Appropriateness Archives - Page 2 of 3 - Implementation Science at UW

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

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**}

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

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**}

✪ A strategy to implement the American College of Sports Medicine’s Exercise is Medicine® (EIM) initiative in a community oncology clinic

✪ An implementation strategy package (video education, HIV self-testing, and co-location) improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya

Abstract:

Background

Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization and the Kenyan Ministry of Health for HIV prevention in pregnancy and postpartum for women at risk for HIV. Integration of PrEP into antenatal care is promising, but delivery gaps exist in the face of healthcare provider shortages in resource-limited settings.

Methods

Between May and November 2021, we conducted a difference-in-differences study (3 months pre-intervention data collection and 3 months post-intervention data collection) analyzing four intervention facilities, where the strategies were implemented, and four comparison facilities, where no strategies were implemented. We tested a combination of three implementation strategies—video-based PrEP information in the waiting bay, HIV self-testing, and dispensing of PrEP in the antenatal care rooms—to improve PrEP delivery. We compared absolute changes in the proportion of antenatal attendees screened for PrEP (PrEP penetration), the proportion receiving all PrEP-specific steps in a visit (HIV testing, risk screening, and PrEP counseling) (PrEP fidelity), and client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes); post hoc, we compared the proportion offered PrEP (PrEP offer) and completing HIV testing. We measured provider perceptions of the acceptability and appropriateness of the implementation strategies.

Results

We observed significant improvements in PrEP penetration, PrEP offer, satisfaction, and knowledge (p < 0.05) and improvements in fidelity that trended towards significance (p = 0.057). PrEP penetration increased 5 percentage points (p = 0.008), PrEP fidelity increased 8 percentage points (p = 0.057), and PrEP offer increased 4 percentage points (p = 0.003) in intervention vs. comparison facilities. Client PrEP knowledge increased by 1.7 out of 6 total points (p < 0.001) and client satisfaction increased by 0.7 out of 24 total points (p = 0.003) in intervention vs. comparison facilities. We observed no changes in service time (0.09-min decrease; p = 0.435) and a small increase in waiting time (0.33-min increase; p = 0.005). HIV testing among those eligible did not change (1.5 percentage point decrease, p = 0.800). Providers felt the implementation strategies were acceptable and appropriate (median acceptability: 20/20; median appropriateness: 19.5/20). However, absolute levels of each step of the PrEP cascade remained suboptimal

Conclusions

An implementation strategy package with video information, HIV self-testing, and co-location of medication dispensing enhanced PrEP delivery across several implementation outcomes and client satisfaction, while not substantially increasing wait time or decreasing provider-client contact time.

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

✪ Formative Evaluation of a Comprehensive Self-Management Intervention for Irritable Bowel Syndrome, Comorbid Anxiety, and Depression: Mixed Methods Study

Abstract:

Background

Irritable bowel syndrome (IBS) is a disorder of the gut-brain interaction that is associated with abdominal pain, altered bowel patterns, and reduced quality of life. Up to 50% of patients with IBS also report anxiety or depressive symptoms. Although effective self-management interventions exist for individuals with IBS, few have been effectively implemented, and most do not consider the unique needs of patients with comorbid IBS and anxiety or depression.

Objective

This study aimed to determine the anticipated acceptability, appropriateness, feasibility, and usability of a comprehensive self-management intervention using an implementation science and human-centered design approach among individuals with comorbid IBS and anxiety or depression and health care providers.

Methods

A convergent mixed methods design was used to elicit feedback on the comprehensive self-management intervention outline and content to identify refinement needs before testing. Patients with IBS and moderate to severe anxiety or depression and health care providers were purposefully sampled from primary care and gastroenterology settings. Participants completed semistructured interviews and surveys on anticipated acceptability, appropriateness, feasibility, and usability.

Results

Patient participants (n=12) were on average 36.8 (SD 12.2) years of age, and 42% (5/12) were currently receiving psychological therapy. Health care providers (n=14) were from primary care (n=7) and gastroenterology (n=7) settings. The mean usability scores (out of 100) were 52.5 (SD 14.5) for patients and 45.6 (SD 11.6) for providers. For patients and providers, qualitative data expanded the quantitative findings for acceptability and appropriateness. Acceptability findings were the comprehensive nature of the intervention and discussion of the gut-brain interaction. For appropriateness, participants reported that the intervention provided structure, accountability, and support. Feasibility was confirmed for patients, but there was a divergence of findings between quantitative and qualitative measures for providers. Patients focused on intervention feasibility, while providers focused on implementation feasibility in the clinic. Identified usability issues to address before implementation included the intervention delivery format, length, and lack of integration into health care settings that, if not addressed, may limit the reach of the intervention

Conclusions

Patients and health care providers found the intervention acceptable and appropriate. Several feasibility and usability issues were identified, including intervention delivery methods, length of intervention, and the best methods to implement in the clinic setting. The next steps are to refine the intervention to address the identified issues and test in a pilot study whether addressing usability issues leads to the anticipated improvements in implementation and uptake.

