The Use of Implementation Science Tools to Design, Implement, and Monitor a Community-Based mHealth Intervention for Child Health in the Amazon

Implementation of the psycho-existential symptom assessment scale in palliative care: Qualitative analysis of stakeholders perspectives

OBJECTIVES

To explore 1) perspectives of feasibility, acceptability, integration and sustainability of the Psycho-existential Symptom Assessment Scale (PeSAS); 2) barriers and benefits of PeSAS in its real-world performance; and 3) clinician confidence and perceived competency in using PeSAS.

METHODS

Thirty-one key stakeholders from nine palliative care services who participated in the implementation of the PeSAS were purposefully sampled and participated in semi-structured interviews. Data was managed using the Determinants Framework.

RESULTS

Benefits of PeSAS were a common language enhancing communication, identifying symptoms of psycho-existential distress, initiating referral, providing acknowledgement for previously unrecognised distress and enhancing patient agency. Key barriers were the availability of skilled clinicians, patient characteristics such as delirium and phase of illness, avoidance of confronting end-of-life conversations, information technology resourcing, and reduced engagement due to language, culture and health literacy.

CONCLUSION

Screening using the PeSAS is feasible and acceptable once clinicians are adequately trained to administer it. Our study highlights the benefits of qualitative enquiry in developing and implementing new interventions.

PRACTICE IMPLICATIONS

The identification and management of psycho-existential symptoms should be part of routine practice in palliative care. However, adequate staff training, resourcing, referral pathways and implementation process and outcome assessments are important to ensure sustainability.

Feasible Peer-Mediated Intervention for Autistic Children Using Minimal Speech: A Qualitative Intervention Development Process

PURPOSE

Qualitative engagement with stakeholders in the development of interventions can provide insight into strategies to maximize feasibility in real-life settings. We engaged stakeholders (autistic adults, early childhood educators, early childhood sector leaders and policy influencers, parents of autistic children, and speech-language pathologists) to inform the development of an educator-led peer-mediated intervention (PMI) for autistic preschoolers who use minimal speech that is feasible to implement in inclusive early childhood education and care (ECEC) settings.

METHOD

A qualitative iterative intervention design process was utilized. Stakeholders (N = 15) attended an online workshop and completed a document review exploring the acceptability and feasibility of the proposed embedded PMI. A two-step analysis procedure using the Theoretical Domains Framework and template analysis was conducted to identify the barriers, enablers, and supports to the implementation of embedded PMI in early childhood settings.

RESULTS

While embedded PMI was unanimously acceptable to stakeholders, several participants expressed concerns regarding feasibility. Barriers to the successful integration and implementation of PMI in inclusive preschool contexts included access to skills, knowledge, and resources. Participants identified strategies to overcome modifiable barriers and to enhance the existing enablers. These strategies are reflected in the following themes: build on the familiar, build capacity in augmentative and alternative communication, adopt a whole center approach, adapt to meet the needs of the ECEC setting, and engage in proactive implementation.

CONCLUSION

To address barriers to the implementation of embedded PMI, action is needed at various levels: macro (national/policy), meso (organization/setting), and micro (individual).

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25155770.

Validation of an instrument to guide the implementation of strategies for mental health care in Colombia

Objectives

To validate the implementation drivers scale among first-level mental health care professionals in Colombia. The scale is designed as a tool to guide the implementation of strategies that effectively reduce gaps in mental health care.

Methods

The Active Implementation Framework was adopted, which is a widely used model for measuring implementation. The participants included 380 individuals (55.56% men) - 349 health personnel trained in the Mental Health Gap Action Programme (mhGAP) and 31 territorial personnel in charge of planning mental health strategies at the territorial level in Colombia. To assess the critical dimensions of mhGAP implementation, we developed a scale of 18 items based on the active implementation framework. We conducted content validity assessments and exploratory factor analysis to evaluate the scale. We used the Organizational Readiness for Knowledge Translation scale as a comparative standard.

