2.70; 95% CI = 1.24, 5.90). Stigma toward people with mental illness was inversely associated with support (aOR = 0.86; 95% CI = 0.78, 0.95). After adjustment, ideology was the only fixed characteristic significantly associated with support for C-SBHPL. State-level contextual factors did not moderate associations between mutable characteristics and support for C-SBHPL.

CONCLUSIONS

Legislators' mutable characteristics are stronger predictors of C-SBHPL support than are most of their fixed characteristics and all state-level contextual factors, and thus should be targeted by dissemination efforts.

State Legislators' Opinions About Adverse Childhood Experiences as Risk Factors for Adult Behavioral Health Conditions

OBJECTIVES

Adverse childhood experiences (ACEs) increase risk of adult behavioral health conditions. State legislators are an important audience to target with evidence about ACEs because they make policy decisions that can prevent ACE exposure and enhance resilience. This study sought to describe state legislators' opinions about ACEs as risk factors for adult behavioral health conditions and identify how opinions vary between legislators with different characteristics.

METHODS

A multimodal survey was conducted in 2017 (response rate, 16.4%; N=475). Dependent variables were the extent to which legislators thought that four ACEs-sexual abuse, physical abuse, witnessing domestic violence, and childhood neglect-increase risk of adult behavioral health conditions. Independent variables were legislator characteristics (e.g., ideology and gender). Rao-Scott chi-square tests and multivariable logistic regression were conducted.

RESULTS

Childhood sexual abuse was identified as a major risk factor by the largest proportion of respondents (77%), followed by childhood physical abuse (59%), witnessing domestic violence (39%), and childhood neglect (38%). The proportion identifying each ACE as a major risk factor was significantly higher among Democrats than among Republicans, liberals than among conservatives, and women than among men. For example, 56% of liberals identified witnessing domestic violence as a major risk factor, compared with 29% of conservatives (p<.001).

CONCLUSIONS

Opinions about ACEs as risk factors for adult behavioral health conditions varied between legislators with different characteristics, especially liberals and conservatives. To enhance the policy impact of evidence about ACEs, advocates might consider developing multiple versions of ACE evidence summaries that are tailored on the basis of these characteristics.

Legislators' Sources of Behavioral Health Research and Preferences for Dissemination: Variations by Political Party

OBJECTIVES

This study sought to characterize primary sources of behavioral health research and dissemination preferences of state legislators and assess differences by political party.

METHODS

A 2017 cross-sectional survey of state legislators (N=475) assessed where legislators seek, and the most important features of, behavioral health research. Bivariate analyses and multivariate logistic regression were conducted.

RESULTS

Advocacy organizations (53%), legislative staff (51%), and state agencies (48%) were identified most frequently as sources of behavioral health research. Universities were identified by significantly more Democrats than Republicans (34% versus 19%; adjusted odds ratio=1.79). Data about budget impact and cost-effectiveness were most frequently rated as very important, but by significantly fewer Democrats than Republicans (77% versus 87% and 76% versus 89%, respectively).

CONCLUSIONS

To reach legislators and satisfy their information preferences, behavioral health researchers should target diverse audiences, partner with intermediary organizations, and craft messages that include economic evaluation data.

Audience segmentation to disseminate behavioral health evidence to legislators: an empirical clustering analysis

Background

Elected officials (e.g., legislators) are an important but understudied population in dissemination research. Audience segmentation is essential in developing dissemination strategies that are tailored for legislators with different characteristics, but sophisticated audience segmentation analyses have not been conducted with this population. An empirical clustering audience segmentation study was conducted to (1) identify behavioral health (i.e., mental health and substance abuse) audience segments among US state legislators, (2) identify legislator characteristics that are predictive of segment membership, and (3) determine whether segment membership is predictive of support for state behavioral health parity laws.

Methods

Latent class analysis (LCA) was used. Data were from a multi-modal (post-mail, e-mail, telephone) survey of state legislators fielded in 2017 (N = 475). Nine variables were included in the LCA (e.g., perceptions of behavioral health treatment effectiveness, mental illness stigma). Binary logistic regression tested associations between legislator characteristics (e.g., political party, gender, ideology) and segment membership. Multi-level logistic regression assessed the predictive validity of segment membership on support for parity laws. A name was developed for each segment that captured its most salient features.

Results

Three audience segments were identified. Budget-oriented skeptics with stigma (47% of legislators) had the least faith in behavioral health treatment effectiveness, had the most mental illness stigma, and were most influenced by budget impact. This segment was predominantly male, Republican, and ideologically conservative. Action-oriented supporters (24%) were most likely to have introduced a behavioral health bill, most likely to identify behavioral health issues as policy priorities, and most influenced by research evidence. This was the most politically and ideologically diverse segment. Passive supporters (29%) had the greatest faith in treatment effectiveness and the least stigma, but were also least likely to have introduced a behavioral health bill. Segment membership was a stronger predictor of support for parity laws than almost all other legislator characteristics.

Conclusions

State legislators are a heterogeneous audience when it comes to behavioral health. There is a need to develop and test behavioral health evidence dissemination strategies that are tailored for legislators in different audience segments. Empirical clustering approaches to audience segmentation are a potentially valuable tool for dissemination science.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0816-8) contains supplementary material, which is available to authorized users.