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

✪ Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya

Abstract:

Background

Delivery of PrEP to adolescent girls and young women (AGYW) and to pregnant women through maternal and child health (MCH) and family planning (FP) clinics is scaling up in Kenya. Evaluation of implementation challenges and strategies is critical to optimize delivery.

Methods

We conducted focus group discussions (FGDs) with healthcare workers (HCWs) in MCH and FP clinics offering PrEP in a large implementation project in Kisumu, Kenya. Discussion guides were based on the Consolidated Framework for Implementation Research (CFIR). FGDs were audio recorded and transcribed. Directed content analysis was used to identify implementation challenges and strategies to overcome them.

Results

Fifty HCWs from 26 facilities participated in 8 FGDs. HCWs believed PrEP integration was appropriate because it met the needs of AGYW and pregnant women by providing a female-controlled prevention strategy and aligned with policy priorities of elimination of vertical HIV transmission. They were universally accepting of PrEP provision, especially through MCH clinics, noting the relative advantage of this approach because it: (1) enabled high coverage, (2) harmonized PrEP and MCH visits, and (3) minimized stigma compared to PrEP offered through HIV care clinics. However, HCWs noted implementation challenges affecting feasibility and adoption including: (1) increased workload and documentation burden amid workforce shortages, (2) insufficient health care worker knowledge (3) multiple implementing partners with competing priorities (4) drug and documentation form stockouts. HCWs employed various implementation strategies to overcome challenges, including task shifting from nurses to HIV testing providers, patient flow modifications (e.g., fast-tracking PrEP clients to reduce wait times), PrEP demand generation and myth clarification during health talks, provider education, dedicated PrEP delivery rooms, and coordination with adolescent-friendly services. Additional suggested strategies to improve PrEP integration included community education to increase broader PrEP awareness and enable shorter counseling sessions, and task-shifting data entry and client risk assessments.

Conclusions

HCWs were enthusiastic about the appropriateness and acceptability of integrating PrEP services into MCH and FP clinics but noted challenges to adoption and feasibility. Strategies to address challenges focused on improving provider time and space constraints, and increasing provider and client knowledge.

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

✪ Rapid ethnography and participatory techniques increase onchocerciasis mass drug administration treatment coverage in Benin: a difference-in-differences analysis

Abstract:

Background

Onchocerciasis, a neglected tropical disease (NTD) that causes blindness, is controlled via mass drug administration (MDA) where entire endemic communities are targeted with preventative chemotherapeutic treatment. However, in many settings, MDA coverage remains low. The purpose of this project was to determine if engaging communities in the development of implementation strategies improves MDA coverage.

Methods

This study took place in an intervention and a control commune in Benin, West Africa. We conducted rapid ethnography in each commune to learn about community member perceptions of onchocerciasis, MDA, and opportunities to increase MDA coverage. Findings were shared with key stakeholders and a structured nominal group technique was used to derive implementation strategies most likely to increase treatment coverage. The implementation strategies were delivered prior to and during onchocerciasis MDA. We conducted a coverage survey within 2 weeks of MDA to determine treatment coverage in each commune. A difference-in-differences design was used to determine if the implementation package effectively increased coverage. A dissemination meeting was held with the NTD program and partners to share findings and determine the perceived acceptability, appropriateness, and feasibility of implementing rapid ethnography as part of routine program improvement.

Results

During rapid ethnography, key barriers to MDA participation included trust in community drug distributors, poor penetration of MDA programs in rural or geographically isolated areas, and low demand for MDA among specific sub-populations driven by religious or socio-cultural beliefs. Stakeholders developed a five-component implementation strategy package, including making drug distributor trainings dynamic, redesigning distributor job aids, tailoring community sensitization messages, formalizing supervision, and preparing local champions. After implementing the strategy package, MDA coverage increased by 13% (95% CI: 11.0–15.9%) in the intervention commune relative to the control commune. Ministry of Health and implementing partners found the approach to be largely acceptable and appropriate; however, there was mixed feedback regarding the feasibility of future implementation of rapid ethnography.

Conclusions

Implementation research conducted in Benin, and indeed throughout sub-Saharan Africa, is often implemented in a top-down manner, with both implementation determinants and strategies derived in the global North. This project demonstrates the importance of participatory action research involving community members and implementers to optimize program delivery.

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

Lessons from the implementation of a trauma center-based program to support primary care providers in managing opioids and pain after trauma hospitalization

Abstract:

Background

Decreasing exposure to prescription opioids is critical to lowering risk of opioid misuse, overdose and opioid use disorder. This study reports a secondary analysis of a randomized controlled trial implementing an opioid taper support program directed to primary care providers (PCPs) of patients discharged from a level I trauma center to their homes distant from the center, and shares lessons for trauma centers in supporting these patients.

