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Pickard KE, Hendrix NM, Greenfield ES, Yohannes M. Using Causative Methods to Determine System-Level Factors Driving the Uptake and Use of Evidence-Based Practices in a Public Early Intervention System. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024; 51:554-566. [PMID: 38431889 DOI: 10.1007/s10488-024-01346-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 03/05/2024]
Abstract
Part C Early Intervention (EI) systems are an entry point to services for autistic toddlers and can be leveraged to facilitate access to autism evidence-based practices (EBPs). However, EI systems are complex and limited research has examined how an EI system's infrastructure (i.e. system-level factors) impacts the adoption and implementation of EBPs. To address this gap, 36 EI providers and 9 EI administrators completed a semi-structured interview or focus group about factors impacting the implementation of autism EBPs. Qualitative analysis included a combination of grounded theory and causative coding. Analyses were refined by input from providers, administrators, and family stakeholders in the form of round tables and presentations at the state's interagency coordinating council. Primary themes centered on: (1) the costs associated with independent contracting structures; (2) operational demands; (3) workforce stability; (4) communication consistency; and (5) implementation supports for EBP implementation. Causative coding helped to demonstrate the perceived relationships between these factors and underscored the important role of incentivization structures, collaboration opportunities, and championing in supporting the use of EBPs within a system that primarily uses independent contracting structures. The current study extends previous research by demonstrating how several system-level factors are perceived to play a role in the adoption and implementation of EBPs by independently contracted EI providers. These findings underscore the need for implementation strategies, such as incentivization strategies and social network building, to increase providers' implementation of autism EBPs within EI systems.
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Affiliation(s)
- Katherine E Pickard
- Department of Pediatrics, Division of Autism and Related Disabilities, Emory University School of Medicine, Atlanta, USA.
- Marcus Autism Center, Children's Healthcare of Atlanta, Atlanta, USA.
| | - Nicole M Hendrix
- Department of Pediatrics, Division of Autism and Related Disabilities, Emory University School of Medicine, Atlanta, USA
- Marcus Autism Center, Children's Healthcare of Atlanta, Atlanta, USA
| | - Elizabeth S Greenfield
- Department of Pediatrics, Division of Autism and Related Disabilities, Emory University School of Medicine, Atlanta, USA
- Marcus Autism Center, Children's Healthcare of Atlanta, Atlanta, USA
| | - Millena Yohannes
- Department of Pediatrics, Division of Autism and Related Disabilities, Emory University School of Medicine, Atlanta, USA
- Marcus Autism Center, Children's Healthcare of Atlanta, Atlanta, USA
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Pellecchia M, Mandell DS, Tomczuk L, Marcus SC, Stewart R, Stahmer AC, Beidas RS, Rieth SR, Lawson GM. A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention. Implement Sci Commun 2024; 5:17. [PMID: 38414019 PMCID: PMC10900730 DOI: 10.1186/s43058-024-00552-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/25/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching. METHODS We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors. RESULTS The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching. CONCLUSION Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.
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Affiliation(s)
- Melanie Pellecchia
- Center for Mental Health, Psychiatry Department, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA.
| | - David S Mandell
- Center for Mental Health, Psychiatry Department, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Liza Tomczuk
- Center for Mental Health, Psychiatry Department, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Steven C Marcus
- Center for Mental Health, Psychiatry Department, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, USA
| | - Rebecca Stewart
- Center for Mental Health, Psychiatry Department, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Aubyn C Stahmer
- University of California, Davis, Mind Institute, Sacramento, USA
| | - Rinad S Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Evanston, USA
| | - Sarah R Rieth
- College of Education, San Diego State University, San Diego, USA
- Child and Adolescent Services Research Center, San Diego, USA
| | - Gwendolyn M Lawson
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
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Spinard A, Taylor CB, Ruzek JI, Jefroykin S, Friedlander T, Feleke I, Lev-Ari H, Szapiro N, Sadeh-Sharvit S. Action recommendations review in community-based therapy and depression and anxiety outcomes: a machine learning approach. BMC Psychiatry 2024; 24:133. [PMID: 38365635 PMCID: PMC10870574 DOI: 10.1186/s12888-024-05570-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/30/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND While the positive impact of homework completion on symptom alleviation is well-established, the pivotal role of therapists in reviewing these assignments has been under-investigated. This study examined therapists' practice of assigning and reviewing action recommendations in therapy sessions, and how it correlates with patients' depression and anxiety outcomes. METHODS We analyzed 2,444 therapy sessions from community-based behavioral health programs. Machine learning models and natural language processing techniques were deployed to discern action recommendations and their subsequent reviews. The extent of the review was quantified by measuring the proportion of session dialogues reviewing action recommendations, a metric we refer to as "review percentage". Using Generalized Estimating Equations modeling, we evaluated the correlation between this metric and changes in clients' depression and anxiety scores. RESULTS Our models achieved 76% precision in capturing action recommendations and 71.1% in reviewing them. Using these models, we found that therapists typically provided clients with one to eight action recommendations per session to engage in outside therapy. However, only half of the sessions included a review of previously assigned action recommendations. We identified a significant interaction between the initial depression score and the review percentage (p = 0.045). When adjusting for this relationship, the review percentage was positively and significantly associated with a reduction in depression score (p = 0.032). This suggests that more frequent review of action recommendations in therapy relates to greater improvement in depression symptoms. Further analyses highlighted this association for mild depression (p = 0.024), but not for anxiety or moderate to severe depression. CONCLUSIONS An observed positive association exists between therapists' review of previous sessions' action recommendations and improved treatment outcomes among clients with mild depression, highlighting the possible advantages of consistently revisiting therapeutic homework in real-world therapy settings. Results underscore the importance of developing effective strategies to help therapists maintain continuity between therapy sessions, potentially enhancing the impact of therapy.
