Oncology mental health providers' adaptation of an evidence-based intervention: A mixed-methods study

BACKGROUND

Adaptations are intentional modifications maximizing the fit of an evidence-based intervention (EBI) in new context. Little is known about EBI adaptation within psychosocial oncology. Guided by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME), this mixed-methods study describes oncology mental health providers' planned adaptations to a psychosocial oncology EBI and examines the relationship between planned adaptations and longitudinal EBI usage.

METHODS

Providers (N = 128) were social workers (47%) and psychologists (40%) practicing in community settings (44%) or academic medical centers (41%). They attended a 3-day training on a multicomponent psychosocial oncology EBI, the Biobehavioral Intervention (BBI). During training, providers prepared an "adaptation plan" describing necessary adaptations to BBI and rationales for change. Qualitative data from adaptation plans were analyzed using directed content analysis. Linear mixed models examined the relationship between adaptation characteristics (number, similarity to the manualized BBI) and EBI usage across 12 months post-training.

RESULTS

Three sets of qualitative themes reflecting FRAME elements emerged: (1) content modifications (e.g., shortening/condensing, selecting elements, adding/removing elements); (2) contextual changes (e.g., alternative group formats); and (3) reasons for adaptations (e.g., organization/setting, provider, and recipient factors). Neither number of adaptations nor adaptation similarity were associated with BBI usage across 12 months post-training.

CONCLUSIONS

To our knowledge, this study is the first to characterize oncology mental health providers' planned adaptations to a psychosocial oncology EBI. Planned adaptations did not increase usage, but importantly they did not decrease usage. The adaptation process enabled providers to make thoughtful adaptation choices, with implementation successful irrespective of setting constraints.

Replicating dissemination and identifying mechanisms of implementation of an empirically supported treatment

OBJECTIVE

Implementation research is needed in cancer control. Replication of the dissemination of empirically supported treatments (ESTs) is important as is the identification of mechanisms by which dissemination leads to implementation. Addressing these gaps, Study 1 (Cohorts 3-6, N = 104) tests for replication of a successful dissemination to community providers (Brothers et al., 2015; Cohorts 1-2; N = 62) and Study 2 (Cohorts 1-6) tests providers' changes on dissemination outcomes as mechanisms of EST usage.

METHOD

The Biobehavioral Intervention (BBI), a psychological EST in cancer control, was disseminated to oncology mental health providers using manual provision, didactics, roleplays, and other strategies. Study 1 tested for pre/post changes in dissemination outcomes (BBI knowledge/skills and attitudes toward and self-efficacy to deliver ESTs/BBI) between cohorts (1-2 vs. 3-6) with repeated measures ANOVAs. In Study 2, the implementation outcome was providers' (N = 166) BBI usage with patients (percent treated). Structural equation models tested dissemination outcome changes as predictors of usage at 2- and 4-months.

RESULTS

Study 1 replicated high dissemination outcomes and significant gains in BBI knowledge (p < .001) in Cohorts 3-6. Unlike Cohorts 1-2, significant gains were observed in self-efficacy (ps < .001) but not attitudes toward ESTs (p = .523) in Cohorts 3-6. In Study 2, gains in providers' self-efficacy (ps < .05) and EST attitudes (p = .008) predicted greater 2-month (58.4% ± 35.5%) and 4-month (66.2% ± 35.0%) usage of the BBI with patients, respectively.

CONCLUSIONS

This is the only replication of a dissemination for a psychological EST in cancer control. Results reliably show disseminations enhancing providers' self-efficacy to use and positive attitudes toward ESTs as mechanisms for EST implementation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sustainability of a biobehavioral intervention implemented by therapists and sustainment in community settings

The ultimate aim of dissemination and implementation of empirically supported treatments (ESTs) in behavioral medicine is (a) sustainability of the therapist/provider's EST usage and (b) sustainment of EST delivery in the setting. Thus far, sustainability has been understudied, and the therapist and setting variables that may be influential are unclear. The purpose of the study was to test the therapists' sustainability of a cancer-specific EST using a prospective longitudinal design and examine its predictors. Oncology mental health therapists (N = 134) from diverse settings (N = 110) completed training in the biobehavioral intervention (BBI) and were provided with 6 months of support for implementation, with no support thereafter. BBI usage (percent of patients treated) was reported at 2, 4, 6, and 12 months. Using a generalized estimating equation with a logistic link function, 12-month sustainability (a nonsignificant change in usage from 6 to 12 months) was studied along with therapist, supervisor, and setting variables as predictors. BBI usage increased through 6 months and, importantly, usage was sustained from 6 (68.4% [95% CI = 62.2%-73.9%]) to 12 months (70.9% [95% CI = 63.6%-77.3%]), with sustainment in 66 settings (60.0%). Predictors of implementation-to-sustainability usage were therapists' early intentions to use the BBI (p < .001) and from the setting, supervisors' positive attitudes toward ESTs (p = .016). Adding to the DI literature, a health psychology intervention was disseminated, implemented, and found sustainable across diverse therapists and settings. Therapists and setting predictors of usage, if modified, might facilitate future sustainability/sustainment of ESTs.

