Implementation of LGBTQ+ affirming care policies in the Veterans Health Administration: preliminary findings on barriers and facilitators in the southern United States

Background

In the United States Department of Veterans Affairs (VA), veterans who are lesbian, gay, bisexual, transgender, queer, and similar gender and sexual minoritized people (LGBTQ+) experience health disparities compared to cisgender, heterosexual veterans. VA's LGBTQ+ Health Program created two healthcare policies on providing LGBTQ+ affirming care (healthcare that is inclusive, validating, and understanding of the LGBTQ+ population). The current project examines providers' barriers and facilitators to providing LGBTQ+ affirming care and LGBTQ+ veterans' barriers and facilitators to receiving LGBTQ+ affirming care.

Methods

Data collection and analysis were informed by the Consolidated Framework for Implementation Research, which was adapted to include three health equity domains. Data collection involved telephone interviews conducted with 11 VA providers and 12 LGBTQ+ veterans at one rural and one urban VA medical center, and one rural VA community clinic. Qualitative data were rapidly analyzed using template analysis, a data reduction technique.

Results

Providers described limited education, limited time, lack of experience with the population, and a lack of awareness of resources as barriers. Providers discussed comfort with consulting trusted peers, interest in learning more about providing LGBTQ+ affirming care, and openness and acceptance of the LGBTQ+ community as facilitators. LGBTQ+ veterans described a lack of provider awareness of their needs, concerns related to safety and discrimination, and structural discrimination as barriers. LGBTQ+ veterans described positive relationships with providers, knowledge of their own healthcare needs, and ability to advocate for their healthcare needs as facilitators. Although VA's LGBTQ+ affirming care policies are in place, providers and veterans noted a lack of awareness regarding specific healthcare processes.

Conclusion

Allowing more time and capacity for education and engaging LGBTQ+ veterans in determining how to improve their healthcare may be the path forward to increase adherence to LGBTQ+ affirming care policies. Engaging patients, especially those from marginalized backgrounds, in strategies focused on the uptake of policy may be a path to improve policy implementation. It is possible that creating truly collaborative structures in which patients, staff, providers, leadership, and policymakers can work together towards policy implementation may be a useful strategy. In turn, improved policy implementation would result in increased physical and mental health for LGBTQ+ veterans.

Trusted Communicators: The Role of Navigation Support in Improving Health and Health Care Access for American Indian Elders

Navigating health care and insurance systems presents significant challenges for American Indian (AI) Elders. Access to culturally congruent assistance with decision-making, scheduling, transportation, and communication can bridge the gap between AI Elders and health systems. This study uses qualitative interviews with professionals providing navigation services to American Indian Elders in a Southwestern state to understand the skills, experiences, and challenges involved in delivering this support. We conducted semi-structured interviews with 16 professionals providing navigation support to AI Elders between November 2018 and August 2020 and used a constant comparative approach to identify themes. Participants' descriptions of their work centered on the themes of (1) respect for Elders; (2) wide-ranging responsibilities; (3) acting as a trusted communicator; (4) developing trust; and (5) challenges to providing navigation support for AI Elders. Efforts to achieve health equity for AI Elders must include supporting individuals such as these within communities and advocating for a just health care system for American Indian people.

Outer-context determinants on the implementation of school-based interventions for LGBTQ+ adolescents

Background

Schools are critical venues for supporting LGBTQ+ youth well-being. Implementing LGBTQ-supportive practices can decrease experiences of stigmatization, discrimination, and victimization that lead to adverse mental health outcomes like anxiety, depression, and suicidality. However, schools are also subject to a wide range of outer-context pressures that may influence their priorities and implementation of LGBTQ-supportive practices. We assessed the role of emergent outer-context determinants in the context of a 5-year cluster randomized controlled trial to study the implementation of LGBTQ-supportive evidence-informed practices (EIPs) in New Mexico high schools.

Method

Using an iterative coding approach, we analyzed qualitative data from annual interviews with school professionals involved in EIP implementation efforts.

Results

The analysis yielded three categories of outer-context determinants that created challenges and opportunities for implementation: (a) social barriers related to heterocentrism, cisgenderism, and religious conservatism; (b) local, state, and national policy and political discourse; and (c) crisis events.

Conclusions

By exploring the implications of outer-context determinants for the uptake of LGBTQ-supportive practices, we demonstrate that these elements are dynamic-not simply reducible to barriers or facilitators-and that assessing outer-context determinants shaping implementation environments is crucial for addressing LGBTQ health equity.

Eight characteristics of rigorous multilevel implementation research: a step-by-step guide

BACKGROUND

Although healthcare is delivered in inherently multilevel contexts, implementation science has no widely endorsed methodological standards defining the characteristics of rigorous, multilevel implementation research. We identify and describe eight characteristics of high-quality, multilevel implementation research to encourage discussion, spur debate, and guide decision-making around study design and methodological issues.

RECOMMENDATIONS

Implementation researchers who conduct rigorous multilevel implementation research demonstrate the following eight characteristics. First, they map and operationalize the specific multilevel context for defined populations and settings. Second, they define and state the level of each construct under study. Third, they describe how constructs relate to each other within and across levels. Fourth, they specify the temporal scope of each phenomenon at each relevant level. Fifth, they align measurement choices and construction of analytic variables with the levels of theories selected (and hypotheses generated, if applicable). Sixth, they use a sampling strategy consistent with the selected theories or research objectives and sufficiently large and variable to examine relationships at requisite levels. Seventh, they align analytic approaches with the chosen theories (and hypotheses, if applicable), ensuring that they account for measurement dependencies and nested data structures. Eighth, they ensure inferences are made at the appropriate level. To guide implementation researchers and encourage debate, we present the rationale for each characteristic, actionable recommendations for operationalizing the characteristics in implementation research, a range of examples, and references to make the characteristics more usable. Our recommendations apply to all types of multilevel implementation study designs and approaches, including randomized trials, quantitative and qualitative observational studies, and mixed methods.

CONCLUSION

These eight characteristics provide benchmarks for evaluating the quality and replicability of multilevel implementation research and promote a common language and reference points. This, in turn, facilitates knowledge generation across diverse multilevel settings and ensures that implementation research is consistent with (and appropriately leverages) what has already been learned in allied multilevel sciences. When a shared and integrated description of what constitutes rigor is defined and broadly communicated, implementation science is better positioned to innovate both methodologically and theoretically.

Readiness to implement screening, brief intervention, and referral to treatment in school-based health centers

The purpose of this study was to evaluate the readiness of a university-based school-based health center (SBHC) program to implement the screening, brief intervention, and referral to treatment (SBIRT) model. We completed preimplementation surveys and interviews with providers, staff, and administrators at participating SBHCs (N = 19) to measure current protocols for and barriers to addressing adolescent substance use and barriers and facilitators to implementing SBIRT. We used the R = MC² heuristic (readiness equals motivation, general organizational capacity, and innovation-specific capacity) to interpret findings from the data. Using the R = MC² heuristic, we identified factors that may aid implementation, including the prioritization of substance use and a supportive organizational culture, as well as potential barriers, including competing high-priority health issues and a lack of resources for innovation. This study contributes to the emerging literature on the implementation of the SBIRT model with adolescents and in SBHCs and demonstrates the practical applicability of the R = MC² heuristic for assessing implementation readiness. SBHCs are ideal locations for addressing substance use but SBHC providers also face unique challenges when implementing the SBIRT model.

Barriers and facilitators to implementing evidence-based interventions in the context of a randomized clinical trial in the United States: a qualitative study

BACKGROUND

Evidence-based interventions, which are typically supported by data from randomized controlled trials (RCTs), are highly valued by providers of human services like child welfare. However, implementing such interventions in the context of a randomized clinical trial is a complex process, as conducting an RCT adds extra tasks for providers and complicating factors for provider organizations. Utilizing the Exploration, Preparation, Implementation, and Sustainment Framework, this study examines factors that facilitate or impede success in the implementation of evidence-based interventions in the context of a largescale trial of SafeCare,® a child maltreatment intervention.

METHODS

Qualitative data were obtained as part of a larger mixed-methods study involving a cluster randomized trial comparing SafeCare to usual services for caregivers within nine child welfare agencies across four states. Between May and October 2017, individual interviews were conducted with a purposive sample of 21 child welfare administrators and 24 supervisors, and 19 focus groups were conducted with 84 providers. Data were coded iteratively and grouped into themes.

RESULTS

Several interconnected themes centered on facilitators and barriers to SafeCare implementation in the context of a randomized clinical trial. Facilitators included: (1) Benefits afforded through RCT participation; (2) Shared vision and sustained buy-in across system and organizational levels; and (3) Ongoing leadership support for SafeCare and the RCT. Barriers that hindered SafeCare were: (1) Insufficient preparation to incorporate SafeCare into services; (2) Perceived lack of fit, leading to mixed support for SafeCare and the RCT; and (3) Requirements of RCT participation at the provider level.

CONCLUSIONS

These data yield insight into an array of stakeholder perspectives on the experience of implementing a new intervention in the context of a largescale trial. This research also sheds light on how the dynamics of conducting an RCT may affect efforts to implement interventions in complex and high-pressure contexts. Findings highlight the importance of aligning knowledge and expectations among researchers, administrators of organizations, and supervisors and providers. Researchers should work to alleviate the burdens of study involvement and promote buy-in among frontline staff not only for the program but also for the research itself.

Understanding implementation research collaborations from a co-creation lens: Recommendations for a path forward

Increasing calls within the field of implementation science (IS) research seek to promote active engagement of diverse and often disenfranchised stakeholder voices to increase buy-in, fidelity, outcome relevance, and sustainment of evidence-based practices (EBPs). Including such voices requires cultural humility and the integration of multiple perspectives and values among organizations, groups, and individuals. However, the IS field lacks guidance for researchers on structuring collaborative approaches to promote a co-created process (i.e., synergistic approach to goal attainment). We contend that improved operationalization of co-created implementation collaborations is critical to sparking synergy and addressing differentials based on power, privilege, knowledge, and access to resources among stakeholders. These differentials can undermine future implementation and sustainment efforts if not addressed early in the research effort. An insufficient understanding of the guiding principles of co-created implementation collaborations may limit the scientific value of evaluation processes, and researchers' ability to replicate outcomes. We propose a perspective foregrounded in the concept of co-creation to guide the structuring of implementation collaboratives through five principles. We offer three case examples informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to illustrate the application of these co-creation principles. Lastly, we offer recommendations for promoting co-creation in IS research moving forward.

