Policy Implementation Science to Advance Population Health: The Potential for Learning Health Policy Systems

Challenges and Opportunities for Paving the Road to Global Health Equity Through Implementation Science

Implementation science focuses on enhancing the widespread uptake of evidence-based interventions into routine practice to improve population health. However, optimizing implementation science to promote health equity in domestic and global resource-limited settings requires considering historical and sociopolitical processes (e.g., colonization, structural racism) and centering in local sociocultural and indigenous cultures and values. This review weaves together principles of decolonization and antiracism to inform critical and reflexive perspectives on partnerships that incorporate a focus on implementation science, with the goal of making progress toward global health equity. From an implementation science perspective, wesynthesize examples of public health evidence-based interventions, strategies, and outcomes applied in global settings that are promising for health equity, alongside a critical examination of partnerships, context, and frameworks operationalized in these studies. We conclude with key future directions to optimize the application of implementation science with a justice orientation to promote global health equity.

Acceptability and feasibility of policy implementation strategies for taxes earmarked for behavioral health services

Background

This study's aims are to: (1) Compare the acceptability and feasibility of five types of implementation strategies that could be deployed to increase the reach of evidence-based practices (EBPs) with revenue from policies that earmark taxes for behavioral health services, and (2) Illustrate how definitions of implementation strategies and measures of acceptability and feasibility can be used in policy-focused implementation science research.

Methods

Web-based surveys of public agency and community organization professionals involved with earmarked tax policy implementation were completed in 2022-2023 (N = 211, response rate = 24.9%). Respondents rated the acceptability and feasibility of five types of implementation strategies (dissemination, implementation process, integration, capacity-building, and scale-up). Aggregate acceptability and feasibility scores were calculated for each type of strategy (scoring range 4-20). Analyses of variance compared scores across strategies and between organizational actor types.

Findings

For acceptability, capacity-building strategies had the highest rating (M = 16.3, SD = 3.0), significantly higher than each of the four other strategies, p ≤ . 004), and scale-up strategies had the lowest rating (M = 15.6). For feasibility, dissemination strategies had the highest rating (M = 15.3, significantly higher than three of the other strategies, p ≤ .002) and scale-up strategies had the lowest rating (M = 14.4).

Conclusions

Capacity-building and dissemination strategies may be well-received and readily deployed by policy implementers to support EBPs implementation with revenue from taxes earmarked for behavioral health services. Adapting definitions of implementation strategies for policy-focused topics, and applying established measures of acceptability and feasibility to these strategies, demonstrates utility as an approach to advance research on policy-focused implementation strategies.

Enhancing Impact: A Call to Action for Equitable Implementation Science

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

A collaborative network trial to evaluate the effectiveness of implementation strategies to maximize adoption of a school-based healthy lunchbox program: a study protocol

Introduction

An important impediment to the large-scale adoption of evidence-based school nutrition interventions is the lack of evidence on effective strategies to implement them. This paper describes the protocol for a "Collaborative Network Trial" to support the simultaneous testing of different strategies undertaken by New South Wales Local Health Districts to facilitate the adoption of an effective school-based healthy lunchbox program ('SWAP IT'). The primary objective of this study is to assess the effectiveness of different implementation strategies to increase school adoption of the SWAP across New South Wales Local Health Districts.

Methods

Within a Master Protocol framework, a collaborative network trial will be undertaken. Independent randomized controlled trials to test implementation strategies to increase school adoption of SWAP IT within primary schools in 10 different New South Wales Local Health Districts will occur. Schools will be randomly allocated to either the intervention or control condition. Schools allocated to the intervention group will receive a combination of implementation strategies. Across the 10 participating Local Health Districts, six broad strategies were developed and combinations of these strategies will be executed over a 6 month period. In six districts an active comparison group (containing one or more implementation strategies) was selected. The primary outcome of the trial will be adoption of SWAP IT, assessed via electronic registration records captured automatically following online school registration to the program. The primary outcome will be assessed using logistic regression analyses for each trial. Individual participant data component network meta-analysis, under a Bayesian framework, will be used to explore strategy-covariate interactions; to model additive main effects (separate effects for each component of an implementation strategy); two way interactions (synergistic/antagonistic effects of components), and full interactions.