Methods

This longitudinal descriptive mixed-methods study uses quantitative/qualitative data from trial intervention arm patients to examine implementation challenges and outcomes: adoption, acceptability, appropriateness, feasibility, fidelity. In the intervention, a physician assistant (PA) contacted patients after discharge to review their discharge instructions and pain management plan, confirm their PCP’s identity and encourage PCP follow-up. The PA reached out to the PCP to review the discharge instructions and offer ongoing opioid taper and pain management support.

Results

The PA reached 32 of 37 patients randomized to the program. Of these 32, 81% discussed topics not targeted by the intervention (eg, social/financial). The PA identified and reached a PCP’s office for only 51% of patients. Of these, all PCP offices (100% adoption) received one to four consults (mean 1.9) per patient (fidelity). Few consults were with PCPs (22%); most were with medical assistants (56%) or nurses (22%). The PA reported that it was not routinely clear to patients or PCPs who was responsible for post-trauma care and opioid taper, and what the taper instructions were.

Conclusions

This level I trauma center successfully implemented a telephonic opioid taper support program during COVID-19 but adapted the program to allow nurses and medical assistants to receive it. This study demonstrates a critical need to improve care transition from hospitalization to home for patients discharged after trauma.

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

✪ Risk-based versus universal PrEP delivery during pregnancy: a cluster randomized trial in Western Kenya from 2018 to 2019

Abstract:

Introduction

Integrating pre-exposure prophylaxis (PrEP) delivery for pregnant and postpartum women within maternal and child health (MCH) clinics is feasible and acceptable. It is unknown whether a risk-guided model would facilitate appropriate PrEP use among MCH attendees better than universally offering PrEP.

Methods

The PrEP Implementation for Mothers in Antenatal Care (PrIMA) study was a cluster randomized trial to assess two models for PrEP delivery among pregnant women seeking routine MCH care at 20 public clinics in Kenya between January 2018 and July 2019 (NCT03070600). In the Universal arm, all participants received PrEP counselling and self-selected whether to initiate PrEP. In the Targeted arm, participants underwent an HIV risk assessment, including an objective risk-scoring tool and an offer of HIV self-tests for at-home partner testing; those determined to be at high risk received a PrEP offer. Participants were followed through 9 months postpartum. Primary outcomes included incident HIV and appropriate PrEP use (defined as PrEP uptake among those at high risk and no PrEP uptake for those not at risk). Outcomes were compared using intention-to-treat analyses, adjusting for baseline HIV risk and marital status.

Results

Among 4447 women enrolled, the median age was 24.0 years (interquartile range [IQR]: 20.9, 28.3), and most were married (84.8%). The median gestational age at enrolment was 24 weeks (IQR: 20, 30). Women in the Targeted arm were more likely to be at high risk for HIV acquisition at baseline (51.6% vs. 33.3%). During 4638 person-years (p-yr) of follow-up, there were 16 maternal HIV infections with no difference in maternal HIV incidence between arms: 0.31/100 p-yr (95% CI: 0.15, 0.65) Targeted and 0.38/100p-yr (95% CI: 0.20, 0.73) Universal (adjusted relative risk [aRR]: 0.85 [CI: 0.28, 2.55]). There was no significant difference in the frequency of appropriate PrEP use between the arms (68.2% vs. 59.1% in Targeted vs. Universal, respectively) (aRR: 1.03 [CI: 0.96, 1.10]).

Conclusions

Given comparable maternal HIV incidence and PrEP uptake in Universal and Targeted approaches, and the simplicity that universal PrEP offers, our findings suggest that universal PrEP counselling is optimal for integrating PrEP in MCH systems.

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

✪ Implementing Dialectical Behavior Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A) in a Low-Income School

Abstract:

Adolescents living in low-income areas often have high need for mental health supports due to experiences of poverty and trauma, coupled with limited access and availability of such supports. This study investigated the implementation of a socio-emotional learning curriculum titled, “Dialectical Behavior Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A),” which was integrated into health classes in a low-income high school.

While preliminary evidence suggests that DBT STEPS-A can be effective in reducing mental health symptoms in high school students, this study is the first to explore the program’s acceptability, appropriateness, and feasibility when implemented in a low-income school. The implementation presented here also diverged from recommended training protocols due to time and cost limitations. Quantitative and qualitative data were collected from 29 school stakeholders prior to implementation and from 23 school stakeholders post-implementation.

Our results indicate that DBT STEPS-A is acceptable and feasible for teachers involved in offering the program and that more work is needed to address appropriateness of the content for racially and socio-economically diverse students, ease of implementing lessons, and support for teachers using DBT STEPS-A skills outside of class. We conclude with a discussion of key implementation challenges and solutions generated.

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

Authors:

✪ Open Access

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

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✪ Open Access

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

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✪ Open Access

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

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✪ Open Access

Read the full text in the open access journal Trauma Surgery and Acute Care Open

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✪ Open Access

Read the full text in the open access journal Journal of the International AIDS Society

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✪ Open Access

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

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