Barriers and Facilitators Archives - Implementation Science at UW

✪ An integrative review of implementation science in climate change and health adaptation research

Abstract:

Introduction

As climate change accelerates, reducing associated health risks requires uptake of effective approaches to adaptation at scale. However, translating climate change and health adaptation (CCHA) interventions into practice remains a persistent challenge for both researchers and practitioners. Implementation science provides tools to study methods and strategies that facilitate the adoption and sustainability of interventions into practice, but its application in the CCHA domain has not yet been examined.

Methods

In response, this integrative literature review identifies how implementation science has been applied to assess determinants, strategies, and outcomes of CCHA interventions, and to evaluate gaps, strengths, and limitations in the existing literature. Nineteen articles were identified through systematic searches of four databases and expert recommendations. Discrete data domains, defined a priori, were extracted and synthesized across articles.

Results

Findings demonstrated wide variability in the use of implementation frameworks, the identification and assessment of implementation strategies and outcomes, and the overall conceptualization of CCHA interventions. Findings highlight a critical opportunity to leverage implementation science as a tool to strengthen the assessment and uptake of CCHA efforts in public health practice.

Conclusion

In the face of the accelerating climate crisis, there is an urgent need for implementation science and climate change and health experts to work together to overcome conceptual and operational challenges to the use of implementation science frameworks and methods to advance the field.

Highlights

The formal use of implementation science in published CCHA research is limited.
Opportunities exist to adapt implementation science frameworks to CCHA research.
Investing in these opportunities can improve uptake of CCHA interventions.

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

✪ Advancing global pediatric cancer survivorship care: barriers, facilitators, and implementation strategies

Abstract:

Background

As more children with cancer experience improved treatment outcomes across the world, challenges arise with ongoing care needs due to a higher risk of mortality and chronic health conditions compared to the general population. Addressing global pediatric cancer survivorship care, especially in low- and middle-income countries (LMICs), is of growing importance. The current study used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC) to examine the barriers, facilitators, and strategies for implementing childhood cancer survivorship care in LMICs.

Methods

Using a larger review (PROSPERO registration CRD42021242548), a total of 8,456 articles were considered. The search identified nine eligible articles mentioning determinants of survivorship care across LMICs. Data were extracted from these articles using the CFIR domains of outer setting, inner setting, and individuals. Assigned CFIR constructs were then paired with ERIC strategies using the CFIR–ERIC matching tool.

Results

The nine studies were published between 2003 and 2020, representing the following countries: India, Brazil, Turkey, China, and Thailand. Inner setting barriers included lack of available resources—funding, space, materials, and guidelines. Outer setting barriers were related to financing, policies, and laws. Individual patient barriers reported were low health literacy, distance to care centers, and low prioritization of follow-up. No common facilitators were noted. The most feasible ERIC strategies for the barriers identified were accessing new funding, developing and distributing educational materials, developing resource-sharing agreements, and conducting local survivorship care needs assessments.

Conclusions

There are limited existing data evaluating childhood cancer survivorship care barriers in LMICs. Of the studies we identified, low resource availability was a frequently reported barrier. As accessing funding can be difficult, resource sharing of contextually adapted guidelines and educational materials can serve as an implementation strategy to improve survivorship care globally.

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

✪ Getting to Implementation: applying data-driven implementation strategies to improve guideline concordant surveillance for hepatocellular carcinoma

Authors:

Vera Yakovchenko, Chaeryon Kang, Brittney Neely, Carolyn Lamorte, Heather McCurdy, Dawn Scott, Anna Nobbe, Gwen Robins, Nsikak R. Ekanem, Monica Merante, Sandra Gibson, Patrick Spoutz, Linda Chia, Rachel I. Gonzalez, Matthew J. Chinman, David Ross, Maggie Chartier, Lauren A. Beste, Jasmohan S. Bajaj, Tamar Taddei, Timothy R. Morgan & Shari S. Rogal

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: December 2025

Read the full text in the open access journal Implementation Science

Abstract:

Background

While guidelines recommend twice-yearly liver cancer (hepatocellular carcinoma, HCC) surveillance for people with cirrhosis, adherence to these guidelines remains variable. We aimed to empirically identify and apply successful implementation strategies through Getting to Implementation (GTI), a manualized facilitation approach.