Discussion

The study will provide rigorous evidence of the effects of a variety of implementation strategies, employed in different contexts, on the adoption of a school-based healthy lunchbox program at scale. Importantly, it will also provide evidence as to whether health service-centered, collaborative research models can rapidly generate new knowledge and yield health service improvements.

Clinical trial registration

This trial is registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12623000558628).

Implementation science for cancer control: One center's experience addressing context, adaptation, equity, and sustainment

Implementation science (IS) has great potential to enhance the frequency, speed, and quality of the translation of evidence-based programs, policies, products, and guidelines into practice. Progress has been made, but with some notable exceptions, this promise has not been achieved for cancer prevention and control. We discuss five interrelated but conceptually distinct, crosscutting issues important to accelerate IS for cancer prevention and control and how our Colorado Implementation Science Center in Cancer Control (COISC3) addressed these issues. These needs and opportunities include more fully addressing changing, multi-level context; guiding rapid, iterative adaptations; evaluating innovative approaches to engagement and health equity; greater attention to costs and economic issues; and sustainability. We summarize conceptual issues; evaluation needs and capacity building activities and then provide examples of how our IS center addressed these five needs for cancer prevention and control. We discuss changes made to address priorities of (i) guiding adaptations of implementation strategies to address changing context and (ii) working on issues identified and prioritized by our primary care partners rather than the research team. We conclude with discussion of lessons learned, limitations, and directions for future research and practice in IS to enhance cancer prevention and control as well as translational behavioral medicine more generally.

Country adoption of WHO 2019 guidance on HIV testing strategies and algorithms: a policy review across the WHO African region

OBJECTIVES

In 2019, the WHO released guidelines on HIV testing service (HTS). We aim to assess the adoption of six of these recommendations on HIV testing strategies among African countries.

DESIGN

Policy review.

SETTING

47 countries within the WHO African region.

PARTICIPANTS

National HTS policies from the WHO African region as of December 2021.

PRIMARY AND SECONDARY OUTCOME MEASURES

Uptake of WHO recommendations across national HTS policies including the standard three-test strategy; discontinuation of a tiebreaker test to rule in HIV infection; discontinuation of western blotting (WB) for HIV diagnosis; retesting prior to antiretroviral treatment (ART) initiation and the use of dual HIV/syphilis rapid diagnostic tests (RDTs) in antenatal care. Country policy adoption was assessed on a continuum, based on varying levels of complete adoption.

RESULTS

National policies were reviewed for 96% (n=45/47) of countries in the WHO African region, 38% (n=18) were published before 2019 and 60% (n=28) adopted WHO guidance. Among countries that had not fully adopted WHO guidance, not yet adopting a three-test strategy was the most common reason for misalignment (45%, 21/47); of which 31% and 22% were in low-prevalence (<5%) and high-prevalence (≥5%) countries, respectively. Ten policies (21%) recommended the use of WB and 49% (n=23) recommended retesting before ART initiation. Dual HIV/syphilis RDTs were recommended in 45% (n=21/47) of policies.

CONCLUSIONS

Many countries in the African region have adopted WHO-recommended HIV testing strategies; however, efforts are still needed to fully adopt WHO guidance. Countries should accelerate their efforts to adopt and implement a three-test strategy, retesting prior to ART initiation and the use of dual HIV/syphilis RDTs.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Implementation costs of sugary drink policies in the United States

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

Advancing the science of policy implementation: a call to action for the implementation science field