Assessing readiness factors for implementation of LGBTQ+ affirmative primary care initiatives: Practice implications from a mixed-method study

INTRODUCTION

Access and utilization barriers in primary care clinics contribute to health disparities that disproportionately affect lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people. Implementing inclusive practice guidelines in these settings may decrease disparities. The purpose of this exploratory/developmental study is to identify key issues affecting the readiness of primary care clinics to implement such guidelines.

METHODS

Using a concurrent mixed-method research design, we conducted surveys, interviews, and focus groups with 36 primary care personnel in clinics in New Mexico, USA, to examine readiness to implement LGBTQ+ inclusive guidelines, analyzing factors affecting motivation, general organizational capacity, and innovation-specific capacity. We supplemented these data by documenting LGBTQ+ inclusive policies and practices at each clinic. We undertook descriptive analyses and between-subscale comparisons controlling for within-rater agreement of the survey data and iterative coding and thematic analysis of the qualitative data.

RESULTS

Quantitatively, participants reported significantly more openness toward adopting guidelines and attitudinal awareness for developing LGBTQ+ clinical skills than clinical preparedness, basic knowledge, and resources to facilitate implementation. Six themes derived from the qualitative findings corroborate and expand on these results: (1) treating all patients the same; (2) addressing diversity in and across LGBTQ+ populations; (3) clinic climates; (4) patient access concerns; (5) insufficient implementation support; and (6) leadership considerations.

CONCLUSION

This study demonstrates that personnel in primary care clinics support initiatives to enhance service environments, policies, and practices for LGBTQ+ patients. However, drawing on Iris Young's theory of structural injustice, we found that neutralizing discourses that construct all patients as the same and time/resource constraints may diminish motivation and capacity in busy, understaffed clinics serving a diverse clientele and reinforce inequities in primary care for LGBTQ+ people. Efforts are needed to build general and innovation-specific capacities for LGBTQ+ initiatives. Such efforts should leverage implementation teams, organizational assessments, education, leadership support, community engagement, and top-down incentives.

Experiences of Health Insurance among American Indian Elders and Their Health Care Providers

CONTEXT

American Indian elders have a lower life expectancy than other aging populations in the United States because of inequities in health and in access to health care. To reduce such disparities, the 2010 Affordable Care Act included provisions to increase insurance enrollment among American Indians. Although the Indian Health Service remains underfunded, increases in insured rates have had significant impacts among American Indians and their health care providers.

METHODS

From June 2016 to March 2017, we conducted qualitative interviews with 96 American Indian elders (age 55+) and 47 professionals (including health care providers, outreach workers, public-sector administrators, and tribal leaders) in two southwestern states. Interviews focused on elders' experiences with health care and health insurance. We analyzed transcripts iteratively using open and focused coding techniques.

FINDINGS

Although tribal health programs have benefitted from insurance payments, the complexities of selecting, qualifying for, and maintaining health insurance are often profoundly alienating and destabilizing for American Indian elders and communities.

CONCLUSIONS

Findings underscore the inadequacy of health-system reforms based on the expansion of private and individual insurance plans in ameliorating health disparities among American Indian elders. Policy makers must not neglect their responsibility to directly fund health care for American Indians.

Positive Trends in School-Based Practices to Support LGBTQ Youth in the United States Between 2010 and 2018

PURPOSE

The present study tests the hypothesis that there has been a significant increase in the implementation of six LGBTQ-supportive school practices in US states between 2010 and 2018.

METHODS

Data were drawn from the publicly available School Health Profiles reports published by the Centers for Disease Control and Prevention, Division of Adolescent and School Health. We conducted unadjusted linear regression models separately for each practice to examine state-specific linear trends in the percentage of secondary schools reportedly engaging in six LGBTQ-supportive practices across all 50 states. In addition, we conducted an unadjusted linear regression on the trend to estimate changes in the median percentage of schools across all states engaging in each of the six practices through time.

RESULTS

In 2010, 5.7% of schools reported implementing all six practices, which increased to 15.3% in 2018. In the period from 2010 to 2018, the implementation of four of six key practices increased significantly in more than half of US states. Most states experienced a mix of either increases in practices or no change in practice prevalence, with no state experiencing a significant decrease.

DISCUSSION

There have been significant gains in the percentage of schools implementing LGBTQ-supportive practices. Yet, despite increases in the examined practices, the median percentage of schools in the United States that implement all six remains low. There is considerable room to improve on the use of these practices in schools across the United States, including increased attention to the quality of implementation and the barriers and facilitators to their instantiation.

Causes and Consequences of Not Having a Personal Healthcare Provider Among American Indian Elders: A Mixed-Method Study

Having a regular relationship with a healthcare provider contributes to better health outcomes and greater satisfaction with care for older adults. Although members of federally recognized American Indian tribes have a legal right to healthcare, American Indian Elders experience inequities in healthcare access that may compromise their ability to establish a relationship with a healthcare provider. This multi-year, community-driven, mixed-method study examines the potential causes and consequences of not having a personal healthcare provider among American Indian Elders. Quantitative surveys and qualitative interviews were conducted with 96 American Indian Elders (age 55 and over) in two states in the Southwestern United States. Quantitative and qualitative data were analyzed separately and then triangulated to identify convergences and divergences in data. Findings confirmed that having a consistent healthcare provider correlated significantly with self-rated measures of health, confidence in getting needed care, access to overall healthcare, and satisfaction with care. Lack of a regular healthcare provider was related to interconnected experiences of self-reliance, bureaucratic and contextual barriers to care, and sentiments of fear and mistrust based in previous interactions with medical care. Increasing health equity for American Indian Elders will thus require tailored outreach and system change efforts to increase continuity of care and provider longevity within health systems and build Elders' trust and confidence in healthcare providers.

The Community as the Unit of Healing: Conceptualizing Social Determinants of Health and Well-Being for Older American Indian Adults

Background and Objectives

Multiple racial and social inequities shape health and access to health care for American Indian Elders, who have a lower life expectancy than all other aging populations in the United States. This qualitative study examines how upstream social determinants of health influence Elders’ ability to access and use health care.

Research Design and Methods

Between June 2016 and March 2017, we conducted individual, semistructured interviews with 96 American Indian Elders, aged 55 and older, and 47 professionals involved in planning or delivering care to Elders in 2 states in the U.S. Southwest. Transcripts were analyzed iteratively using grounded theory approaches, including open and focused coding. A group of American Indian Elders and allies called the Seasons of Care Community Action Board guided interpretation and prioritization of findings.

Results

Participants described multiple barriers that hindered Elders’ ability to access health care services and providers, which were largely tied to funding shortages and bureaucratic complexities associated with health care and insurance systems. Where available, community resources bridged service gaps and helped Elders navigate systems.

Discussion and Implications

Longstanding structural inequities for American Indians manifest in barriers to health equity, many of which are situated at the community level. These are compounded by additional disparities affecting older adults, rural residents, and marginalized citizens in general. Findings underscore the importance of health and policy initiatives for American Indian Elders that emphasize the community as the focus of intervention.

Power and resistance in schools: Implementing institutional change to promote health equity for sexual and gender minority youth

Introduction

Schools in the United States are hierarchical institutions that actively (re)produce the power relations of the wider social world, including those associated with heteronormativity. Structural stigma, informed by heteronormativity and perpetuated through schools, contributes to the production of academic and health disparities among youth who are lesbian, gay, bisexual, transgender, queer, or of other gender and sexual identities (LGBTQ+). We draw upon 5 years of qualitative data from a cluster randomized controlled trial conducted in New Mexico that used implementation science frameworks to promote the uptake and sustainment of evidence-informed practices (EIPs) to examine how power operates to hinder or promote the ability of school staff to change school environments, disrupt structural stigma, and increase safety and support for LGBTQ+ youth.

Methods

Data sources included annual individual and small group qualitative interviews with school professionals (e.g., administrators, school nurses, teachers, and other staff), several of whom took part in Implementation Resource Teams (IRTs) charged with applying the EIPs. Other data sources included bi-weekly periodic reflections with implementation coaches and technical assistance experts. Data were recorded, transcribed, and analyzed using deductive and inductive coding techniques.

Results

The IRTs experienced variable success in implementing EIPs. Their efforts were influenced by: (1) constraining school characteristics, including staff turnover and resource scarcity; (2) community-based opposition to change and concerns about community backlash; (3) the presence or absence of supportive school leadership; and (4) variations in school, district, and state policies affecting LGBTQ+ students and attitudes about their importance. Findings illustrate how diverse power structures operated in and across outer and inner contexts to bound, shift, amplify, and otherwise shape how new practices were received and implemented.

Conclusion

Findings indicate that the efforts of IRTs were often a form of resistant power that operated within and against school hierarchies to leverage epistemic, discursive, and material power toward implementation. To improve health equity, implementation scientists must attend to the multiple real and perceived power structures that shape implementation environments and influence organizational readiness and individual motivation. Implementers must also work to leverage resistant power to counter the institutional structures and social norms that perpetuate inequities, like heteronormativity and structural stigma.

Getting to Know: American Indian Elder Health Seeking in an Under-funded Healthcare System

American Indian (AI) Elders are the heart of the community. Existing research explores links between specific health behaviors and social determinants of health, but there is little theory explaining patient behaviors in the context of the Indian Health Service (IHS) system of care. We drew from a multiyear mixed-methods participatory study of Elder healthcare experiences to identify the systemic, interpersonal, and historic factors in the IHS that impact their health-seeking behaviors. We conducted an interpretive grounded theory analysis guided by Indigenous methodologies to analyze interviews with 96 AI Elders from two Southwestern states. Our resulting theory, Getting to Know, explains how Elders knew, owned, accessed, and were denied information and resources in their efforts to receive care. Findings highlight how Elders' health-seeking behaviors reflect longstanding inequities, the many ways Elder knowledge was incongruent with Western knowledge embedded in the IHS system, and how this conflict contributed to Elder discomfort in clinical settings. Future work will test the applicability of Getting to Know in other AI communities and design culturally safe care to meet Elder needs. By applying an Indigenous-centered analysis to the voices of Elders, we identified key influences on health outcomes not previously observed in the literature. By illuminating these influences, we show how culturally safe care can be better formulated to meet the needs of Elders, ultimately improving health for AI communities.