Method

A hybrid type III, stepped-wedge, cluster-randomized trial was conducted at 12 underperforming Veterans Health Administration (VA) sites between October 2020 and October 2022. GTI included a stepwise approach to guide sites to detail their current state, set implementation goals, identify implementation barriers, select implementation strategies, make a work plan, conduct an evaluation, and sustain their work. Outcomes were defined using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

Results

Facilitators supported site teams with an average of 20±6 facilitation hours over a 12-month period. Ten of 12 sites (83%) adopted GTI and applied a median of five strategies (e.g., dashboard use, small tests of change, direct patient outreach). Reach, the primary outcome, increased from mean 29.1% to mean 38.8% at-risk Veterans receiving HCC surveillance from pre- to post-intervention, and further increasing to 41.3% in the sustainment period. In both unadjusted and adjusted models, the odds of HCC surveillance were significantly higher during intervention (adjusted odds ratio, aOR=1.67, 95% CI:1.59, 1.75) and during sustainment (aOR=1.69, 95% CI:1.60, 1.78) compared with baseline, and with difference between active and sustainment periods, indicating sustained improvement after active facilitation ended.

Conclusions

GTI sustainably improved HCC surveillance, suggesting that applying data-driven implementation strategies within a manualized facilitation approach can improve care.

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

✪ Feasibility and Implementation of INTERVAL-GAP4: A Global Randomised Controlled Trial of Intense Hybrid-supervised/Self-managed Versus Self-directed Exercise for Metastatic Prostate Cancer

Authors:

Stacey A Kenfield, Nicolas H Hart, Kerry S Courneya, Rosemary Greenwood , June M Chan, Jennette Sison, Li Zhang, Sarah RudmaN, Leah Ung, Moritz Schumann, Erin L Van Blarigan, Sam McKeown, Charles J Ryan, James Catto, Daniel A Galvão, Robert U Newton, Fred Saad; INTERVAL-GAP4 Site Investigators and INTERVAL-GAP4 Steering and Management Committees (Stephen R. Plymate, Committee Member

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: December 2025

Read the full text in the open access journal European Urology Open Science

Abstract:

Background and objective

Physical activity is associated with a lower risk of mortality in men with prostate cancer (PC); yet, randomised controlled trials with survival endpoints are nonexistent. INTense ExeRcise for surviVAL-Global Action Plan 4 (INTERVAL-GAP4) was a global phase 3 trial designed to test whether structured, hybrid-supervised/self-managed exercise improves survival in men with metastatic PC. The trial was stopped early due to poor accrual. This paper reports feasibility and implementation outcomes.

Methods

Men with metastatic PC were randomised (1:1) to a supervised/self-managed moderate- to high-intensity resistance and aerobic programme (three sessions per week for 2 yr) or to self-directed exercise. We evaluated site activation, recruitment, year 1 adherence, adverse events, and barriers to global trial feasibility. Efficacy outcomes—including survival, physical fitness, and biomarker results—will be reported separately.

Key findings and limitations

Of 21 activated sites across seven countries, 13 (62%) randomised patients. Of 938 patients approached, 232 (25%) consented and 145 (15%) were randomised (75 in the intervention and 70 in the control group) between April 2016 and February 2023. The median age was 70 yr (range: 44–89 yr). The study closed early after reaching 17% of the intended target. The median adherence in the intervention arm was 84% (interquartile range: 61–95%), with no difference between metastatic castrate-resistant and hormone-sensitive PC. At 12 mo, 58% of intervention participants met exercise guidelines versus 24% of controls. In year 1, 162 adverse events occurred in the intervention group and 109 in the control group; 19 adverse events were study related, all in the intervention arm. The major feasibility challenges included administrative burden, infrastructure limitations, logistics of supervised exercise delivery, and coronavirus disease 2019 disruptions.

Conclusions and clinical implications

While high adherence to a demanding exercise programme was achieved in selected metastatic PC patients, global recruitment proved difficult. Future large-scale exercise-oncology trials require streamlined protocols, realistic timelines, and greater alignment with site resources. Implementation science research is needed to support integration of exercise into routine advanced cancer care. A forthcoming paper will present the trial’s survival and physical fitness efficacy outcomes.

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

✪ Protocol for the process evaluation of a randomised clinical trial of incremental-start versus conventional haemodialysis: the TwoPlus study

Authors:

Mariana Murea, Kristie L Foley, Samir C Gautam, Jennifer E Flythe , Jochen G Raimann, Emaad Abdel-Rahman, Alaa S Awad, Vandana Dua Niyyar, Cassandra Kovach, Glenda V Roberts, Nicole M Jefferson, Paul T Conway, Laura M Rosales, Jobira Woldemichael, Hiba I Sheikh, Gaurav Raman, Anne M Huml, Daphne H Knicely, Irtiza Hasan, Bhaktidevi Makadia , Janice Lea, John T Daugirdas, Nihan Gencerliler, Jasmin Divers, Peter Kotanko, TwoPlus Research Consortium & Ucheoma C Nwaozuru

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: November 2025

Read the full text in the open access journal BMJ Open

Abstract:

Introduction

Process evaluation provides insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines the protocol for a process evaluation embedded in a hybrid type 1 effectiveness-implementation randomised clinical trial of incremental-start haemodialysis (HD) versus conventional HD delivered to patients starting chronic dialysis (the TwoPlus Study). The trial will simultaneously assess the effectiveness of incremental-start HD in real-world settings and the implementation strategies needed to successfully integrate this intervention into routine practice. This manuscript describes the rationale and methods used to capture how incremental-start HD is implemented across settings and the factors influencing its implementation success or failure within this trial.