Public policies have been essential in addressing many of the most pressing public health problems in the USA and around the world. A large and convincing body of multidisciplinary research has established the impacts or effectiveness of public policies, such as smoke-free air laws and nutrition standards, on improving health outcomes and behaviors. Most of this research assumes that because an evidence-based policy is adopted or takes effect, it is implemented as intended. This assumption, however, is often incorrect. Like with clinical guidelines and other interventions, implementation science has an important role to play in promoting the uptake and implementation of evidence-based public policies that promote public health. To realize this potential, there remains a critical need to first establish a common understanding of what public policy is, the role of specific policies in the context of implementation (i.e., is it the evidence-based intervention or the implementation strategy?), and to establish an appropriate methodological foundation for the field of policy implementation science. We recommend that the field must evolve to (i) include policy experts and actors on policy implementation science study teams; (ii) identify theories, models, and frameworks that are suitable for policy implementation science; (iii) identify policy implementation strategies; (iv) adapt and/or identify study designs best suited for policy implementation science research; and (v) identify appropriate policy implementation outcome measures.

Implementing an integrated diabetic foot care programme in Ireland: podiatrists' experience

BACKGROUND

International evidence suggests that an integrated multidisciplinary approach to diabetic foot management is necessary to prevent ulceration and progression to amputation. Many health systems have introduced policies or models of care supporting the introduction of this evidence into practice, but little is known about the experiences of those involved in implementation. This study addresses this gap by examining the experiences of podiatrists providing integrated diabetic foot care.

METHODS

Between October 2017 and April 2018, an online survey comprising closed and open-ended questions on podiatrists' demographics, clinical activity, links with other services, continuous professional development activities and experiences of implementing the Model of Care was administered to podiatrists (n = 73) working for Ireland's Health Service Executive in the community and hospital setting. Data were analysed using descriptive statistics and qualitative content analysis.

RESULTS

The response rate was 68% (n = 50), with 46% (n = 23), 38% (n = 19) and 16% (n = 8) working across hospital, community and both settings, respectively. Most reported treating high-risk patients (66%), those with active foot disease (61%) and educating people about the risk of diabetes to the lower limb (80%). Reported challenges towards integrated diabetic foot care include a perceived lack of awareness of the role of podiatry amongst other healthcare professionals, poor integration between hospital and community podiatry services, especially where new services had been developed, and insufficient number of podiatrists to meet service demands.

CONCLUSION

Previous evidence has shown that there is often a gap between what is set out by a policy and what it looks like when delivered to service users. Results from the current study support this, highlighting that while most podiatrists work in line with national recommendations, there are specific gaps and challenges that need to be addressed to ensure successful policy implementation.

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.

Understanding Associations of Personal Values With Support for Tobacco and Alcohol Control Policies

INTRODUCTION

This cross-sectional analysis of the 2020 Health Information National Trends Survey (N=3,604) examines the associations of personal values with tobacco and alcohol control policy support, which may inform policy-related communication efforts.

METHODS

Respondents selected which of 7 value options they considered most important in their daily life and rated their support for 8 proposed tobacco and alcohol control policies (1=strongly oppose, 5=strongly support). Weighted proportions for each value were described across sociodemographic characteristics, smoking status, and alcohol use. Weighted bivariate and multivariable regressions tested the associations of values with mean policy support (alpha=0.89). Analyses occurred from 2021 to 2022.

RESULTS

The most frequently selected values were assuring my family is safe and secure (30.2%), being happy (21.1%), and making my own decisions (13.6%). Selected values varied across sociodemographic and behavioral characteristics. For example, people with lower education and incomes were overrepresented among those selecting making my own decisions and keeping myself in good health. After adjusting for sociodemographics, smoking, and alcohol use, people selecting family safety (β=0.20, 95% CI=0.06, 0.33) or religious connection (β=0.34, 95% CI=0.14, 0.54) as most important reported higher policy support than those selecting making their own decisions, the value associated with the lowest mean policy support. Mean policy support did not significantly differ across any other value comparisons.

CONCLUSIONS

Personal values are associated with support for alcohol and tobacco control policies, with making my own decisions associated with the lowest policy support. Future research and communication efforts may consider aligning tobacco and alcohol control policies with the idea of supporting autonomy.

Embracing dynamic public health policy impacts in infectious diseases responses: leveraging implementation science to improve practice

Rationale

The host-pathogen relationship is inherently dynamic and constantly evolving. Applying an implementation science lens to policy evaluation suggests that policy impacts are variable depending upon key implementation outcomes (feasibility, acceptability, appropriateness costs) and conditions and contexts.

