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Implementation Science at UW

Keywords: Aaron R. Lyon

✪ Changing hearts and minds: theorizing how, when, and under what conditions three social influence implementation strategies work

Authors:

Bryan J Weiner, Rosemary D Meza, Predrag Klasnja, Rebecca Lengnick-Hall, Gretchen J Buchanan, Aaron R Lyon, Kayne D Mettert, Marcella H Boynton, Byron J Powell, and Cara C Lewis

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: September 2024

Read the full text in the open access journal Frontiers in Health Services

Abstract:

Background

Opinion leadership, educational outreach visiting, and innovation championing are commonly used strategies to address barriers to implementing innovations and evidence-based practices in healthcare settings. Despite voluminous research, ambiguities persist in how these strategies work and under what conditions they work well, work poorly, or work at all. The current paper develops middle-range theories to address this gap.

Methods

Conceptual articles, systematic reviews, and empirical studies informed the development of causal pathway diagrams (CPDs). CPDs are visualization tools for depicting and theorizing about the causal process through which strategies operate, including the mechanisms they activate, the barriers they address, and the proximal and distal outcomes they produce. CPDs also clarify the contextual conditions (i.e., preconditions and moderators) that influence whether, and to what extent, the strategy's causal process unfolds successfully. Expert panels of implementation scientists and health professionals rated the plausibility of these preliminary CPDs and offered comments and suggestions on them.

Findings

Theoretically, opinion leadership addresses potential adopters' uncertainty about likely consequences of innovation use (determinant) by promoting positive attitude formation about the innovation (mechanism), which results in an adoption decision (proximal outcome), which leads to innovation use (intermediate outcome). As this causal process repeats, penetration, or spread of innovation use, occurs (distal outcome). Educational outreach visiting addresses knowledge barriers, attitudinal barriers, and behavioral barriers (determinants) by promoting critical thinking and reflection about evidence and practice (mechanism), which results in behavioral intention (proximal outcome), behavior change (intermediate outcome), and fidelity, or guideline adherence (distal outcome). Innovation championing addresses organizational inertia, indifference, and resistance (determinants) by promoting buy-in to the vision, fostering a positive implementation climate, and increasing collective efficacy (mechanisms), which leads to participation in implementation activities (proximal outcome), initial use of the innovation with increasing skill (intermediate outcome) and, ultimately, greater penetration and fidelity (distal outcomes). Experts found the preliminary CPDs plausible or highly plausible and suggested additional mechanisms, moderators, and preconditions, which were used to amend the initial CPD.

Discussion

The middle-range theories depicted in the CPDs furnish testable propositions for implementation research and offer guidance for selecting, designing, and evaluating these social influence implementation strategies in both research studies and practice settings.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ A Community-Partnered Research Process for Implementation Strategy Design: Developing Resources to Support Behavioral Classroom Interventions

Authors:

Gwendolyn M. Lawson, Julie Sarno Owens, David S. Mandell, Samantha Tavlin, Steven Rufe, Aubrey Depa, Aaron R. Lyon, & Thomas J. Power

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: June 2024

Read the full text in the open access journal School Mental Health

Abstract:

Schools need effective, sustainable implementation strategies to support teachers in using effective Tier 1 (i.e., whole class) and Tier 2 (i.e., targeted) behavioral interventions in the classroom. This paper describes an iterative, community-partnered process of developing implementation resources to support teachers in using Tier 1 and 2 positive behavior management interventions; we call these resources the Positive Behavior Management Toolkit (PBMT). There were two key aspects to the iterative development process: 1) working with a Program Development Team of district—and school-employed partners to identify priorities, interpret data, provide feedback on resources, and plan for sustainment; and 2) conducting a series of tryouts in which teachers used a version of the PBMT in their classrooms and provided quantitative and qualitative feedback on acceptability, appropriateness, feasibility, and recommendations for improvement. In partnership with the Program Development Team, we used data from the tryouts to inform revisions to the PBMT. This paper presents quantitative and qualitative data from the tryouts and describes how these data informed revisions to the PBMT. We also describe the processes by which we engaged the team, considerations related to contextual appropriateness, and lessons learned related to community-engaged intervention development research.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): a modified Delphi study

Authors:

Stephanie K. Brewer, Catherine M. Corbin, Ana A. Baumann, Shannon Wiltsey Stirman, Janine M. Jones, Michael D. Pullmann, Aaron R. Lyon & MODIFI Expert Panel

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: June 2024

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

Method

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability and inclusion (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

Results

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

Discussion

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

Contributions to the literature
  • Adaptation of evidence-based practices, programs, and treatments is often needed to ensure successful implementation. However, existing theories/models/frameworks do not outline concrete adaptation steps that are feasible for real-world settings.
  • We created a resource-efficient method (MODIFI) for developing and assessing intervention adaptations in local settings. This method was iteratively developed through a mixed-methods modified Delphi process, which resulted in consensus among experts in implementation science and practice.
  • MODIFI leverages human centered design techniques and is tailored to the needs of intervention implementers in applied settings, filling a crucial gap in the research to practice pipeline.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): a modified Delphi study

Authors:

Stephanie K. Brewer, Catherine M. Corbin, Ana A. Baumann, Shannon Wiltsey Stirman, Janine M. Jones, Michael D. Pullmann, Aaron R. Lyon & MODIFI Expert Panel

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: June 2024

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

Method

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability and inclusion (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

Results

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

Discussion

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

Contributions to the literature
  • Adaptation of evidence-based practices, programs, and treatments is often needed to ensure successful implementation. However, existing theories/models/frameworks do not outline concrete adaptation steps that are feasible for real-world settings.
  • We created a resource-efficient method (MODIFI) for developing and assessing intervention adaptations in local settings. This method was iteratively developed through a mixed-methods modified Delphi process, which resulted in consensus among experts in implementation science and practice.
  • MODIFI leverages human centered design techniques and is tailored to the needs of intervention implementers in applied settings, filling a crucial gap in the research to practice pipeline.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Inter-organizational alignment and implementation outcomes in integrated mental healthcare for children and adolescents: a cross-sectional observational study

Authors:

Yanchen Zhang, Madeline Larson, Mark G. Ehrhart, Kevin King, Jill Locke, Clayton R. Cook, & Aaron R. Lyon

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: May 2024

Read the full text in the open access journal Implementaion Science

Abstract:

Background

Integrated care involves care provided by a team of professionals, often in non-traditional settings. A common example worldwide is integrated school-based mental health (SBMH), which involves externally employed clinicians providing care at schools. Integrated mental healthcare can improve the accessibility and efficiency of evidence-based practices (EBPs) for vulnerable populations suffering from fragmented traditional care. However, integration can complicate EBP implementation due to overlapping organizational contexts, diminishing the public health impact. Emerging literature suggests that EBP implementation may benefit from the similarities in the implementation context factors between the different organizations in integrated care, which we termed inter-organizational alignment (IOA). This study quantitatively explored whether and how IOA in general and implementation context factors are associated with implementation outcomes in integrated SBMH.

Methods

SBMH clinicians from community-based organizations (CBOs; nclinician = 27) and their proximal student-support school staff (nschool = 99) rated their schools and CBOs (clinician only) regarding general (organizational culture and molar climate) and implementation context factors (Implementation Climate and Leadership), and nine common implementation outcomes (e.g., treatment integrity, service access, acceptability). The levels of IOA were estimated by intra-class correlations (ICCs). We fitted multilevel models to estimate the standalone effects of context factors from CBOs and schools on implementation outcomes. We also estimated the 2-way interaction effects between CBO and school context factors (i.e., between-setting interdependence) on implementation outcomes.

Results

The IOA in general context factors exceeded those of implementation context factors. The standalone effects of implementation context factors on most implementation outcomes were larger than those of general context factors. Similarly, implementation context factors between CBOs and schools showed larger 2-way interaction effects on implementation outcomes than general context factors.