Using Concept Mapping to Understand Gender- and Age-Specific Factors Influencing Health Care Access among American Indian Elders

Inequities in access to health care create barriers to physical and mental health treatment for the rapidly aging American Indian population in the United States. This study uses concept mapping-a participatory, mixed-methods approach to understanding complex phenomena-to examine the perceived impacts of multilevel factors influencing Elders' ability to access and use health care and how these perceptions vary according to gender and age, with the aim of identifying tailored strategies to address inequities. Using data from a purposive sample of American Indian Elders (n = 65) in two states, we compared ratings of thematic clusters and individual factors perceived to impact Elder health care across four participant subgroups: women aged 55-64, women aged 65+, men aged 55-64, and men aged 65+. Provider Issues and Relationships and Tribal/National Policy were themes perceived to have a particularly high impact on Elder health. Key variations between subgroups regarding individual health care access factors reflected unique interpersonal and accessibility challenges among older women, problems stemming from lack of familiarity with health care among younger Elders and men, and challenges navigating complex bureaucracies and tribal decision-making processes among older Elders. Findings underscore the need to address multilevel gender- and age-specific factors contributing to health disparities for Elders.

Health Care Access and Utilization for American Indian Elders: A Concept-Mapping Study

OBJECTIVES

Inequities in access to and utilization of health care greatly influence the health and quality of life of American Indian elders (AIEs). This study explores the importance and perceived prevalence of factors affecting health care use within this population and assesses the changeability of these factors to produce a list of action items that are timely and relevant to improving health care access and utilization.

METHOD

Concept mapping was conducted with AIEs (n = 65) and professional stakeholders (n = 50), including tribal leaders, administrators of public-sector health systems, outreach workers, and health care providers. Data were analyzed using multidimensional scaling and cluster analyses.

RESULTS

The final concept-map model comprised nine thematic clusters related to factors affecting elder health care: Difficulties Obtaining and Using Insurance; Insecurity from Lack of Knowledge; Limited Availability of Services; Scheduling Challenges; Provider Issues and Relationships; Family and Emotional Challenges; Health-Related Self-Efficacy and Knowledge; Accessibility and Transportation Barriers; and Tribal/National Policy.

DISCUSSION

Findings suggest that improvements in access to and utilization of health care among AIEs will require actions across multiple domains, including health system navigation services, workforce improvements, and tribal, state, and federal policy. A multilevel socioecological approach is necessary to organize and undertake these actions.

Macro- and meso-level contextual influences on health care inequities among American Indian elders

BACKGROUND

American Indian elders, aged 55 years and older, represent a neglected segment of the United States (U.S.) health care system. This group is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other aging populations in the country. Despite the U.S. government's federal trust responsibility to meet American Indians' health-related needs through the Indian Health Service (IHS), elders are negatively affected by provider shortages, limited availability of health care services, and gaps in insurance. This qualitative study examines the perspectives of professional stakeholders involved in planning, delivery of, and advocating for services for this population to identify and analyze macro- and meso-level factors affecting access to and use of health care and insurance among American Indian elders at the micro level.

METHODS

Between June 2016 and March 2017, we undertook in-depth qualitative interviews with 47 professional stakeholders in two states in the Southwest U.S., including health care providers, outreach workers, public-sector administrators, and tribal leaders. The interviews focused on perceptions of both policy- and practice-related factors that bear upon health care inequities impacting elders. We analyzed iteratively the interview transcripts, using both open and focused coding techniques, followed by a critical review of the findings by a Community Action Board comprising American Indian elders.

RESULTS

Findings illuminated complex and multilevel contextual influences on health care inequities for elders, centering on (1) gaps in elder-oriented services; (2) benefits and limits of the Affordable Care Act (ACA); (2) invisibility of elders in national, state, and tribal policymaking; and (4) perceived threats to the IHS system and the federal trust responsibility.

CONCLUSIONS

Findings point to recommendations to improve the prevention and treatment of illness among American Indian elders by meeting their unique health care and insurance needs. Policies and practices must target meso and macro levels of contextual influence. Although Medicaid expansion under the ACA enables providers of essential services to elders, including the IHS, to enhance care through increased reimbursements, future policy efforts must improve upon this funding situation and fulfill the federal trust responsibility.

A randomized control trial to test a peer support group approach for reducing social isolation and depression among female Mexican immigrants

BACKGROUND

Female Mexican Immigrants (FMIs) experience high rates of depression compared with other populations. For this population, depression is often exacerbated by social isolation associated with the experience of immigration. Aim 1. To measure whether a culturally situated peer group intervention will reduce depression and stress associated with the experience of immigration. Aim 2. To test whether an intervention using a "women's funds of knowledge" approach results in improved resilience, knowledge and empowerment. Aim 3. To investigate whether a culturally situated peer group intervention using a women's funds of knowledge approach can give participants a sense and experience of social and physical connection ("emplacement") that is lost in the process of immigration.

METHODS

This mixed-methods study will implement "Tertulias" ("conversational gatherings" in Spanish), a peer support group intervention designed to improve health outcomes for FMI participants in Albuquerque, New Mexico. We will document results of the intervention on our primary hypotheses of a decrease in depression, and increases in resilience and social support, as well as on our secondary hypotheses of decreased stress (including testing of hair cortisol as a biomarker for chronic stress), and an increase in social connectedness and positive assessment of knowledge and empowerment.

DISCUSSION

This project will address mental health disparities in an underserved population that experiences high rates of social isolation. Successful completion of this project will demonstrate that health challenges that may appear too complex and too hard to address can be using a multi-level, holistic approach. Our use of hair samples to test for the 3-month average levels of systemic cortisol will contribute to the literature on an emerging biomarker for analyzing chronic stress.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov on 2/3/20, Identifier # NCT04254198 .

Producing insecurity: Healthcare access, health insurance, and wellbeing among American Indian elders

Although health care is a treaty-guaranteed right for members of federally recognized tribes, decades of research describe persistent disparities in health and access to health services for American Indians. Despite gains in insurance enrollment after the passage of the 2010 Affordable Care Act, underfunding of the Indian Health Service and national debate over the new health law contributes to insecurity, especially among the majority of American Indians aged 55 and older who rely on public insurance. We consider the production of insecurity surrounding health care for American Indian elders, analyzing its pragmatic and affective consequences. Between June 2016 and March 2017, we conducted 96 quantitative surveys and in-depth qualitive interviews with American Indian elders aged 55 and older in two states in the U.S. Southwest. Interviews were recorded, professionally transcribed, and analyzed iteratively using open and focused coding. We found that elders consistently shared discourses of doubt, fear, and uncertainty that centered on: 1) interactions with healthcare providers and facilities, especially the IHS; 2) calculations regarding health insurance and the potential costs of healthcare services; and 3) dynamics at the national level around health policy, particularly for American Indians. We argue that persistent perceptions of healthcare insecurity present a major barrier to wellbeing that remains unaddressed by existing health policy interventions for this population, which focus predominately on individual-level knowledge and behavior.

Production and maintenance of the institutional in/visibility of sexual and gender minority students in schools

This research investigates how school professionals, as institutional actors, influence school climates experienced by lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth. Although research links institutional characteristics to outcomes for LGBTQ youth, scholars do not yet fully understand the mechanisms. We address this gap through a mesolevel analysis of staff perspectives on schools' responsibilities to LGBTQ students. Using data from 96 semistructured interviews with high school staff during the 2016-2017 school year, we found that participants used three main cues to assess visibility of the school's LGBTQ population: (a) student self-advocacy; (b) students' enactment of LGBTQ stereotypes; and (c) same-sex relationships. Reliance on these cues led staff to underestimate the LGBTQ population and employ narrative frames to rationalize the status quo: small LGBTQ population did not merit allocating resources; all students were treated equally; LGBTQ-inclusive policies further marginalized LGBTQ students; and student issues were addressed through individualized interventions. Our research shows how staff's biases collide with institutional inertia to influence school climate, one crucial facet of the ecological contexts of LGBTQ youth. We conclude with discussion of implications and recommendations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Amplification of school-based strategies resulting from the application of the dynamic adaptation process to reduce sexual and gender minority youth suicide

Background

Evidence-informed practices (EIPs) are imperative to increase school safety for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) students and their peers. Recently, the Expert Recommendations for Implementing Change (ERIC), a taxonomy of discrete implementation strategies used in health care settings, was adapted for schools. The School Implementation Strategies, Translating the ERIC Resources (SISTER) resulted in 75 discrete implementation strategies. In this article, we examine which SISTER strategies were used to implement six EIPs to reduce suicidality among LGBTQ high school students. We applied the dynamic adaptation process (DAP), a phased, data-driven implementation planning process, that accounts for adaptation while encouraging fidelity to the core elements of EIPs.

Methods

Qualitative data derived from 36 semi-structured interviews and 16 focus groups conducted with school professionals during the first of a 3-year effort to implement EIPs in 19 high schools. We undertook iterative comparative analysis of these data, mapping codes to the relevant domains in the SISTER. We then synthesized the findings by creating a descriptive matrix of the SISTER implementation strategies employed by schools.

Results

We found that 20 SISTER strategies were encouraged under the DAP, nine of which were amplified by school personnel. Nine additional SISTER strategies not specifically built into the DAP were implemented independently by school personnel, given the freedom the DAP provided, resulting in a total of 29 SISTER strategies.