COVID-19 case study

Experiences with non-pharmaceutical interventions (NPIs) including masking, testing, and social distancing/business and school closures during the COVID-19 pandemic response highlight the importance of considering public health policy impacts through an implementation science lens of constantly evolving contexts, conditions, evidence, and public perceptions. As implementation outcomes (feasibility, acceptability) changed, the effectiveness of these interventions changed thereby altering public health policy impact. Sustainment of behavioral change may be a key factor determining the duration of effectiveness and ultimate impact of pandemic policy recommendations, particularly for interventions that require ongoing compliance at the level of the individual.

Practical framework for assessing and evaluating pandemic policy

Updating public health policy recommendations as more data and alternative interventions become available is the evidence-based policy approach and grounded in principles of implementation science and dynamic sustainability. Achieving the ideal of real-time policy updates requires improvements in public health data collection and analysis infrastructure and a shift in public health messaging to incorporate uncertainty and the necessity of ongoing changes. In this review, the Dynamic Infectious Diseases Public Health Response Framework is presented as a model with a practical tool for iteratively incorporating implementation outcomes into public health policy design with the aim of sustaining benefits and identifying when policies are no longer functioning as intended and need to be adapted or de-implemented.

Conclusions and implications

Real-time decision making requires sensitivity to conditions on the ground and adaptation of interventions at all levels. When asking about the public health effectiveness and impact of non-pharmaceutical interventions, the focus should be on when, how, and for how long they can achieve public health impact. In the future, rather than focusing on models of public health intervention effectiveness that assume static impacts, policy impacts should be considered as dynamic with ongoing re-evaluation as conditions change to meet the ongoing needs of the ultimate end-user of the intervention: the public.

Building a new regional home for implementation science: Annual Midwest Clinical & Translational Research Meetings

The vision of the Central Society for Clinical and Translational Research (CSCTR) is to "promote a vibrant, supportive community of multidisciplinary, clinical, and translational medical research to benefit humanity." Together with the Midwestern Section of the American Federation for Medical Research, CSCTR hosts an Annual Midwest Clinical & Translational Research Meeting, a regional multispecialty meeting that provides the opportunity for trainees and early-stage investigators to present their research to leaders in their fields. There is an increasing national and global interest in implementation science (IS), the systematic study of activities (or strategies) to facilitate the successful uptake of evidence-based health interventions in clinical and community settings. Given the growing importance of this field and its relevance to the goals of the CSCTR, in 2022, the Midwest Clinical & Translational Research Meeting incorporated new initiatives and sessions in IS. In this report, we describe the role of IS in the translational research spectrum, provide a summary of sessions from the 2022 Midwest Clinical & Translational Research Meeting, and highlight initiatives to complement national efforts to build capacity for IS through the annual meetings.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization

Importance

Health systems are increasingly addressing health-related social needs. The Massachusetts Flexible Services program (Flex) is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources.

Objective

To understand barriers and facilitators of Flex implementation in 1 Medicaid ACO during the first 17 months of the program.

Design, Setting, and Participants

This mixed-methods qualitative evaluation study from March 2020 to July 2021 used the Reach, Efficacy, Adoption, Implementation, Maintenance/Practical, Robust Implementation, and Sustainability Model (RE-AIM/PRISM) framework. Two Mass General Brigham (MGB) hospitals and affiliated community health centers were included in the analysis. Quantitative data included all MGB Medicaid ACO enrollees. Qualitative interviews were conducted with 15 members of ACO staff and 17 Flex enrollees.

Main Outcomes and Measures

Reach was assessed by the proportion of ACO enrollees who completed annual social needs screening (eg, food insecurity and housing insecurity) and the proportion and demographics of Flex enrollees. Qualitative interviews examined other RE-AIM/PRISM constructs (eg, implementation challenges, facilitators, and perceived effectiveness).