Results

The implementation drivers scale identified four dimensions: system enablers for implementation, accessibility of the strategy, adaptability and acceptability, and strategy training and supervision. These dimensions had Cronbach alpha values of 0.914, 0.868, 0.927, and 0.725, respectively, indicating high internal consistency. In addition, all dimensions demonstrated adequate correlation with the Organizational Readiness for Knowledge Translation scale.

Conclusion

The implementation drivers scale effectively determines the adaptability and implementation of various components of mental health programs, particularly those focusing on community-based approaches and primary care settings. As such, this scale can contribute to the more effective implementation of strategies outlined by global and local political frameworks, thus improving mental health care.

Leveraging monitoring, evaluation, and learning to scale the Enabling Inclusion® program for children with disabilities in India and globally

Introduction

Children with disabilities in low- and middle-income countries face many challenges and lack adequate services, including access to rehabilitation professionals. To address this lack of access, Amar Seva Sangam Ayikudy (ASSA), a non-governmental organization (NGO) in India, designed a technology-leveraged rehabilitation program called Enabling Inclusion® (EI®), and implemented it in one state (Tamil Nadu, India) before scaling it. The model is supported by the EI® app, which enables organizations to screen, assess and monitor progress of children with disabilities via rehabilitation specialists and community rehabilitation workers, and to provide family-centered, goal-based interventions. An extensive monitoring, evaluation, and learning (MEL) framework is embedded into the program. This paper explores how this MEL system supported the scaling of the EI® model, reaching additional beneficiaries nationally and globally.

Methods

This paper describes ASSA's MEL framework and demonstrates its use for decision-making in the process of scaling. It also explores how collaborations with various government departments, NGOs, and private partners contributed to the scaling of the EI® model and technology.

Results

Scaling of the EI® program was achieved by (1) expansion of the program in rural Tamil Nadu (vertical scale-up) in partnership with the Tamil Nadu government and private partners, and (2) by licensing the EI® app and model to other NGOs in various states in India and globally (horizontal scale-up). Systematic examination of key program and performance indicators, as well as stakeholder feedback, informed decisions to modify the EI® app over time. This included further customizing to the needs of children and service providers, covering a greater range of age groups and contexts, and modifying service delivery models. Child functional independence, participation, and inclusion was further strengthened by mobilizing parent empowerment groups, community awareness programs, school advocacy, and entitlements from the government. Flexibility in the implementation model of the EI® app allowed for adaptation to local contexts and organizations, and facilitated its scale-up.

Conclusion

A dynamic, inclusive, and locally grounded MEL system, a flexible and collaborative approach, and an adaptive implementation model increased the accessibility of an early intervention and childhood rehabilitation program for children with disabilities and their families throughout the state of Tamil Nadu, across India, and internationally.

The Creation of a Field Manual for Community Health Workers to Teach Child Health and Development During Home Visits: A Case Study of Participatory Content Creation

Community health workers (CHWs) play a crucial role in improving child health and development in underserved populations. However, CHWs often face challenges in accessing appropriate guidance and materials for their home visits, hindering their ability to deliver accurate and relevant information to families. Extensive searches for existing resources were conducted to search for established field manual guidebooks for CHWs, however, no suitable material was found, highlighting the need for this case study. The exercise aimed to develop a comprehensive field manual guidebook and animated videos to support CHWs in the Amazon of Peru during their home visits. A multidisciplinary team of specialists was assembled to develop the material. The material development process employed a design thinking methodology, incorporating participatory content creation workshops with CHWs and experts in health topics relevant to the Amazon. This approach ensured cultural relevance and sensitivity in conveying information. The team created a list of 38 essential health and early childhood development messages for Amazonian communities. Infographics were designed for each topic, accompanied by easy-to-understand language and images to assist CHWs in conveying information effectively. To provide additional support, seven animated videos were created based on health behavior theory, covering topics such as anemia, healthy diet, diarrhea, breastfeeding, clean water, child-caregiver bond, and early childhood stimulation. The videos were designed for CHWs to share with caregivers during home visits, enhancing information transmission. The resulting guidebook, infographics, and animated videos were presented to CHWs in Loreto, Peru for feedback. Updated versions were printed and distributed to CHWs in seven communities in Loreto.