Conclusion

This study offers insight into how schools select and elaborate implementation strategies. The DAP fosters freedom to expand beyond study-supported strategies. Qualitative data illuminate motives for strategy diversification, such as improving EIP fit. Qualitative methods allow for an in-depth illustration of the strategies that school personnel enacted in their efforts to implement the EIPs. We discuss the utility of the DAP in supporting EIP implementation to reduce disparities for LGBTQ students.

Plain language abstract

Implementation science is, in part, concerned with implementation strategies, which are actions made to bridge implementation gaps between evidence-informed practices and the contexts in which practices are to be used. Implementation experts compiled a list of strategies for promoting the use of new practices in school settings. The authors of this article examine which implementation strategies in this list were promoted by the research team and which were employed independently by school personnel. Our results illustrate how school personnel applied strategies based on the conditions and needs of their individual schools. These results will contribute to knowledge about implementation strategies and improve readiness by building in strategies implementation teams will use. The authors conducted interviews and focus groups with school personnel involved in implementing six evidence-informed practices for reducing suicidality and other negative outcomes for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) high school students. Findings are from the end of the first year of implementation and provide a glimpse into how and why certain implementation strategies were employed by school personnel to facilitate adoption of the practices. Findings describe how they applied these strategies in communities where LGBTQ people were marginalized and where anti-LGBTQ stigma influenced policies and resulted in barriers to implementation. This article contributes to efforts to identify and tailor implementation strategies that can encourage the use of evidence-informed practices to improve the well-being of LGBTQ youth and other health disparity populations.

Applying a Structural-Competency Framework to the Implementation of Strategies to Reduce Disparities for Sexual and Gender Minority Youth

BACKGROUND

Sexual and gender minority youth (SGMY) are at high risk for adverse health outcomes. Safer schools decrease this risk. The US Centers for Disease Control and Prevention has identified 6 practices that can make schools safer for SGMY, yet few US schools implement them all. We apply a structural competency framework to elucidate factors contributing to this implementation gap.

METHODS

We conducted 75 interviews and 32 focus groups with school professionals in 18 New Mexico high schools to assess factors impacting implementation of the practices over 2 years. We analyzed data using iterative coding, thematic identification techniques, and the sensitizing concept of structural competency.

RESULTS

Themes included: rendering an invisible population visible; critical thinking about LGBTQ inequalities; building school personnel capacity; intersecting cultural, religious, and political conflicts; and tackling community-based sources of stigma and discrimination.

CONCLUSIONS

Underlying cultural and structural forces render SGMY invisible and constrain what schools can accomplish. Professional development encouraging critical thinking about structural inequities is foundational, but efforts to close the implementation gap must attend to structural forces producing disparities for SGMY. Structural competency can strengthen the ability of the Whole School, Whole Community, and Whole Child model's cross-sector coordination of policy and process to meet the needs of every student.

Incorporators, Early Investors, and Learners: a longitudinal study of organizational adaptation during EBP implementation and sustainment

BACKGROUND

The majority of literature on evidence-based practice (EBP) adaptation focuses on changes to clinical practices without explicitly addressing how organizations must adapt to accommodate a new EBP. This study explores the process of organizational-rather than EBP-adaptation during implementation and sustainment. To the authors' knowledge, there are no previous implementation studies that focus on organizational adaptation in this way.

METHODS

This analysis utilizes a case study approach to examine longitudinal qualitative data from 17 community-based organizations (CBOs) in one state and seven county-based child welfare systems. The CBOs had sustained a child-neglect intervention EBP (SafeCare®) for 2 to 10 years. The unit of analysis was the organization, and each CBO represented a case. Organizational-level profiles were created to describe the organizational adaptation process.

RESULTS

Three organizational-level adaptation profiles were identified as follows: incorporators (n = 7), early investors (n = 6), and learners (n = 4). Incorporators adapted by integrating SafeCare into existing operations to meet contractual or EBP fidelity requirements. Early Investors made substantial organizational adaptations during the early implementation period, then operated relatively consistently as the EBP became embedded in the organization and service system. Learners were characterized by steady and continuous attention to new ways that the organization could adapt to support the EBP.

CONCLUSION

The profiles demonstrated that there can be multiple effective paths to EBP sustainment. Organizational adaptation was calibrated to fit a CBO's operations (e.g., size of the program) and immediate environmental constraints (e.g., funding levels). Additionally, organizations fulfilled different functional roles in the network of entities involved in EBP implementation. Knowing organizational roles and adaptation profiles can guide implementation planning and help to structure contract designs that bridge the outer (system) and inner (organizational) contexts. Adaptation profiles can also inform the intensity of the implementation strategy tailoring process and the way that strategies are marketed to organizations.

"Creative Financing": Funding Evidence-Based Interventions in Human Service Systems

Implementation and sustainment of evidence-based interventions (EBIs) is influenced by outer (e.g., broader environments in which organizations operate) and inner (e.g., organizations, their administrators, and staff) contexts. One important outer-context element that shapes the inner context is funding, which is complex and unpredictable. There is a dearth of knowledge on how funding arrangements affect sustainment of EBIs in human service systems and the organizations delivering them, including child welfare and behavioral health agencies. This study uses qualitative interview and focus group data with stakeholders at the system, organizational, and provider levels from 11 human service systems in two states to examine how stakeholders strategically negotiate diverse and shifting funding arrangements over time. Study findings indicate that, while diverse funding streams may contribute to flexibility of organizations and possible transformations in the human service delivery environment, a dedicated funding source for EBIs is crucial to their successful implementation and sustainment.

Factors Impacting Implementation of Evidence-Based Strategies to Create Safe and Supportive Schools for Sexual and Gender Minority Students

PURPOSE

The Centers for Disease Control and Prevention recommends six evidence-based strategies to improve safety and support for sexual and gender minority (SGM) youth in U.S. schools. However, only a small minority of schools implement all strategies. This study draws on implementation science to assess contextual challenges to strategy implementation.

METHODS

Semistructured interviews were conducted with at least two stakeholders at each of 42 high schools in New Mexico. Interviews consisted of open-ended questions centered on attitudes toward, access to, and availability of school and community supports for SGM youth, school policies, and practices, and organizational factors believed to impact implementation. Transcripts were imported into NVivo 11 for iterative coding and qualitative analysis.

RESULTS

We identified eleven overarching sets of factors related to the preparedness of schools to implement the evidence-based strategies: (1) political climate; (2) community context; (3) community resources; (4) policies and practices; (5) staff knowledge and exposure to SGM issues; (6) training deficits; (7) prevalence of neutrality discourses suggesting SGM students should not be singled out for "special treatment" or intervention; (8) student attitudes and support; (9) de facto safe spaces; (10) health education curricula; and (11) pragmatic considerations, such as time, staff turnover, and workloads. Key factors believed to hinder implementation included lack of resources, staffing concerns, and knowledge deficits.

CONCLUSIONS

These results can be used to inform the development of implementation strategies to modify school health systems from within to best support evidence-based practices for SGM youth and other stigmatized populations.

Perspectives from Community-Based Organizational Managers on Implementing and Sustaining Evidence-Based Interventions in Child Welfare

The managers of community-based organizations that are contracted to deliver publicly funded programs, such as in the child welfare sector, occupy a crucial role in the implementation and sustainment of evidence-based interventions to improve the effectiveness of services, as they exert influence across levels of stakeholders in multitiered systems. This study utilized qualitative interviews to examine the perspectives and experiences of managers in implementing Safe Care®, an evidence-based intervention to reduce child maltreatment. Factors influencing managers' abilities to support SafeCare® included policy and ideological trends, characteristics of leadership in systems and organizations, public-private partnerships, procurement and contracting, collaboration and coopetition, and support for organizational staff.

"Improving Native American elder access to and use of health care through effective health system navigation"

BACKGROUND

Public insurance reforms of the past two decades have failed to substantively address the healthcare needs of American Indians in general, let alone the particular needs of American Indian elders, ages 55 years and older. Historically, this population is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other United States aging populations, representing a neglected group within the healthcare system. Despite the pervasive belief that the Indian Health Service will address all their health-related needs, American Indian elders are negatively affected by gaps in insurance and lack of access to health care. While the 2010 Patient Protection and Affordable Care Act included provisions to ameliorate disparities for American Indians, its future is uncertain. In this context, American Indian elders with variable health literacy must navigate a complex and unstable healthcare system, regardless of where they seek care.

METHODS

This community-driven study features a mixed-method, participatory design to examine help-seeking behavior and healthcare experiences of American Indian elders in New Mexico, in order to develop and evaluate a tailored intervention to enhance knowledge of, access to, and use of insurance and available services to reduce healthcare disparities. This study includes qualitative and quantitative interviews combined with concept mapping and focus groups with American Indian elders and other key stakeholders.

DISCUSSION

The information gathered will generate new practical knowledge, grounded in actual perspectives of American Indian elders and other relevant stakeholders, to improve healthcare practices and policies for a population that has been largely excluded from national and state discussions of healthcare reform. Study data will inform development and evaluation of culturally tailored programming to enhance understanding and facilitate negotiation of the changing landscape of health care by American Indian elders. This work will fill a gap in research on public insurance initiatives, which do not typically focus on this population, and will offer a replicable model for enhancing the effects of such initiatives on other underserved groups affected by healthcare inequities.

TRIAL REGISTRATION

This protocol does not include the collection of health outcome data. Clinicaltrials.gov, NCT03550404 . Registered June 6, 2018.

A Mixed-Method Assessment of a Pilot Peer Advocate Intervention for Rural Gender and Sexual Minorities

Mental health disparities affect lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in rural America. There are few empirically-based mental health interventions for this population. This exploratory study uses a mixed-method approach to assess implementation issues related to the feasibility, acceptability, appropriateness, and preliminary impacts of a novel peer-based intervention designed to enhance support and treatment engagement among rural LGBTQ people with mental distress and/or addiction issues. Quantitative and qualitative results illuminate intervention strengths and areas for improvement. Strengths centered on enhancing social support, advocacy behaviors, and engagement in treatment. Implementation challenges and recommendations to advance the intervention model are discussed.