Predicting implementation of an empirically supported treatment for cancer patients using the theory of planned behavior

BACKGROUND

There is a continuing gap between the availability of cancer control empirically supported treatments (ESTs) to address psychological needs of cancer patients and their dissemination to and implementation by providers in the community. The Theory of Planned Behavior (TPB), with constructs of attitudes, subjective norms, perceived behavioral control, and intentions, is used to understand the pathways to and prediction of providers' behavior, that is, implementation of a cancer control EST and its provision to patients.

PURPOSE

The purpose of the study was to prospectively test the TPB in predicting providers' usage of a cancer-specific EST, the biobehavioral intervention (BBI).

METHOD

Providers (N = 166) were trained. At training's end, providers completed measures of attitudes, perceived behavioral control, and intentions to use the BBI, and their supervisors completed measures of attitudes operationalized as subjective norms. Providers were followed up and 4 months later reported their usage of the BBI with patients in the last 2 months. Regression-based path analyses tested attitudes, perceived behavioral control, subjective norms, and intentions as predictors of BBI usage and for the possible effect of intentions as a mediator.

RESULTS

Provider's BBI usage was high, delivered to 65.6% of patients. Providers' attitudes toward the BBI (b = .006; 95% confidence interval [CI: .002, .010]) and subjective norms (supervisors' attitudes toward providers' EST usage; b = .021; 95% CI [.007, .034]) predicted usage. Intentions predicted usage in univariate analyses but was not a mediator for usage.

CONCLUSIONS

Use of theory in implementation science can test and identify variables key to implementation success. Here the TPB identified providers' and supervisors' attitudes as predictors of EST usage. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluating the effectiveness and implementation of evidence-based treatment: A multisite hybrid design

The gap between treatment development and efficacy testing to scaled up implementations of evidence-based treatment (EBT) is an estimated 20 years, and hybrid research designs aim to reduce the gap. One was used for a multisite study in cancer control, testing coprimary aims: (a) determine the feasibility and utility of a flexible EBT implementation strategy and (b) determine the clinical effectiveness of an EBT as implemented by newly trained providers. Therapists from 15 diverse sites implemented the biobehavioral intervention (BBI) for cancer patients (N = 158) as part of standard care. For implementation, therapists determined treatment format, number of sessions, and so forth and reported session-by-session fidelity. Patients completed fidelity and outcome assessments. Results showed therapists BBI implementation was done with fidelity, for example, session "dose" (59%), core content coverage (60-70%), and others. Patient reported fidelity was favorable and comparable to the BBI efficacy trial. Effectiveness data show the primary outcome, patients' scores on the Profile of Mood States total mood disturbance, significantly improved (R² = 0.06, β = -0.24, p < .01) as did a secondary outcome, physical activity (R² = 0.02, β = 0.13, p < .05). This first use of a hybrid design in health psychology provided support for a novel strategy that allowed providers implementation flexibility. Still, the EBT was delivered with fidelity and in addition, therapists generated novel procedures to enhance setting-specific usage of BBI and its ultimate effectiveness with patients. This research is an example of translational research spanning theory and efficacy tests to dissemination and implementation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Implementation of an evidence-based biobehavioral treatment for cancer patients

One aim of dissemination and implementation (DI) research is to study the translation of evidence-based treatments (EBTs) from the research environments of their development and testing to broader communities where they are needed. There are few behavioral medicine DI studies and none in cancer survivorship. A determinant model (Setting, Therapist, Education, imPlementation, and Sustainability (STEPS)) was used to conceptualize DI of mental health treatment and frame a longitudinal study of implementation of a behavioral medicine EBT-a biobehavioral intervention (BBI) for cancer patients. Using effective dissemination strategies, therapists were trained in the BBI and followed to determine if implementation occurred. Participants (N = 108) were psychologists, social workers, and other oncology mental health providers from diverse settings to whom the BBI had been disseminated. BBI trainers then provided 6 months of support for implementation (e.g., monthly conference calls). Therapists reported number of patients treated, with or without the BBI, at 2, 4, and 6 months; use of support strategies was tracked. Generalized linear mixed models show that the proportion of patients treated with BBI ranged from 58 to 68%, with a 2% increase across follow-ups. Therapist and setting characteristics did not predict usage. Implementation of a behavioral medicine EBT provides a "real-world" demonstration of a BBI moved from the research setting to diverse communities. As the first study in cancer, it is an encouraging example of training and supporting mental health providers to deliver evidence-based psychological treatment and finding their success in doing so.