Results

Of 67 098 Medicaid ACO enrollees from March 2020 to July 2021 (mean [SD] age, 28.8 [18.7] years), 38 442 (57.3%) completed at least 1 social needs screening; 10 730 (16.0%) screened positive for food insecurity, and 7401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults (mean [SD] age, 46.6 [11.8] years) and 173 (0.7%) children (<21 years; mean [SD] age, 10.1 [5.5]) enrolled in Flex; of these 831 people, 613 (73.8%) were female, 444 (53.4%) were Hispanic/Latinx, and 172 (20.7%) were Black. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (eg, reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food.

Conclusions and Relevance

This mixed-methods qualitative evaluation study found that to improve implementation, Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.

Universal Masking in Health Care Settings: A Pandemic Strategy Whose Time Has Come and Gone, For Now

During the COVID-19 pandemic in the United States, the use of facemasks has been mandated in all health care settings for individuals older than 2 years, whether present as health care personnel, patients, or visitors. In this commentary, a group of health care epidemiologists, infectious diseases physicians, and researchers argue for the withdrawal of the universal masking policy given the current status of the COVID-19 pandemic.

Integrating pragmatic and implementation science randomized clinical trial approaches: a PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) analysis

BACKGROUND

Over the past two decades, pragmatic and implementation science clinical trial research methods have advanced substantially. Pragmatic and implementation studies have natural areas of overlap, particularly relating to the goal of using clinical trial data to leverage health care system policy changes. Few investigations have addressed pragmatic and implementation science randomized trial methods development while also considering policy impact.

METHODS

The investigation used the PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) and PRECIS-2-Provider Strategies (PRECIS-2-PS) tools to evaluate the design of two multisite randomized clinical trials that targeted patient-level effectiveness outcomes, provider-level practice changes and health care system policy. Seven raters received PRECIS-2 training and applied the tools in the coding of the two trials. Descriptive statistics were produced for both trials, and PRECIS-2 wheel diagrams were constructed. Interrater agreement was assessed with the Intraclass Correlation (ICC) and Kappa statistics. The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) qualitative approach was applied to understanding integrative themes derived from the PRECIS-2 ratings and an end-of-study policy summit.

RESULTS

The ICCs for the composite ratings across the patient and provider-focused PRECIS-2 domains ranged from 0.77 to 0.87, and the Kappa values ranged from 0.25 to 0.37, reflecting overall fair-to-good interrater agreement for both trials. All four PRECIS-2 wheels were rated more pragmatic than explanatory, with composite mean and median scores ≥ 4. Across trials, the primary intent-to-treat analysis domain was consistently rated most pragmatic (mean = 5.0, SD = 0), while the follow-up/data collection domain was rated most explanatory (mean range = 3.14-3.43, SD range = 0.49-0.69). RAPICE field notes identified themes related to potential PRECIS-2 training improvements, as well as policy themes related to using trial data to inform US trauma care system practice change; the policy themes were not captured by the PRECIS-2 ratings.

CONCLUSIONS

The investigation documents that the PRECIS-2 and PRECIS-2-PS can be simultaneously used to feasibly and reliably characterize clinical trials with patient and provider-level targets. The integration of pragmatic and implementation science clinical trial research methods can be furthered by using common metrics such as the PRECIS-2 and PRECIS-2-PS. Future study could focus on clinical trial policy research methods development.

TRIAL REGISTRATION

DO-SBIS ClinicalTrials.gov NCT00607620. registered on January 29, 2008. TSOS ClinicalTrials.gov NCT02655354, registered on July 27, 2015.

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.