Contracting and Procurement for Evidence-Based Interventions in Public-Sector Human Services: A Case Study

Sustainment of evidence-based interventions (EBIs) in human services depends on the inner context of community-based organizations (CBOs) that provide services and the outer context of their broader environment. Increasingly, public officials are experimenting with contracting models from for-profit industries to procure human services. In this case study, we conducted qualitative interviews with key government and CBO stakeholders to examine implementation of the Best Value-Performance Information Procurement System to contract for EBIs in a child welfare system. Findings suggest that stakeholder relationships may be compromised when procurement disregards local knowledge, communication, collaboration, and other factors supporting EBIs and public health initiatives.

Leading for the long haul: a mixed-method evaluation of the Sustainment Leadership Scale (SLS)

Background

Despite our progress in understanding the organizational context for implementation and specifically the role of leadership in implementation, its role in sustainment has received little attention. This paper took a mixed-method approach to examine leadership during the sustainment phase of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Utilizing the Implementation Leadership Scale as a foundation, we sought to develop a short, practical measure of sustainment leadership that can be used for both applied and research purposes.

Methods

Data for this study were collected as a part of a larger mixed-method study of evidence-based intervention, SafeCare®, sustainment. Quantitative data were collected from 157 providers using web-based surveys. Confirmatory factor analysis was used to examine the factor structure of the Sustainment Leadership Scale (SLS). Qualitative data were collected from 95 providers who participated in one of 15 focus groups. A framework approach guided qualitative data analysis. Mixed-method integration was also utilized to examine convergence of quantitative and qualitative findings.

Results

Confirmatory factor analysis supported the a priori higher order factor structure of the SLS with subscales indicating a single higher order sustainment leadership factor. The SLS demonstrated excellent internal consistency reliability. Qualitative analyses offered support for the dimensions of sustainment leadership captured by the quantitative measure, in addition to uncovering a fifth possible factor, available leadership.

Conclusions

This study found qualitative and quantitative support for the pragmatic SLS measure. The SLS can be used for assessing leadership of first-level leaders to understand how staff perceive leadership during sustainment and to suggest areas where leaders could direct more attention in order to increase the likelihood that EBIs are institutionalized into the normal functioning of the organization.

The good coach: implementation and sustainment factors that affect coaching as evidence-based intervention fidelity support

PURPOSE

Evidence-based interventions (EBIs) for human services unfold within complicated social and organizational circumstances and are influenced by the attitudes and behaviors of diverse stakeholders situated within these environments. Coaching is commonly regarded as an effective strategy to support service providers in delivering EBIs and attaining high levels of fidelity over time. The purpose of this paper is to address a lacuna in research examining the factors influencing coaching, an important EBI support component.

METHODOLOGY

The authors use the Exploration, Preparation, Implementation, and Sustainment framework to consider inner- and outer-context factors that affect coaching over time. This case study of coaching draws from a larger qualitative data set from three iterative investigations of implementation and sustainment of a home visitation program, SafeCare®. SafeCare is an EBI designed to reduce child neglect.

FINDINGS

The authors elaborate on six major categories of findings derived from an iterative data coding and analysis process: perceptions of "good" and "bad" coaches by system sustainment status; coach as peer; in-house coaching capacity; intervention developer requirements vs other outer-context needs; outer- context support; and inner-context support.

PRACTICAL IMPLICATIONS

Coaching is considered a key component for effective implementation of EBIs in public-sector systems, yet is under-studied. Understanding inner- and outer-context factors illuminates the ways they affect the capacity of coaches to support service delivery.

ORIGINALITY

This paper demonstrates that coaching can accomplish more than provision of EBI fidelity support. Stakeholders characterized coaches as operating as boundary spanners who link inner and outer contexts to enable EBI implementation and sustainment.

Research-Supported Intervention and Discretion Among Frontline Workers Implementing Home Visitation Services

OBJECTIVE

We examine how frontline workers and supervisors delivering a research supported intervention (RSI) to reduce child neglect negotiated system-related challenges, the pragmatics of RSI implementation, and their professional identities and relationships with clients.

METHODS

We conducted semi-structured interviews, small group discussions, and focus groups with frontline workers and supervisors in one large county over two time periods. We used iterative coding to analyze qualitative data.

RESULTS

Frontline workers navigated several aspects of RSI implementation and sustainment: (1) contract requirements and information dissemination, (2) fidelity, (3) competing demands and crises, (4) structure versus creativity, and (5) relationships with clients.

CONCLUSIONS

Workers dynamically negotiated multiple system- and provider-level (or outer- and inner-contextual) demands influencing RSI provision for clients with complex service needs. Results affirm the need to attend to the unintended consequences of implementing new contract, reimbursement, and other system organizational processes and to address the "committed work" supporting RSI delivery.

The transformation of behavioral healthcare in New Mexico

Since 1997, public-sector behavioral healthcare in New Mexico has remained under continual transition. We have conducted qualitative research to examine recent efforts in NM to establish a recovery-oriented behavioral healthcare system, focusing on comprehensive community support services, clinical homes, and core service agencies. We examine how decisions made in the outer context (e.g., the system level) shaped the implementation of each initiative within the inner context of service provision (e.g., provider agencies). We also clarify how sociopolitical factors, as exemplified in changes instituted by one gubernatorial administration and undone by its successor, can undermine implementation efforts and create crises within fragile behavioral healthcare systems. Finally, we discuss findings in relation to efforts to promote wraparound service planning and to establish medical home models under national healthcare reform.

The Roles of System and Organizational Leadership in System-Wide Evidence-Based Intervention Sustainment: A Mixed-Method Study

If evidence-based interventions (EBIs) are not sustained, investments are wasted and public health impact is limited. Leadership has been suggested as a key determinant of implementation and sustainment; however, little empirical work has examined this factor. This mixed-methods study framed using the Exploration, Preparation, Implementation, Sustainment (EPIS) conceptual framework examines leadership in both the outer service system context and inner organizational context in eleven system-wide implementations of the same EBI across two U.S. states and 87 counties. Quantitative data at the outer context (i.e., system) and inner context (i.e., team) levels demonstrated that leadership predicted future sustainment and differentiated between sites with full, partial, or no sustainment. In the outer context positive sustainment leadership was characterized as establishing a project's mission and vision, early and continued planning for sustainment, realistic project plans, and having alternative strategies for project survival. Inner context frontline transformational leadership predicted sustainment while passive-avoidant leadership predicted non-sustainment. Qualitative results found that sustainment was associated with outer context leadership characterized by engagement in ongoing supportive EBI championing, marketing to stakeholders; persevering in these activities; taking action to institutionalize the EBI with funding, contracting, and system improvement plans; and fostering ongoing collaboration between stakeholders at state and county, and community stakeholder levels. For frontline leadership the most important activities included championing the EBI and providing practical support for service providers. There was both convergence and expansion that identified unique contributions of the quantitative and qualitative methods. Greater attention to leadership in both the outer system and inner organizational contexts is warranted to enhance EBI implementation and sustainment.

Implementing school nursing strategies to reduce LGBTQ adolescent suicide: a randomized cluster trial study protocol

BACKGROUND

Reducing youth suicide in the United States (U.S.) is a national public health priority, and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) youth are at elevated risk. The Centers for Disease Control and Prevention (CDC) endorses six evidence-based (EB) strategies that center on meeting the needs of LGBTQ youth in schools; however, fewer than 6 % of U.S. schools implement all of them. The proposed intervention model, "RLAS" (Implementing School Nursing Strategies to Reduce LGBTQ Adolescent Suicide), builds on the Exploration, Preparation, Implementation, and Sustainment (EPIS) conceptual framework and the Dynamic Adaptation Process (DAP) to implement EB strategies in U.S. high schools. The DAP accounts for the multilevel context of school settings and uses Implementation Resource Teams (IRTs) to facilitate appropriate expertise, advise on acceptable adaptations, and provide data feedback to make schools implementation ready and prepared to sustain changes.

METHODS/DESIGN

Mixed methods will be used to examine individual, school, and community factors influencing both implementation process and youth outcomes. A cluster randomized controlled trial will assess whether LGBTQ students and their peers in RLAS intervention schools (n = 20) report reductions in suicidality, depression, substance use, bullying, and truancy related to safety concerns compared to those in usual care schools (n = 20). Implementation progress and fidelity for each EB strategy in RLAS intervention schools will be examined using a modified version of the Stages of Implementation Completion checklist. During the implementation and sustainment phases, annual focus groups will be conducted with the 20 IRTs to document their experiences identifying and advancing adaptation supports to facilitate use of EB strategies and their perceptions of the DAP.

DISCUSSION

The DAP represents a data-informed, collaborative, multiple stakeholder approach to progress from exploration to sustainment and obtain fidelity during the implementation of EB strategies in school settings. This study is designed to address the real-world implications of enabling the use of EB strategies by school nurses with the goal of decreasing suicide and youth risk behaviors among LGBTQ youth. Through its participatory processes to refine and sustain EB strategies in high schools, the RLAS represents a novel contribution to implementation science.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02875535.

Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science : Seattle, WA, USA. 24-26 September 2015

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Cara Lewis, Doyanne Darnell, Suzanne Kerns, Maria Monroe-DeVita, Sara J. Landes, Aaron R. Lyon, Cameo Stanick, Shannon Dorsey, Jill Locke, Brigid Marriott, Ajeng Puspitasari, Caitlin Dorsey, Karin Hendricks, Andria Pierson, Phil Fizur, Katherine A. Comtois

A1: A behavioral economic perspective on adoption, implementation, and sustainment of evidence-based interventions

Lawrence A. Palinkas

A2: Towards making scale up of evidence-based practices in child welfare systems more efficient and affordable

Patricia Chamberlain

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A5: Efficient synthesis: Using qualitative comparative analysis and the Consolidated Framework for Implementation Research across diverse studies

Laura J. Damschroder, Julie C. Lowery

A6: Establishing a veterans engagement group to empower patients and inform Veterans Affairs (VA) health services research

Sarah S. Ono, Kathleen F. Carlson, Erika K. Cottrell, Maya E. O’Neil, Travis L. Lovejoy

A7: Building patient-practitioner partnerships in community oncology settings to implement behavioral interventions for anxious and depressed cancer survivors

Joanna J. Arch, Jill L. Mitchell

A8: Tailoring a Cognitive Behavioral Therapy implementation protocol using mixed methods, conjoint analysis, and implementation teams

Cara C. Lewis, Brigid R. Marriott, Kelli Scott

A9: Wraparound Structured Assessment and Review (WrapSTAR): An efficient, yet comprehensive approach to Wraparound implementation evaluation

Jennifer Schurer Coldiron, Eric J. Bruns, Alyssa N. Hook

A10: Improving the efficiency of standardized patient assessment of clinician fidelity: A comparison of automated actor-based and manual clinician-based ratings

Benjamin C. Graham, Katelin Jordan

A11: Measuring fidelity on the cheap

Rochelle F. Hanson, Angela Moreland, Benjamin E. Saunders, Heidi S. Resnick

A12: Leveraging routine clinical materials to assess fidelity to an evidence-based psychotherapy

Shannon Wiltsey Stirman, Cassidy A. Gutner, Jennifer Gamarra, Dawne Vogt, Michael Suvak, Jennifer Schuster Wachen, Katherine Dondanville, Jeffrey S. Yarvis, Jim Mintz, Alan L. Peterson, Elisa V. Borah, Brett T. Litz, Alma Molino, Stacey Young McCaughanPatricia A. Resick

A13: The video vignette survey: An efficient process for gathering diverse community opinions to inform an intervention

Nancy Pandhi, Nora Jacobson, Neftali Serrano, Armando Hernandez, Elizabeth Zeidler- Schreiter, Natalie Wietfeldt, Zaher Karp

A14: Using integrated administrative data to evaluate implementation of a behavioral health and trauma screening for children and youth in foster care

Michael D. Pullmann, Barbara Lucenko, Bridget Pavelle, Jacqueline A. Uomoto, Andrea Negrete, Molly Cevasco, Suzanne E. U. Kerns

A15: Intermediary organizations as a vehicle to promote efficiency and speed of implementation

Robert P. Franks, Christopher Bory

A16: Applying the Consolidated Framework for Implementation Research constructs directly to qualitative data: The power of implementation science in action

Edward J. Miech, Teresa M. Damush

A17: Efficient and effective scaling-up, screening, brief interventions, and referrals to treatment (SBIRT) training: a snowball implementation model

Jason Satterfield, Derek Satre, Maria Wamsley, Patrick Yuan, Patricia O’Sullivan

A18: Matching models of implementation to system needs and capacities: addressing the human factor

Helen Best, Susan Velasquez

A19: Agency characteristics that facilitate efficient and successful implementation efforts

Miya Barnett, Lauren Brookman-Frazee, Jennifer Regan, Nicole Stadnick, Alison Hamilton, Anna Lau

A20: Rapid assessment process: Application to the Prevention and Early Intervention transformation in Los Angeles County

Jennifer Regan, Alison Hamilton, Nicole Stadnick, Miya Barnett, Anna Lau, Lauren Brookman-Frazee

A21: The development of the Evidence-Based Practice-Concordant Care Assessment: An assessment tool to examine treatment strategies across practices

Nicole Stadnick, Anna Lau, Miya Barnett, Jennifer Regan, Scott Roesch, Lauren Brookman-Frazee

A22: Refining a compilation of discrete implementation strategies and determining their importance and feasibility

Byron J. Powell, Thomas J. Waltz, Matthew J. Chinman, Laura Damschroder, Jeffrey L. Smith, Monica M. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A23: Structuring complex recommendations: Methods and general findings

Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica J. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A24: Implementing prolonged exposure for post-traumatic stress disorder in the Department of Veterans Affairs: Expert recommendations from the Expert Recommendations for Implementing Change (ERIC) project

Monica M. Matthieu, Craig S. Rosen, Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Enola K. Proctor, JoAnn E. Kirchner

A25: When readiness is a luxury: Co-designing a risk assessment and quality assurance process with violence prevention frontline workers in Seattle, WA

Sarah C. Walker, Asia S. Bishop, Mariko Lockhart

A26: Implementation potential of structured recidivism risk assessments with justice- involved veterans: Qualitative perspectives from providers

Allison L. Rodriguez, Luisa Manfredi, Andrea Nevedal, Joel Rosenthal, Daniel M. Blonigen

A27: Developing empirically informed readiness measures for providers and agencies for the Family Check-Up using a mixed methods approach

Anne M. Mauricio, Thomas D. Dishion, Jenna Rudo-Stern, Justin D. Smith

A28: Pebbles, rocks, and boulders: The implementation of a school-based social engagement intervention for children with autism

Jill Locke, Courtney Benjamin Wolk, Colleen Harker, Anne Olsen, Travis Shingledecker, Frances Barg, David Mandell, Rinad S. Beidas

A29: Problem Solving Teletherapy (PST.Net): A stakeholder analysis examining the feasibility and acceptability of teletherapy in community based aging services

Marissa C. Hansen, Maria P. Aranda, Isabel Torres-Vigil

A30: A case of collaborative intervention design eventuating in behavior therapy sustainment and diffusion

Bryan Hartzler

A31: Implementation of suicide risk prevention in an integrated delivery system: Mental health specialty services

Bradley Steinfeld, Tory Gildred, Zandrea Harlin, Fredric Shephard

A32: Implementation team, checklist, evaluation, and feedback (ICED): A step-by-step approach to Dialectical Behavior Therapy program implementation

Matthew S. Ditty, Andrea Doyle, John A. Bickel III, Katharine Cristaudo

A33: The challenges in implementing muliple evidence-based practices in a community mental health setting

Dan Fox, Sonia Combs

A34: Using electronic health record technology to promote and support evidence-based practice assessment and treatment intervention

David H. Lischner

A35: Are existing frameworks adequate for measuring implementation outcomes? Results from a new simulation methodology

Richard A. Van Dorn, Stephen J. Tueller, Jesse M. Hinde, Georgia T. Karuntzos

A36: Taking global local: Evaluating training of Washington State clinicians in a modularized cogntive behavioral therapy approach designed for low-resource settings

Maria Monroe-DeVita, Roselyn Peterson, Doyanne Darnell, Lucy Berliner, Shannon Dorsey, Laura K. Murray

A37: Attitudes toward evidence-based practices across therapeutic orientations

Yevgeny Botanov, Beverly Kikuta, Tianying Chen, Marivi Navarro-Haro, Anthony DuBose, Kathryn E. Korslund, Marsha M. Linehan

A38: Predicting the use of an evidence-based intervention for autism in birth-to-three programs

Colleen M. Harker, Elizabeth A. Karp, Sarah R. Edmunds, Lisa V. Ibañez, Wendy L. Stone

A39: Supervision practices and improved fidelity across evidence-based practices: A literature review

Mimi Choy-Brown

A40: Beyond symptom tracking: clinician perceptions of a hybrid measurement feedback system for monitoring treatment fidelity and client progress

Jack H. Andrews, Benjamin D. Johnides, Estee M. Hausman, Kristin M. Hawley

A41: A guideline decision support tool: From creation to implementation

Beth Prusaczyk, Alex Ramsey, Ana Baumann, Graham Colditz, Enola K. Proctor

A42: Dabblers, bedazzlers, or total makeovers: Clinician modification of a common elements cognitive behavioral therapy approach

Rosemary D. Meza, Shannon Dorsey, Shannon Wiltsey-Stirman, Georganna Sedlar, Leah Lucid

A43: Characterization of context and its role in implementation: The impact of structure, infrastructure, and metastructure

Caitlin Dorsey, Brigid Marriott, Nelson Zounlome, Cara Lewis

A44: Effects of consultation method on implementation of cognitive processing therapy for post-traumatic stress disorder

Cassidy A. Gutner, Candice M. Monson, Norman Shields, Marta Mastlej, Meredith SH Landy, Jeanine Lane, Shannon Wiltsey Stirman

A45: Cross-validation of the Implementation Leadership Scale factor structure in child welfare service organizations

Natalie K. Finn, Elisa M. Torres, Mark. G. Ehrhart, Gregory A. Aarons

A46: Sustainability of integrated smoking cessation care in Veterans Affairs posttraumatic stress disorder clinics: A qualitative analysis of focus group data from learning collaborative participants

Carol A. Malte, Aline Lott, Andrew J. Saxon

A47: Key characteristics of effective mental health trainers: The creation of the Measure of Effective Attributes of Trainers (MEAT)

Meredith Boyd, Kelli Scott, Cara C. Lewis

A48: Coaching to improve teacher implementation of evidence-based practices (EBPs)

Jennifer D. Pierce

A49: Factors influencing the implementation of peer-led health promotion programs targeting seniors: A literature review

Agathe Lorthios-Guilledroit, Lucie Richard, Johanne Filiatrault

A50: Developing treatment fidelity rating systems for psychotherapy research: Recommendations and lessons learned

Kevin Hallgren, Shirley Crotwell, Rosa Muñoz, Becky Gius, Benjamin Ladd, Barbara McCrady, Elizabeth Epstein

A51: Rapid translation of alcohol prevention science

John D. Clapp, Danielle E. Ruderman

A52: Factors implicated in successful implementation: evidence to inform improved implementation from high and low-income countries

Melanie Barwick, Raluca Barac, Stanley Zlotkin, Laila Salim, Marnie

Davidson

A53: Tracking implementation strategies prospectively: A practical approach

Alicia C. Bunger, Byron J. Powell, Hillary A. Robertson

A54: Trained but not implementing: the need for effective implementation planning tools

Christopher Botsko

A55: Evidence, context, and facilitation variables related to implementation of Dialectical Behavior Therapy: Qualitative results from a mixed methods inquiry in the Department of Veterans Affairs

Sara J. Landes, Brandy N. Smith, Allison L. Rodriguez, Lindsay R. Trent, Monica M. Matthieu

A56: Learning from implementation as usual in children’s mental health

Byron J. Powell, Enola K. Proctor

A57: Rates and predictors of implementation after Dialectical Behavior Therapy Intensive Training

Melanie S. Harned, Marivi Navarro-Haro, Kathryn E. Korslund, Tianying Chen, Anthony DuBose, André Ivanoff, Marsha M. Linehan