Measurement for Change: Reflections from innovators' experiences with monitoring, evaluation, and learning systems for Early Childhood Development

In this review paper, we explore how on-the-ground Early Childhood Development (ECD) innovators are using monitoring, evaluation, and learning (MEL) systems to guide the design and implementation of ECD programs, as well as how MEL systems can influence policy and support the achievement of impact at scale. We reflect on articles in the Frontiers series “Effective delivery of integrated interventions in early childhood: innovations in evidence use, monitoring, evaluation, and learning.” The 31 contributions to the series reflect the breadth and depth of complexity that characterizes ECD, including global geographic spread, with studies from Asia, Europe, Africa, and Latin America and the Caribbean. Our synthesis finds that integrating MEL processes and systems into the fabric of a program or policy initiative can broaden the underlying value proposition. Specifically, ECD organizations sought to design their MEL systems to ensure programs fit the values, goals, experiences and conceptual frameworks of diverse stakeholders, so that participating makes sense to all. For example, formative, exploratory research identified the priorities and needs of the target population and frontline service providers, and informed the content and delivery of an intervention. ECD organizations also designed their MEL systems to support a shift of accountability toward broader ownership: They included delivery agents and program participants alike as subjects rather than objects, through active participation in data collection, and by providing opportunities for equitable discussion of results and decision-making. Programs collected data to respond to specialized characteristics, priorities and needs, embedding program activities into existing day-to-day routines. Further, papers pointed to the importance of intentionally involving a variety of stakeholders in national and international dialogues to ensure that diverse ECD data collection efforts are aligned and multiple perspectives are considered in the development of national ECD policies. And, several papers illustrate the value of creative methods and measurement tools to integrate MEL into a program or policy initiative. Finally, our synthesis concludes that these findings align with the five aspirations that were formulated as part of the Measurement for Change dialogue, which motivated the launch of the series.

A Health Equity Implementation Approach to Child Health Literacy Interventions

Health and behavioural inequalities exist in all populations, including children. As a social determinant of health, health literacy is a crucial driver of equitable health outcomes in children. With the increasing calls for more actions on addressing low health literacy and inequalities, health literacy interventions to improve children's healthy behaviours have emerged as a key strategy to reduce health inequities. However, health literacy interventions face implementation challenges impacting upon potential outcomes, and disparities in the implementation of health literacy interventions also occur. Variation exists in child health literacy intervention target groups, timing, content and formats, and there is a lack of implementation specificity, resulting in a lack of clarity about which intervention strategies are the most effective in improving health literacy, related health behaviours, and associated health outcomes. While actions to facilitate child health intervention implementation exist, to minimise further perpetuation of child health inequities, this perspective calls for a health equity implementation approach to child health literacy interventions.

Using the Consolidated Framework for Implementation Research to Inform the Design of the Mobile Inspección Visual con Ácido Acético System: Mixed Methods Case Study

BACKGROUND

There is growing evidence supporting the use of mobile health (mHealth) interventions in low- and middle-income countries to address resource limitations in the delivery of health information and services to vulnerable populations. In parallel, there is an increasing emphasis on the use of implementation science tools and frameworks for the early identification of implementation barriers and to improve the acceptability, appropriateness, and adoption of mHealth interventions in resource-limited settings. However, there are limited examples of the application of implementation science tools and frameworks to the formative phase of mHealth design for resource-limited settings despite the potential benefits of this work for enhancing subsequent implementation, scale-up, and sustainability.

OBJECTIVE

We presented a case study on the use of an implementation science framework in mHealth design. In particular, we illustrated the usability of the Consolidated Framework for Implementation Research (CFIR) for organizing and interpreting formative research findings during the design of the mobile Inspección Visual con Ácido Acético (mIVAA) system in Lima, Peru.

METHODS

We collected formative data from prospective users of the mIVAA intervention using multiple research methodologies, including structured observations, surveys, group and individual interviews, and discussions with local stakeholders at the partnering organization in Peru. These activities enabled the documentation of clinical workflows, perceived barriers to and facilitators of mIVAA, overarching barriers to cervical cancer screening in community-based settings, and related local policies and guidelines in health care. Using a convergent mixed methods analytic approach and the CFIR as an organizing framework, we mapped formative research findings to identify key implementation barriers and inform iterations of the mIVAA system design.