The next 'pandemic playbook' needs to prioritize the needs of children-and a clear roadmap for opening schools

The national influenza pandemic response plan includes short-term school closures as an infection mitigation measure, based on modeling data regarding the role of pediatric populations and schools as drivers of disease spread. Modeled estimates regarding the role of children and their in-school contacts as drivers of community transmission of endemic respiratory viruses were used in part to justify prolonged school closures throughout the United States. However, disease transmission models extrapolated from endemic pathogens to novel ones may underestimate the degree to which spread is driven by population immunity and overestimate the impact of school closures as a means of reducing child contacts, particularly in the longer-term. These errors, in turn, may have caused incorrect estimations about the potential benefits of closing schools on a society level while simultaneously failing to account for the significant harms of long-term educational disruption. Pandemic response plans need to be updated to include nuances regarding drivers of transmission such as pathogen type, population immunity, and contact patterns, and disease severity in different groups. Expected duration of impact also needs to be considered, recognizing that effectiveness of different interventions, particularly those focused on limiting social interactions, are short-lived. Additionally, future iterations should include risk-benefit assessments. Interventions that are particularly harmful to certain groups, such as school closures are on children, should be de-emphasized and time limited. Finally, pandemic responses should include ongoing and continuous policy re-evaluation and should include a clear plan for de-implementation and de-escalation.

Responding to "Don't Say Gay" Laws in the US: Research Priorities and Considerations for Health Equity

INTRODUCTION

Despite increased legal rights for lesbian, gay, bisexual, transgender, and queer-identifying (LGBTQ +) people in the USA over the past 30 years, there has been an increasing number of anti-LGBTQ + laws proposed and passed at the state level. One of the most notorious laws, Florida's HB 1557, also known as the "Don't Say Gay" law, garnered substantial national attention for prohibiting discussions of sexual orientation or gender identity in public school classrooms. Other states quickly proposed similar laws, but little scholarship exists on the potential impacts of these laws.

METHODS

We explore the potential health equity ramifications of laws like Florida's HB 1557, focusing on the individual, interpersonal, and broader policy and practice implications. Examining these policies through the lens of political determinants of health, we identify theoretical and methodological approaches needed to address recent "Don't Say Gay" policies.

RESULTS

Theoretical approaches emphasizing power, intersectionality, and the role of politics in health should guide research examining the impacts of recent anti-LGBTQ + policies. Laws like Florida's HB 1557 emphasize the need for methodological approaches that emphasize collaborative engagement between researchers and community members, and future research may be needed to understand how stressors created by law and policy can have individual and interpersonal consequences.

CONCLUSIONS

Public health researchers have a role to play in reversing policies that negatively affect LGBTQ + individuals and undermine health equity. Research combating harmful policies may require theoretical approaches attentive to power differences and methodological approaches that squarely focus on disrupting power imbalances.

Improving Policy for the Prevention of Falls Among Community-Dwelling Older People—A Scoping Review and Quality Assessment of International National and State Level Public Policies

Objectives: Effective public policy to prevent falls among independent community-dwelling older adults is needed to address this global public health issue. This paper aimed to identify gaps and opportunities for improvement of future policies to increase their likelihood of success.

Methods: A systematic scoping review was conducted to identify policies published between 2005–2020. Policy quality was assessed using a novel framework and content criteria adapted from the World Health Organization’s guideline for Developing policies to prevent injuries and violence and the New Zealand Government’s Policy Quality Framework.

Results: A total of 107 articles were identified from 14 countries. Content evaluation of 25 policies revealed that only 54% of policies met the WHO criteria, and only 59% of policies met the NZ criteria. Areas for improvement included quantified objectives, prioritised interventions, budget, ministerial approval, and monitoring and evaluation.

Conclusion: The findings suggest deficiencies in a substantial number of policies may contribute to a disconnect between policy intent and implementation. A clear and evidence-based model falls prevention policy is warranted to enhance future government efforts to reduce the global burden of falls.

Grounding implementation science in health equity for cancer prevention and control

BACKGROUND

The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions.

DISCUSSION

In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Strategies for implementing music-based interventions for people with dementia in long-term care facilities: A systematic review

OBJECTIVES

Research has found that music-based interventions can decrease behavioral and psychological symptoms of dementia or behaviors that challenge (BPSD/BtC). However, how to effectively implement these interventions is unclear. This study synthesizes available evidence regarding implementation strategies and outcomes of music-based interventions for people with dementia at residential long-term care facilities.