A58: Socio-contextual determinants of research evidence use in public-youth systems of care

Antonio R. Garcia, Minseop Kim, Lawrence A. Palinkas, Lonnie Snowden, John Landsverk

A59: Community resource mapping to integrate evidence-based depression treatment in primary care in Brazil: A pilot project

Annika C. Sweetland, Maria Jose Fernandes, Edilson Santos, Cristiane Duarte, Afrânio Kritski, Noa Krawczyk, Caitlin Nelligan, Milton L. Wainberg

A60: The use of concept mapping to efficiently identify determinants of implementation in the National Institute of Health--President’s Emergent Plan for AIDS Relief Prevention of Mother to Child HIV Transmission Implementation Science Alliance

Gregory A. Aarons, David H. Sommerfeld, Benjamin Chi, Echezona Ezeanolue, Rachel Sturke, Lydia Kline, Laura Guay, George Siberry

A61: Longitudinal remote consultation for implementing collaborative care for depression

Ian M. Bennett, Rinad Beidas, Rachel Gold, Johnny Mao, Diane Powers, Mindy Vredevoogd, Jurgen Unutzer

A62: Integrating a peer coach model to support program implementation and ensure long- term sustainability of the Incredible Years in community-based settings

Jennifer Schroeder, Lane Volpe, Julie Steffen

A63: Efficient sustainability: Existing community based supervisors as evidence-based treatment supports

Shannon Dorsey, Michael D Pullmann, Suzanne E. U. Kerns, Nathaniel Jungbluth, Lucy Berliner, Kelly Thompson, Eliza Segell

A64: Establishment of a national practice-based implementation network to accelerate adoption of evidence-based and best practices

Pearl McGee-Vincent, Nancy Liu, Robyn Walser, Jennifer Runnals, R. Keith Shaw, Sara J. Landes, Craig Rosen, Janet Schmidt, Patrick Calhoun

A65: Facilitation as a mechanism of implementation in a practice-based implementation network: Improving care in a Department of Veterans Affairs post-traumatic stress disorder outpatient clinic

Ruth L. Varkovitzky, Sara J. Landes

A66: The ACT SMART Toolkit: An implementation strategy for community-based organizations providing services to children with autism spectrum disorder

Amy Drahota, Jonathan I. Martinez, Brigitte Brikho, Rosemary Meza, Aubyn C. Stahmer, Gregory A. Aarons

A67: Supporting Policy In Health with Research: An intervention trial (SPIRIT) - protocol and early findings

Anna Williamson

A68: From evidence based practice initiatives to infrastructure: Lessons learned from a public behavioral health system’s efforts to promote evidence based practices

Ronnie M. Rubin, Byron J. Powell, Matthew O. Hurford, Shawna L. Weaver, Rinad S. Beidas, David S. Mandell, Arthur C. Evans

A69: Applying the policy ecology model to Philadelphia’s behavioral health transformation efforts

Byron J. Powell, Rinad S. Beidas, Ronnie M. Rubin, Rebecca E. Stewart, Courtney Benjamin Wolk, Samantha L. Matlin, Shawna Weaver, Matthew O. Hurford, Arthur C. Evans, Trevor R. Hadley, David S. Mandell

A70: A model for providing methodological expertise to advance dissemination and implementation of health discoveries in Clinical and Translational Science Award institutions

Donald R. Gerke, Beth Prusaczyk, Ana Baumann, Ericka M. Lewis, Enola K. Proctor

A71: Establishing a research agenda for the Triple P Implementation Framework

Jenna McWilliam, Jacquie Brown, Michelle Tucker

A72: Cheap and fast, but what is “best?”: Examining implementation outcomes across sites in a state-wide scaled-up evidence-based walking program, Walk With Ease

Kathleen P Conte

A73: Measurement feedback systems in mental health: Initial review of capabilities and characteristics

Aaron R. Lyon, Meredith Boyd, Abigail Melvin, Cara C. Lewis, Freda Liu, Nathaniel Jungbluth

A74: A qualitative investigation of case managers’ attitudes toward implementation of a measurement feedback system in a public mental health system for youth

Amelia Kotte, Kaitlin A. Hill, Albert C. Mah, Priya A. Korathu-Larson, Janelle R. Au, Sonia Izmirian, Scott Keir, Brad J. Nakamura, Charmaine K. Higa-McMillan

A75: Multiple pathways to sustainability: Using Qualitative Comparative Analysis to uncover the necessary and sufficient conditions for successful community-based implementation

Brittany Rhoades Cooper, Angie Funaiole, Eleanor Dizon

A76: Prescribers’ perspectives on opioids and benzodiazepines and medication alerts to reduce co-prescribing of these medications

Eric J. Hawkins, Carol A. Malte, Hildi J. Hagedorn, Douglas Berger, Anissa Frank, Aline Lott, Carol E. Achtmeyer, Anthony J. Mariano, Andrew J. Saxon

A77: Adaptation of Coordinated Anxiety Learning and Management for comorbid anxiety and substance use disorders: Delivery of evidence-based treatment for anxiety in addictions treatment centers

Kate Wolitzky-Taylor, Richard Rawson, Richard Ries, Peter Roy-Byrne, Michelle Craske

A78: Opportunities and challenges of measuring program implementation with online surveys

Dena Simmons, Catalina Torrente, Lori Nathanson, Grace Carroll

A79: Observational assessment of fidelity to a family-centered prevention program: Effectiveness and efficiency

Justin D. Smith, Kimbree Brown, Karina Ramos, Nicole Thornton, Thomas J. Dishion, Elizabeth A. Stormshak, Daniel S. Shaw, Melvin N. Wilson

A80: Strategies and challenges in housing first fidelity: A multistate qualitative analysis

Mimi Choy-Brown, Emmy Tiderington, Bikki Tran Smith, Deborah K. Padgett

A81: Procurement and contracting as an implementation strategy: Getting To Outcomes® contracting

Ronnie M. Rubin, Marilyn L. Ray, Abraham Wandersman, Andrea Lamont, Gordon Hannah, Kassandra A. Alia, Matthew O. Hurford, Arthur C. Evans

A82: Web-based feedback to aid successful implementation: The interactive Stages of Implementation Completion (SIC)^TM tool

Lisa Saldana, Holle Schaper, Mark Campbell, Patricia Chamberlain

A83: Efficient methodologies for monitoring fidelity in routine implementation: Lessons from the Allentown Social Emotional Learning Initiative

Valerie B. Shapiro, B.K. Elizabeth Kim, Jennifer L. Fleming, Paul A. LeBuffe

A84: The Society for Implementation Research Collaboration (SIRC) implementation development workshop: Results from a new methodology for enhancing implementation science proposals

Sara J. Landes, Cara C. Lewis, Allison L. Rodriguez, Brigid R. Marriott, Katherine Anne Comtois

A85: An update on the Society for Implementation Research Collaboration (SIRC) Instrument Review Project

Coaching mental health peer advocates for rural LGBTQ people

Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) people are affected by mental health disparities, especially in rural communities. We trained peer advocates in rural areas in the fundamentals of mental health, outreach, education, and support for this population. The peer advocates were coached by licensed mental health professionals. We evaluated this process through iterative qualitative analysis of semi-structured interviews and written logs from coaches and advocates. The six major themes comprising the results centered on (1) coaching support, (2) peer advocate skills and preparation, (3) working with help seekers, (4) negotiating diversity, (5) logistical challenges in rural contexts, and (6) systemic challenges. We concluded that peer advocacy for LGBTQ people with mental distress offers an affirmative, community-based strategy to assist the underserved. To be successful, however, peer advocates will likely require ongoing training, coaching, and infrastructural support to negotiate contextual factors that can influence provision of community resources and support to LGBTQ people within rural communities.

The role of collaborations in sustaining an evidence-based intervention to reduce child neglect

Child neglect is the most prevalent form of child maltreatment and represents 79.5% of open child-welfare cases. A recent study found the evidence-based intervention (EBI) SafeCare(®) (SC) to significantly reduce child neglect recidivism rates. To fully capitalize on the effectiveness of such EBIs, service systems must engage in successful implementation and sustainment; however, little is known regarding what factors influence EBI sustainment. Collaborations among stakeholders are suggested as a means for facilitating EBI implementation and sustainment. This study combines descriptive quantitative survey data with qualitative interview and focus group findings to examine the role of collaboration within the context of public-private partnerships in 11 child welfare systems implementing SC. Participants included administrators of government child welfare systems and community-based organizations, as well as supervisors, coaches, and home visitors of the SC program. Sites were classified as fully-, partially-, and non-sustaining based on implementation fidelity. One-way analysis of variance was used to examine differences in stakeholder reported Effective Collaboration scores across fully-sustaining, partially-sustaining, and non-sustaining sites. Qualitative transcripts were analyzed via open and focused coding to identify the commonality, diversity, and complexity of collaborations involved in implementing and sustaining SC. Fully-sustaining sites reported significantly greater levels of effective collaboration than non-sustaining sites. Key themes described by SC stakeholders included shared vision, building on existing relationships, academic support, problem solving and resource sharing, and maintaining collaborations over time. Both quantitative and qualitative results converge in highlighting the importance of effective collaboration in EBI sustainment in child welfare service systems.

STRUCTURAL INEQUALITY AND SOCIAL SUPPORT FOR WOMEN PRISONERS RELEASED TO RURAL COMMUNITIES

Incarceration and community reentry for rural women reflect gendered processes. We draw upon in-depth semi-structured interviews and focus groups to examine the return of women prisoners to underserved rural communities, while attending to the perspectives of their closest social supporters. Our findings underscore the complexity of the reentry process for rural women and its particular impact on their families. We challenge dominant discourses of personal responsibility that detract from the structura violence and injustice shaping reentry experiences for women and their social supporters. We also consider the policy implications of discharge and reentry planning for rural women and their families, as well as strategies to reduce recidivism.