Implementing evidence-based psychological treatments for cancer patients

OBJECTIVE

New regulations and guidelines require implementation of screening and evidence based psychological treatment (EBT) for cancer patients, but little research exists to assist psychosocial care providers with implementation. This study aimed to develop a conceptual framework for community providers to consider as they embark on implementation of EBTs.

METHODS

Full-time psychosocial care providers received dissemination training in delivery of a cancer-specific EBT and then received implementation support. Qualitative data were collected in two phases. In Phase I, after training, trainees (N = 52) participated in six monthly group conference calls with six to eight trainees and EBT trainers. Qualitative data from the calls were analyzed using a grounded theory paradigm. In Phase II, the resultant framework was piloted with additional trainees (N = 73) during EBT training to prompt early planning for implementation at their home institutions.

RESULTS

In Phase I, themes of 'person' (i.e. attitudes, vocalizations, and behaviors of others) and 'environment' factors (i.e. material, monetary, and time resources of organizations) affecting implementation emerged. It appeared that both factors influenced how easily barriers could be addressed, although positive person factors also appeared to positively influence environment factors. In Phase II, trainees found the framework acceptable and considered it when generating solutions for implementation challenges.

CONCLUSIONS

The framework suggests tailoring implementation efforts to consider person and environment factors. As person support is developed, resource limitations of the environment may be more easily addressed.

Behavioral activation for depressed breast cancer patients: the impact of therapeutic compliance and quantity of activities completed on symptom reduction

OBJECTIVE

Behavioral activation (BA) is an empirically validated treatment that reduces depression by increasing overt behaviors and exposure to reinforcing environmental contingencies. Although research has identified an inverse correlation between pleasant or rewarding activities and depression, the causal relation between increased structured activities and reduced depression has not directly been studied.

METHOD

In the context of a recent randomized trial (Hopko, Armento, et al., 2011), this study used longitudinal data and growth curve modeling to examine relationships among the quantity of activities completed, proportion of activities completed (i.e., therapeutic compliance), environmental reward, and depression in breast cancer patients treated with BA treatment for depression (n = 23).

RESULTS

Therapeutic compliance with assigned activities was causally related to depression reduction, whereas the specific quantity of completed activities was not systematically related. Logistic regression indicated that for patients completing all assigned activities, treatment response and remission were achieved for all patients. Neither therapeutic compliance nor the quantity of completed activities was directly associated with self-reported environmental reward during the BA interval (Session 3 to posttreatment), and environmental reward did not mediate the relation between activation and depression.

CONCLUSIONS

Patient compliance with BA assignments is causally associated with depression reduction, whereas the quantity of completed activities is less relevant toward conceptualizing positive treatment outcome. Study findings are discussed in the context of behavioral models of depression and BA therapy.

Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: randomized trial

OBJECTIVE

Major depression is the most common psychiatric disorder among breast cancer patients and is associated with substantial impairment. Although some research has explored the utility of psychotherapy with breast cancer patients, only 2 small trials have investigated the potential benefits of behavior therapy among patients with well-diagnosed depression.

METHOD

In a primarily Caucasian, well-educated sample of women (age = 55.4 years, SD = 11.9) diagnosed with breast cancer and major depression (n = 80), this study was a randomized clinical trial testing the efficacy of 8 sessions of behavioral activation treatment for depression (BATD) compared to problem-solving therapy. Primary outcome measures assessed depression, environmental reward, anxiety, quality of life, social support, and medical outcomes.

RESULTS

Across both treatments, results revealed strong treatment integrity, excellent patient satisfaction with treatment protocols, and low patient attrition (19%). Intent-to-treat analyses suggested both treatments were efficacious, with both evidencing significant pre-post treatment gains across all outcome measures. Across both treatments, gains were associated with strong effect sizes, and based on response and remission criteria, a reliable change index, and numbers-needed-to-treat analyses, approximately ¾ of patients exhibited clinically significant improvement. No significant group differences were found at posttreatment. Treatment gains were maintained at 12-month follow-up, with some support for stronger maintenance of gains in the BATD group.

CONCLUSIONS

BATD and problem-solving interventions represent practical interventions that may improve psychological outcomes and quality of life among depressed breast cancer patients. Study limitations and future research directions are discussed.