Conclusions

This study preliminarily supported the importance of IOA in context factors for integrated SBMH. The findings shed light on how IOA in implementation and general context factors may be differentially associated with implementation outcomes across a broad array of integrated mental healthcare settings.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Helping Educational Leaders Mobilize Evidence (HELM): The iterative redesign of the Leadership and Organizational Change for Implementation (LOCI) intervention for use in schools

Authors:

Jill Locke, Cathy M. Corbin, Vaughan K. Collins, Mark G. Ehrhart, Roger Goosey, Kurt Hatch, Christine Espeland, Clayton R. Cook, and Aaron R. Lyon

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2024

Read the full text in the open access journal Implementation Research and Practice

Abstract:

Background

Few “intervention agnostic” strategies have been developed that can be applied to the broad array of evidence-based practices (EBPs) in schools. This paper describes two studies that reflect the initial iterative redesign phases of an effective leadership-focused implementation strategy—Leadership and Organizational Change for Implementation (LOCI)—to ensure its acceptability, feasibility, contextual appropriateness, and usability when used in elementary schools. Our redesigned strategy—Helping Educational Leaders Mobilize Evidence (HELM)—is designed to improve principals’ use of strategic implementation leadership to support the adoption and high-fidelity delivery of a universal EBP to improve student outcomes.

Method

In Study 1, focus groups were conducted (n = 6) with 54 district administrators, principals, and teachers. Stakeholders provided input on the appropriateness of original LOCI components to maximize relevance and utility in schools. Transcripts were coded using conventional content analysis. Key themes referencing low appropriateness were summarized to inform LOCI adaptations. We then held a National Expert Summit (Study 2) with 15 research and practice experts. Participants provided feedback via a nominal group process (NGP; n = 6 groups) and hackathon (n = 4 groups). The research team rated each NGP suggestion for how actionable, impactful/effective, and feasible it was. We also coded hackathon notes for novel ideas or alignment with LOCI components.

Results

Study 1 suggestions included modifications to LOCI content and delivery. Study 2's NGP results revealed most recommendations to be actionable, impactful/effective, and feasible. Hackathon results surfaced two novel ideas (distributed leadership teams and leaders’ knowledge to support educators EBP use) and several areas of alignment with LOCI components.

Conclusion

Use of these iterative methods informed the redesign of LOCI and the development of HELM. Because it was collaboratively constructed, HELM has the potential to be an effective implementation strategy to support the use of universal EBP in schools.

Plain Language Summary

Our research team designed a strategy (HELM) for school principals to improve the support they provide to staff to implement practices proven to work in research for improving student outcomes. We designed HELM by conducting focus groups with school district administrators, principals, and teachers. Participants were asked for their feedback on how to adapt an existing leadership strategy (LOCI) to the school context. After collecting this feedback, we held a meeting with 15 research and practice experts. During this meeting, the group of experts reviewed the focus group feedback and decided how to incorporate it into the design of the HELM strategy. We believe that collecting this feedback and involving research and practice experts in interpreting and integrating participant feedback into the HELM strategy will make HELM a more effective strategy for supporting school principals’ in implementing supports in their schools.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Leveraging human-centered design and causal pathway diagramming toward enhanced specification and development of innovative implementation strategies: a case example of an outreach tool to address racial inequities in breast cancer screening

Authors:

Leah M. Marcotte, Raina Langevin, Bridgette H. Hempstead, Anisha Ganguly, Aaron R. Lyon, Bryan J. Weiner, Nkem Akinsoto, Paula L. Houston, Victoria Fang, & Gary Hsieh

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2024

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Implementation strategies are strategies to improve uptake of evidence-based practices or interventions and are essential to implementation science. Developing or tailoring implementation strategies may benefit from integrating approaches from other disciplines; yet current guidance on how to effectively incorporate methods from other disciplines to develop and refine innovative implementation strategies is limited. We describe an approach that combines community-engaged methods, human-centered design (HCD) methods, and causal pathway diagramming (CPD)—an implementation science tool to map an implementation strategy as it is intended to work—to develop innovative implementation strategies.

Methods

We use a case example of developing a conversational agent or chatbot to address racial inequities in breast cancer screening via mammography. With an interdisciplinary team including community members and operational leaders, we conducted a rapid evidence review and elicited qualitative data through interviews and focus groups using HCD methods to identify and prioritize key determinants (facilitators and barriers) of the evidence-based intervention (breast cancer screening) and the implementation strategy (chatbot). We developed a CPD using key determinants and proposed strategy mechanisms and proximal outcomes based in conceptual frameworks.

Results

We identified key determinants for breast cancer screening and for the chatbot implementation strategy. Mistrust was a key barrier to both completing breast cancer screening and using the chatbot. We focused design for the initial chatbot interaction to engender trust and developed a CPD to guide chatbot development. We used the persuasive health message framework and conceptual frameworks about trust from marketing and artificial intelligence disciplines. We developed a CPD for the initial interaction with the chatbot with engagement as a mechanism to use and trust as a proximal outcome leading to further engagement with the chatbot.