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Affiliation(s)
- Amit Spinard
- Eleos Health, 117 Kendrick Street, Suite 300, Needham, MA, 02494, USA.
| | - C Barr Taylor
- Center for m2Health, Palo Alto University, Palo Alto, CA, USA
- Department of Psychiatry, Stanford Medical Center, Stanford, CA, USA
| | - Josef I Ruzek
- Center for m2Health, Palo Alto University, Palo Alto, CA, USA
- Department of Psychiatry, Stanford Medical Center, Stanford, CA, USA
| | - Samuel Jefroykin
- Eleos Health, 117 Kendrick Street, Suite 300, Needham, MA, 02494, USA
| | - Tamar Friedlander
- Eleos Health, 117 Kendrick Street, Suite 300, Needham, MA, 02494, USA
| | - Israela Feleke
- Eleos Health, 117 Kendrick Street, Suite 300, Needham, MA, 02494, USA
| | - Hila Lev-Ari
- Eleos Health, 117 Kendrick Street, Suite 300, Needham, MA, 02494, USA
| | - Natalia Szapiro
- Eleos Health, 117 Kendrick Street, Suite 300, Needham, MA, 02494, USA
| | - Shiri Sadeh-Sharvit
- Eleos Health, 117 Kendrick Street, Suite 300, Needham, MA, 02494, USA
- Center for m2Health, Palo Alto University, Palo Alto, CA, USA
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Becker-Haimes EM, Brady M, Jamison J, Jager-Hyman S, Reilly ME, Patel E, Brown GK, Mandell DS, Oquendo MA. An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER). Implement Sci Commun 2023; 4:148. [PMID: 38001478 PMCID: PMC10675939 DOI: 10.1186/s43058-023-00530-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation. METHODS We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews). DISCUSSION Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes. TRIAL REGISTRATION Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.
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Affiliation(s)
- Emily M Becker-Haimes
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA.
- Hall Mercer Community Mental Health, University of Pennsylvania Health System, Philadelphia, USA.
| | - Megan Brady
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Jesslyn Jamison
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Shari Jager-Hyman
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Megan E Reilly
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Esha Patel
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Gregory K Brown
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - David S Mandell
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
| | - Maria A Oquendo
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 3 Rd floor, Philadelphia, PA, 19104, USA
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Ahuna JK, Becker KD, Chorpita BF. Predicting Therapists' Intentions to Use Innovations: Comparing the Role of Individual, Organizational, and Innovation Characteristics. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:946-965. [PMID: 37715814 DOI: 10.1007/s10488-023-01295-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/18/2023]
Abstract
Theories emphasize the role of individual and organizational characteristics in implementation outcomes, yet research indicates that these characteristics account for only a small amount of variance in those outcomes. Innovation characteristics might be important proximal determinants of implementation outcomes but are infrequently examined in mental health services research. This study examined the relative variance explained by individual, organizational, and innovation characteristics on behavioral intentions, a central implementation outcome in implementation theories. Data were collected from 95 therapists and 28 supervisors who participated in a cluster randomized trial that tested the effectiveness of two clinical decision-making innovations. Multilevel models compared individual, organizational, and innovation characteristics as predictors of therapists' intentions to use the innovations. Subsequent mediational path analyses tested whether innovation characteristics mediated the effect of innovation type on intentions. Individual and organizational characteristics explained 29% of the variability in therapists' intentions. Approximately 75% of the variability in therapists' intentions was accounted for by innovation characteristics. Individual and organizational characteristics were not statistically significant predictors of intentions after controlling for innovation characteristics. The indirect effect of innovation type on intentions through therapists' beliefs was statistically significant (B = 0.410, 95% Bootstrapped CI = [0.071, 0.780]), but the direct effect of innovation type was not (B = 0.174, p = .365). Innovation characteristics are related to therapist intentions and might explain why some innovations are received more favorably than others. Future studies should explore the complex interrelationships between these beliefs alongside other individual or organizational characteristics.
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Affiliation(s)
- Jonathan K Ahuna
- Department of Psychology, University of South Carolina, 1512 Pendleton Street, Barnwell College, Suite #220, Columbia, SC, 29208, USA
| | - Kimberly D Becker
- Department of Psychology, University of South Carolina, 1512 Pendleton Street, Barnwell College, Suite #220, Columbia, SC, 29208, USA
| | - Bruce F Chorpita
- Department of Psychology, University of California, Los Angeles, Box 951563, Los Angeles, CA, 90095, USA.
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Fishman J, Yang C, Mandell DS. A review of attitude research that is specific, accurate, and comprehensive within its stated scope: responses to Aarons. Implement Sci 2022; 17:29. [PMID: 35534829 PMCID: PMC9088109 DOI: 10.1186/s13012-022-01200-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Jessica Fishman
- Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA. .,Message Effects Lab at Annenberg School, University of Pennsylvania, 3620 Walnut Street, Philadelphia, PA, 19104, USA.
| | - Catherine Yang
- Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - David S Mandell
- Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA
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