METHODS

Study registered with PROSPERO (registration number: CRD42020194354). We searched the following databases: PsychInfo, PubMed, MEDLINE, CINAHL, and The Cochrane Library. Inclusion criteria included articles targeting music-based interventions conducted for people with dementia, studies conducted in residential long-term care facilities, and articles that reported implementation strategies and outcomes of the intervention.

RESULTS

Of the included eight studies, half were studies of music therapy and the other half were on individualized music. 49 implementation strategies were reported. The most frequently reported category of strategies was planning (34.7%), followed by education (24.5%), quality management (24.5%), restructuring (12.2%), and finance (4.1%). No strategies under the category of attending to the policy context were reported. The most frequently reported implementation outcomes were appropriateness (27.3%), followed by adoption (22.7%), fidelity (22.7%), acceptability (9.1%), sustainability (9.1%), and cost (9.1%). No studies measured feasibility or penetration.

CONCLUSIONS

Although various effective implementation strategies were identified, we were unable to examine the effectiveness of individual implementation strategies due to the designs of the selected studies. Less attention has been paid to strategies that aim at structural changes of intervention delivery systems. Future studies should investigate facilitators and barriers of implementing music-based interventions especially focusing on structural aspects.

Quantitative measures used in empirical evaluations of mental health policy implementation: A systematic review

Background

Mental health is a critical component of wellness. Public policies present an opportunity for large-scale mental health impact, but policy implementation is complex and can vary significantly across contexts, making it crucial to evaluate implementation. The objective of this study was to (1) identify quantitative measurement tools used to evaluate the implementation of public mental health policies; (2) describe implementation determinants and outcomes assessed in the measures; and (3) assess the pragmatic and psychometric quality of identified measures.

Method

Guided by the Consolidated Framework for Implementation Research, Policy Implementation Determinants Framework, and Implementation Outcomes Framework, we conducted a systematic review of peer-reviewed journal articles published in 1995-2020. Data extracted included study characteristics, measure development and testing, implementation determinants and outcomes, and measure quality using the Psychometric and Pragmatic Evidence Rating Scale.

Results

We identified 34 tools from 25 articles, which were designed for mental health policies or used to evaluate constructs that impact implementation. Many measures lacked information regarding measurement development and testing. The most assessed implementation determinants were readiness for implementation, which encompassed training (n  =  20, 57%) and other resources (n  =  12, 34%), actor relationships/networks (n  =  15, 43%), and organizational culture and climate (n  =  11, 31%). Fidelity was the most prevalent implementation outcome (n  =  9, 26%), followed by penetration (n  =  8, 23%) and acceptability (n  =  7, 20%). Apart from internal consistency and sample norms, psychometric properties were frequently unreported. Most measures were accessible and brief, though minimal information was provided regarding interpreting scores, handling missing data, or training needed to administer tools.

Conclusions

This work contributes to the nascent field of policy-focused implementation science by providing an overview of existing measurement tools used to evaluate mental health policy implementation and recommendations for measure development and refinement. To advance this field, more valid, reliable, and pragmatic measures are needed to evaluate policy implementation and close the policy-to-practice gap.

Plain Language Summary

Mental health is a critical component of wellness, and public policies present an opportunity to improve mental health on a large scale. Policy implementation is complex because it involves action by multiple entities at several levels of society. Policy implementation is also challenging because it can be impacted by many factors, such as political will, stakeholder relationships, and resources available for implementation. Because of these factors, implementation can vary between locations, such as states or countries. It is crucial to evaluate policy implementation, thus we conducted a systematic review to identify and evaluate the quality of measurement tools used in mental health policy implementation studies. Our search and screening procedures resulted in 34 measurement tools. We rated their quality to determine if these tools were practical to use and would yield consistent (i.e., reliable) and accurate (i.e., valid) data. These tools most frequently assessed whether implementing organizations complied with policy mandates and whether organizations had the training and other resources required to implement a policy. Though many were relatively brief and available at little-to-no cost, these findings highlight that more reliable, valid, and practical measurement tools are needed to assess and inform mental health policy implementation. Findings from this review can guide future efforts to select or develop policy implementation measures.