Conclusions

The use of interdisciplinary methods is core to implementation science. HCD is a particularly synergistic discipline with multiple existing applications of HCD to implementation research. We present an extension of this work and an example of the potential value in an integrated community-engaged approach of HCD and implementation science researchers and methods to combine strengths of both disciplines and develop human-centered implementation strategies rooted in causal perspective and healthcare equity.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Centering School Leaders’ Expertise: Usability Evaluation of a Leadership-Focused Implementation Strategy to Support Tier 1 Programs in Schools

Authors:

Vaughan K. Collins, Catherine M. Corbin, Jill J. Locke, Clayton R. Cook, Mark G. Ehrhart, Kurt D. Hatch & Aaron R. Lyon

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2024

Read the full text open access in the journal School Mental Health

Abstract:

Although there are a growing number of implementation strategies to increase the adoption, fidelity, and sustainment of evidence-based practices (EBP), they are often complex and bulky, which can interfere with their widespread application. To address these challenges, the Helping Educational Leaders Mobilize Evidence (HELM) strategy was created as an adaptation of the evidence-based Leadership and Organizational Change for Implementation (LOCI) implementation strategy to enhance elementary school principals’ use of strategic implementation leadership to support the adoption and delivery of Tier 1 (i.e., universal social, emotional, and behavioral) EBP. In service of its iterative development, a human-centered design methodology was employed to increase the successful uptake and use of HELM. The Cognitive Walkthrough for Implementation Strategies (CWIS), a novel mixed-methods approach to evaluate implementation strategy usability, was applied to identify and test HELM strategy tasks of critical importance. A sample of 15 elementary school principals participated in group cognitive walkthrough testing as either school principal recipients or HELM coaches. Both user types rated the strategy as acceptable (principal M = 77.8, SD = 15.5; coach M = 87.5, SD = 7.9). Five usability issues were identified using a highly structured common usability issue framework and provided direction for the generation of redesign solutions to be incorporated in a subsequent version of the HELM strategy. The evaluation of the strategy’s usability improved its alignment with user needs, expectations, and contextual constraints, rendering a more usable strategy and broadly applicable information surrounding the development of psychosocial implementation strategies in real-world settings.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Fidelity-consistency and deliberateness of modifications in parenting programs

Authors:

Kristoffer Pettersson, Pernilla Liedgren, Aaron R. Lyon, Henna Hasson & Ulrica von Thiele Schwarz

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: February 2024

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Evidence-based interventions (EBIs) are frequently modified in practice. It is recommended that decisions to modify EBIs should be made deliberately to ensure fidelity-consistency, yet the relationship between fidelity-consistency and deliberateness is not well understood. This study aims to explore modifications in a sample of practitioners delivering evidence-based parenting programs (i.e., interventions to strengthen parent–child relationships, reduce harmful interactions, and improve child health and well-being). The study investigated three research questions: (1) What kind of modifications are made during the delivery of parenting programs? (2) To what degree are the identified modifications consistent with the core functions of each program? and (3) Is deliberateness associated with the fidelity-consistency of the identified modifications?

Methods

In total, 28 group leaders of five widely disseminated parenting programs in Sweden participated in five focus groups, and two participants from each group also participated in individual interviews (n = 10). A content analysis approach was used where the identification of modifications was directed by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and then assessed for fidelity-consistency and four levels of deliberateness (universal, situational, conditional, and unintentional). Chi-square tests were performed to compare consistent and inconsistent modifications, and logistic regression was performed to explore whether deliberateness predicted consistency

Results

A total of 137 content modifications were identified, covering most of the content modification categories in FRAME. The most common were tailoring/tweaking/refining, adding elements, shortening/condensing, lengthening/extending, and integrating another treatment. Modifications were mostly fidelity-consistent but consistency varied greatly among categories. Furthermore, modifications made unintentionally or situationally were more likely to be fidelity-inconsistent

Conclusions

These results indicate that explicit consideration of modifications and their impact could be essential for sustaining the fidelity-consistent use of EBIs, even as such interventions are continuously modified.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**