From a "perfect storm" to "smooth sailing": policymaker perspectives on implementation and sustainment of an evidence-based practice in two states

Policymakers shape implementation and sustainment of evidence-based practices (EBPs), whether they are developing or responding to legislation and policies or negotiating public sector resource constraints. As part of a large mixed-method study, we conducted qualitative interviews with 24 policymakers involved in delivery of the same EBP in two U.S. states. We analyzed transcripts via open and focused coding techniques to identify the commonality, diversity, and complexity of implementation challenges; approaches to overcoming those challenges; and the importance of system-level contextual factors in ensuring successful implementation. Key findings centered on building support and leadership for EBPs; funding and contractual strategies; partnering with stakeholders; tackling challenges via proactive planning and problem solving; and the political, legal, and systemic pressures affecting EBP longevity. The policymaker perspectives offer guidance on nurturing system and organizational practice environments to achieve positive outcomes and for optimally addressing macro-level influences that bear upon the instantiation of EBPs in public sector child welfare systems.

Mixed-method study of a conceptual model of evidence-based intervention sustainment across multiple public-sector service settings

BACKGROUND

This study examines sustainment of an EBI implemented in 11 United States service systems across two states, and delivered in 87 counties. The aims are to 1) determine the impact of state and county policies and contracting on EBI provision and sustainment; 2) investigate the role of public, private, and academic relationships and collaboration in long-term EBI sustainment; 3) assess organizational and provider factors that affect EBI reach/penetration, fidelity, and organizational sustainment climate; and 4) integrate findings through a collaborative process involving the investigative team, consultants, and system and community-based organization (CBO) stakeholders in order to further develop and refine a conceptual model of sustainment to guide future research and provide a resource for service systems to prepare for sustainment as the ultimate goal of the implementation process.

METHODS

A mixed-method prospective and retrospective design will be used. Semi-structured individual and group interviews will be used to collect information regarding influences on EBI sustainment including policies, attitudes, and practices; organizational factors and external policies affecting model implementation; involvement of or collaboration with other stakeholders; and outer- and inner-contextual supports that facilitate ongoing EBI sustainment. Document review (e.g., legislation, executive orders, regulations, monitoring data, annual reports, agendas and meeting minutes) will be used to examine the roles of state, county, and local policies in EBI sustainment. Quantitative measures will be collected via administrative data and web surveys to assess EBI reach/penetration, staff turnover, EBI model fidelity, organizational culture and climate, work attitudes, implementation leadership, sustainment climate, attitudes toward EBIs, program sustainment, and level of institutionalization. Hierarchical linear modeling will be used for quantitative analyses. Qualitative analyses will be tailored to each of the qualitative methods (e.g., document review, interviews). Qualitative and quantitative approaches will be integrated through an inclusive process that values stakeholder perspectives.

DISCUSSION

The study of sustainment is critical to capitalizing on and benefiting from the time and fiscal investments in EBI implementation. Sustainment is also critical to realizing broad public health impact of EBI implementation. The present study takes a comprehensive mixed-method approach to understanding sustainment and refining a conceptual model of sustainment.

State mental health policy: Back to the future: New Mexico returns to the early days of Medicaid managed care

Gubernatorial administrations in New Mexico have initiated four overhauls of the publicly funded behavioral health care system over the past two decades. The most recent effort, Centennial Care, was implemented under a Section 1115 Medicaid waiver in January 2014. The authors describe Centennial Care, which closely resembles the now defunct restructuring of the public system that introduced Medicaid managed behavioral health care to the state in 1997. They also note disruptions in services to clients and hardships for providers, described locally as a "behavioral health crisis," that resulted from actions taken in 2013 by the current gubernatorial administration to force the takeover of 15 nonprofit service delivery agencies by five Arizona companies. These actions led to an onsite investigation by the Centers for Medicare and Medicaid Services.

Collaboration, negotiation, and coalescence for interagency-collaborative teams to scale-up evidence-based practice

Implementation and scale-up of evidence-based practices (EBPs) is often portrayed as involving multiple stakeholders collaborating harmoniously in the service of a shared vision. In practice, however, collaboration is a more complex process that may involve shared and competing interests and agendas, and negotiation. The present study examined the scale-up of an EBP across an entire service system using the Interagency Collaborative Team approach. Participants were key stakeholders in a large-scale county-wide implementation of an EBP to reduce child neglect, SafeCare. Semistructured interviews and/or focus groups were conducted with 54 individuals representing diverse constituents in the service system, followed by an iterative approach to coding and analysis of transcripts. The study was conceptualized using the Exploration, Preparation, Implementation, and Sustainment framework. Although community stakeholders eventually coalesced around implementation of SafeCare, several challenges affected the implementation process. These challenges included differing organizational cultures, strategies, and approaches to collaboration; competing priorities across levels of leadership; power struggles; and role ambiguity. Each of the factors identified influenced how stakeholders approached the EBP implementation process. System-wide scale-up of EBPs involves multiple stakeholders operating in a nexus of differing agendas, priorities, leadership styles, and negotiation strategies. The term collaboration may oversimplify the multifaceted nature of the scale-up process. Implementation efforts should openly acknowledge and consider this nexus when individual stakeholders and organizations enter into EBP implementation through collaborative processes.

The effects of behavioral health reform on safety-net institutions: a mixed-method assessment in a rural state

In July 2005, New Mexico initiated a major reform of publicly-funded behavioral healthcare to reduce cost and bureaucracy. We used a mixed-method approach to examine how this reform impacted the workplaces and employees of service agencies that care for low-income adults in rural and urban areas. Information technology problems and cumbersome processes to enroll patients, procure authorizations, and submit claims led to payment delays that affected the financial status of the agencies, their ability to deliver care, and employee morale. Rural employees experienced lower levels of job satisfaction and organizational commitment and higher levels of turnover intentions under the reform when compared to their urban counterparts.

Hitting the Wall: Youth Perspectives on Boredom, Trouble, and Drug Use Dynamics in Rural New Mexico

We examine the experience of boredom and its relationship to troublemaking and drug use among rural youth in southwestern New Mexico. We draw on qualitative research with area youth to describe what they think about drug use and how they situate it within their social circumstances. We then locate youth drug use within globalized processes affecting this setting, including a local economic environment with limited educational and employment opportunities for youth. Drug use emerges as a common social practice that enables youth to ameliorate boredom, yet only some youth become known as troublemakers. Study findings offer insight into how dominant social institutions-schools and juvenile justice authorities-shape the construction of trouble from the perspectives of youth. We contend that boredom and troublemaking among rural youth are not simply age-appropriate forms of self-expression but instead represent manifestations of social position, political economic realities, and assessments of possible futures.

CULTURALLY COMPETENT SERVICES WITHIN A STATEWIDE BEHAVIORAL HEALTHCARE TRANSFORMATION: A MIXED-METHOD ASSESSMENT

In 2005, New Mexico created a single health plan to administer all publicly-funded behavioral health services. Our mixed-method study combined surveys, document review, and ethnography to examine this reform's influence on culturally competent services (CCS). Participants were executives, providers, and support staff of behavioral healthcare agencies. Key variables included language access services and organizational supports, i.e., training, self-assessments of CCS, and maintenance of client-level data. Survey and document review suggested minimal effects on statewide capacity for CCS during the first three years of the reform. Ethnographic research helped explain these findings: (1) state government, the managed behavioral health plan and agencies failed to champion CCS; and (2) increased administrative requirements minimized time and financial resources for CCS. There was also insufficient appreciation among providers for CCS. Although agencies made progress in addressing language assistance services, availability and quality remained limited.

The impact of state behavioral health reform on Native American individuals, families, and communities

In 2005, the State of New Mexico undertook a sweeping transformation of all publicly funded behavioral health services. The reform was intended to enhance the cultural responsiveness and appropriateness of these services. To examine achievement of this objective, we conducted a qualitative study of the involvement of Native Americans in reform efforts and the subsequent impacts of reform on services for Native Americans. We found that the reform was relatively unsuccessful at creating mechanisms for genuine community input or improving behavioral health care for this population. These shortcomings were related to limited understandings of administrators concerning how tribal governments and health care systems operate, and the structural limitations of a managed care system that does not allow flexibility for culturally appropriate utilization review, screening, or treatment. However, interaction between the State and tribes increased, and we conclude that aspects of the reform could be strengthened to achieve more meaningful involvement and service improvements.

"An Old Way to Solve an Old Problem": Provider Perspectives on Recovery-Oriented Services and Consumer Capabilities in New Mexico

The goal of recovery has emerged as a core value in the reformation of public and private mental health services in the last twenty years. However, definitions of recovery remain as varied as methods of implementation. Through an ethnographic lens, we examine meanings of recovery in the context of a major statewide reform of mental health services in New Mexico, focusing specifically on provider-voiced concerns regarding recovery and recovery-oriented care. We argue that the concept of recovery functions as a symbol that seemingly reconciles the long-standing tension between biological and social explanations of mental illness. Drawing upon provider perspectives, we also discuss concerns that popular rhetoric about recovery may mask some needed fundamental changes to transform the mental health system to a recovery orientation. Finally, we consider recovery from a capabilities standpoint and discuss how this view lends itself to addressing both individual and social components of mental illness.

The Soft Underbelly of System Change: The Role of Leadership and Organizational Climate in Turnover during Statewide Behavioral Health Reform

This study examined leadership, organizational climate, staff turnover intentions, and voluntary turnover during a large-scale statewide behavioral health system reform. The initial data collection occurred nine months after initiation of the reform with a follow-up round of data collected 18 months later. A self-administered structured assessment was completed by 190 participants (administrators, support staff, providers) employed by 14 agencies. Key variables included leadership, organizational climate, turnover intentions, turnover, and reform-related financial stress ("low" versus "high") experienced by the agencies. Analyses revealed that positive leadership was related to a stronger empowering climate in both high and low stress agencies. However, the association between more positive leadership and lower demoralizing climate was evident only in high stress agencies. For both types of agencies empowering climate was negatively associated with turnover intentions, and demoralizing climate was associated with stronger turnover intentions. Turnover intentions were positively associated with voluntary turnover. Results suggest that strong leadership is particularly important in times of system and organizational change and may reduce poor climate associated with turnover intentions and turnover. Leadership and organizational context should be addressed to retain staff during these periods of systemic change.