Methods and analysis

We will use the Consolidated Framework for Implementation Research (CFIR) and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) frameworks to inform process evaluation. Mixed methods include surveys conducted with treating providers (physicians) and dialysis personnel (nurses and dialysis administrators); semi-structured interviews with patient participants, caregivers of patient participants, treating providers (physicians and advanced practice practitioners), dialysis personnel (nurses, dieticians and social workers); and focus group meetings with study investigators and stakeholder partners. Data will be collected on the following implementation determinants: (a) organisational readiness to change, intervention acceptability and appropriateness; (b) inner setting characteristics underlying barriers and facilitators to the adoption of HD intervention at the enrollment centres; (c) external factors that mediate implementation; (d) adoption; (e) reach; (f) fidelity, to assess adherence to serial timed urine collection and HD treatment schedule; and (g) sustainability, to assess barriers and facilitators to maintaining intervention. Qualitative and quantitative data will be analysed iteratively and triangulated following a convergent parallel and pragmatic approach. Mixed methods analysis will use qualitative data to lend insight to quantitative findings. Process evaluation is important to understand factors influencing trial outcomes and identify potential contextual barriers and facilitators for the potential implementation of incremental-start HD into usual workflows in varied outpatient dialysis clinics and clinical practices. The process evaluation will help interpret and contextualise the trial clinical outcomes’ findings.

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

✪ Exploring Factors Across Levels Impacting Educators’ Selection of Evidence-Based Practices for Autistic Students

Abstract:

Introduction

Front-line implementers report that selecting an evidence-based practice is the most challenging aspect of supporting Autistic students, which may contribute to the long-standing implementation gap. There is a need to understand educators’ (special education teachers’, general education teachers’, and paraeducators’) decision-making and determinants of their evidence-based practice (EBP) selection.

Method

This study aimed to identify educators’ decision-making factors, focusing on (a) information sources and (b) factors within the student, intervention, educator, and classroom levels. Eighty-one educators (general education teachers, special education teachers, and paraeducators) participated in semistructured interviews regarding their EBP selection for a specific student they served in inclusive classrooms.

Results

General and special education teachers cited EBP sources from their teacher preparation and colleagues with autism expertise, while paraeducators relied on existing classroom practices and guidance from other educators. EBP decision-making frequently revolved around student and intervention characteristics, focusing less on educator, environment, and resource determinants. Educators made individualized EBP decisions for each student, selecting EBPs that served all students. They also shared that their decision-making was most supported through collaboration, despite limited opportunity.

Conclusion

The study provides insights into key team members’ EBP selection for Autistic students to aid in the development of implementation supports.

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

✪ Assessing ‘connective tissue’ in public-private partnerships: a stakeholder survey on multisectoral collaboration in global health

Abstract:

Background

Public-private partnerships have the potential to advance solutions to complex dilemmas such as the prevention and control of noncommunicable diseases. Knowledge creation, trust, and social capital among partners – encapsulated in the term “connective tissue” – are key considerations for the cohesion and sustainability of multisectoral collaborative efforts in global health.

Methods

A survey was conducted with 23 stakeholders of projects in four countries supported by Access Accelerated, a collective of biopharmaceutical and life sciences companies. The survey elicited perspectives on the factors that strengthen collaboration and develop knowledge creation, trust, and social capital within the multisectoral partner network.

Results

Survey respondents related how connective tissue was cultivated through implementation of multiple projects with shared goals. Identified barriers to effective collaboration included resource constraints, while facilitators included shared objectives and overlapping activities. Qualitative responses provide deeper understanding of how multisectoral collaboration contributed to the sustainability of the Access Accelerated initiative.

Conclusion

Measurement of connective tissue enhances understanding of project performance by addressing dynamic and previously overlooked outcomes of multisectoral collaboration. Multisectoral health initiatives can incorporate implementation science methods into measurement approaches to strengthen connective tissue among partners and stakeholders.

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

✪ Perceptions and practices of long-acting injectable antipsychotic administration in community pharmacies within Washington state: A qualitative implementation science study

Abstract:

Background

Use of long-acting injectable antipsychotics (LAIAs) for schizophrenia are associated with improved medication adherence and reduce relapse and hospitalizations compared to oral antipsychotics; however, despite these advantages LAIAs remain underutilized. Community pharmacies could improve access and reduce logistical barriers to LAIA administration; however, relatively few deliver this service, and we do not yet fully understand why.