RESULTS

In the setting of our case study, most implementation barriers were identified in the CFIR domains of intervention characteristics and inner setting. All but one barrier were addressed before mIVAA deployment by modifying the system design and adding supportive resources. Solutions involved improvements to infrastructure, including cellular data plans to avoid disruption from internet failure; improved process and flow, including an updated software interface; and better user role definition for image capture to be consistent with local health care laws.

CONCLUSIONS

The CFIR can serve as a comprehensive framework for organizing formative research data and identifying key implementation barriers during mHealth intervention design. In our case study of the mIVAA system in Peru, formative research contributing to the CFIR domains of intervention characteristics and inner setting elicited the most key barriers to implementation. The early identification of barriers enabled design iterations before system deployment. Future efforts to develop mHealth interventions for low- and middle-income countries may benefit from using the approach presented in this case study as well as prioritizing the CFIR domains of intervention characteristics and inner setting.

An mHealth tool for community health workers to improve caregiver knowledge of child health in the Amazon: An effectiveness-implementation hybrid evaluation

When community health workers (CHWs) are effective, they can teach healthy child rearing practices in their communities and improve child health and development outcomes. An effective mHealth tool can improve the capacity of CHWs to transmit knowledge to caregivers. This article evaluates the implementation of an mHealth tool in a CHW program in the Amazon of Peru. The intervention was designed, implemented, and evaluated with the guidance of multiple implementation science tools. A Hybrid Type 3 evaluation design was used to test the effectiveness of the implementation strategies and appropriateness of the intervention. The implementation outcomes: acceptability, adoption, dosage, and fidelity were analyzed with mixed methods approach to determine if the intervention was successfully installed in the CHW program. The service outcome, knowledge scores, was analyzed with an independent samples t-test and one way ANOVA to determine the effect of the program. The implementation strategies resulted in high degrees of acceptability, adoption, and fidelity of the mHealth tool. The surveillance component of the mHealth tools was not adequately adopted. The group of caregivers that received home visits with the mHealth tool (N = 48) had significantly higher knowledge scores (+1.26 standard deviations) than those in the control group (N = 138) (t(184) = -4.39, p<0.001). The COVID-19 pandemic significantly decreased the dosage of the intervention received by the participants. The CHEST App intervention is a promising tool to improve the capacity of CHWs during their home visits. Trial registered with ISRCTN on 11/29/2018 at https://doi.org/10.1186/ISRCTN43591826.

How to Implement a Simulation-Based Education Programme: Lessons from the UK Urology Simulation Boot Camp

The operative and non-technical skills exposure of urology trainees has reduced due to a number of factors, including the European Working Time Directive, and the COVID-19 pandemic. Simulation-based education (SBE) is an innovative addition to clinical experience which can begin to address the skills-based learning deficiency in order to help trainees meet their curriculum requirements and optimise the exposure required for a trainee to become a competent general urology consultant. Surgical simulation is an effective training tool but has a complex implementation process, requiring considerable planning tailored to specific educational targets, to ensure it is sustainable and reproducible. Methodology from the field of implementation science offers an invaluable approach to design an effective simulation-based training adjunct, as exemplified by the example of the UK Urology Simulation Boot Camp (USBC), a comprehensive training course which incorporates core technical and non-technical skills based on the current Joint Committee on Surgical Training (JCST) urological training curriculum to equip newly appointed urology trainees to work as competent junior registrars. Delivered annually in Leeds since 2015, the course has had excellent feedback and results in improving the urological knowledge of trainees, as well as increases in trainees’ confidence. This paper will provide a summary of how the course was designed, delivered, reproduced, sustained and evaluated. Its success is demonstrated by its incorporation into the UK urology training programme, and since 2018, it is now recommended to all new urology residents in the UK. The course implementation model would be applicable to other surgical specialties.