Objective

To assess the contextual fit of administering LAIAs in community pharmacies, identify determinants influencing implementation, and inform implementation strategies to optimize and increase LAIA delivery across Washington State.

Methods

Key informant interviews were conducted with community pharmacy staff in Washington State using a hybrid deductive–inductive qualitative approach to explore determinants and compatibility of LAIA administration. Interviews were conducted using a semi-structured guide informed by Proctor's Implementation Outcomes Framework. Using rapid analysis, transcripts were summarized in a structured matrix and coded into a priori domains. Barriers and facilitators were inductively categorized and then deductively-mapped to the Consolidated Framework for Implementation Research domains; recommendations were identified to inform future implementation strategies.

Results

Ten interviews were conducted with 9 community pharmacists and one pharmacy technician. Current practices varied across participants administering LAIAs in community pharmacies. Reimbursement and payment for LAIA administration emerged as the top barrier. Appointment-based models were seen as facilitators by improving predictability for staffing and medication inventory. Participants recommended streamlining reimbursement and turnkey toolkits for training, care coordination, and communication between prescribers.

Conclusion

For community pharmacies within Washington State, payment models and reimbursement present a critical barrier to LAIA administration. Optimizing billing processes, improving funding and contracting mechanisms, and engaging payers may expand LAIA services. These represent both outer-setting and inner-setting factors, meaning that optimizing LAIA administration in community pharmacies will require system-level, multistakeholder involvement and research.

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

✪ “Though there are some challenges, we try our best to follow the guidelines”: a qualitative study exploring determinants of providing guideline-adherent care to hospitalized children in Kenya

Abstract:

Background

Clinical treatment guidelines are designed to improve quality of care by offering clear recommendations for health workers; however, across many settings, implementing guidelines is a challenge. For over 20 years, comprehensive World Health Organization guidelines for care of hospitalized children have provided guidance for treating the primary causes of childhood death. These recommendations were adapted in Kenya and codified in the Basic Paediatric Protocol; however, adherence to these evidence-based interventions remains suboptimal.

Methods

This qualitative study identified the barriers and facilitators of providing guideline-adherent care to children admitted to two hospitals in Kenya. The semi-structured question guide was informed by the Theoretical Domains Framework (TDF). Three focus group discussions and 16 in-depth interviews were conducted with 35 health workers. Participants were nurses, doctors, clinical officers, or nutritionists (including in-charges and clinical supervisors). Interviews were audio recorded and transcribed. Transcripts were coded using a TDF-based codebook, validated, and analyzed for themes.

Results

TDF domains with the greatest influence on the thematic findings were environmental context and resources, social influences, beliefs about consequences, and beliefs about capabilities. Health workers were knowledgeable about guidelines and felt strongly that adherence to them was beneficial; however, they also faced barriers implementing them. Challenges related to the environmental context were pervasive, including shortages of staff and supplies. Participants praised the simplicity of guidelines but also noted that simplified diagnostic criteria don’t align with complex patient presentations. While guidelines empowered some nurses to make clinical decisions, respondents reported that strict professional roles sometimes delayed diagnosis and treatment. Further, health workers reported some deviations were intentional (ex. when guidelines were not aligned to their beliefs) and other times they were unintentional (ex. when complex patient presentations make guideline adherence difficult).

Conclusions

Knowledge of guidelines and motivation to use them were not major determinants in this analysis. Rather, human and material resource shortages presented the greatest barrier to guideline adherence in this setting. Improving guidelines by involving health workers in participatory development of guidelines would improve both clarity and feasibility. Health workers are well-versed in guideline recommendations, so educational strategies should focus on knowledge gaps or changes in the latest version of guidelines.

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

Tailored strategies to increase the use of an evidence-based psychotherapy for posttraumatic stress disorder: A stepped-wedge randomized trial in military clinics

Authors:

Craig S Rosen, Alan L Peterson, David S Riggs, Christopher K Haddock, Chunki Fong, Stacey Young-McCaughan, Jeffrey Cook, Katherine Anne Comtois, Elisa V Borah, C Adrian Davis, Katherine A Dondanville, Erin P Finley, Sara A Jahnke, Melissa Mistretta, Andrea Neitzer, Shannon Wiltsey-Stirman, Erin R Frick, Olivia Hayes, Spencer Clayton, Allison M Conforte, Araceli Flores, Jeremy Jinkerson , Zachary K Jones, Hana J Kim, Margaret Letendre, Jared S Link, Debra Nofziger, Erik N Ringdahl, John W Waggoner, Craig Woodworth, Emily Ho, Carmen P McLean & TACTICS Research Group

^{University of Washington affiliated authors are displayed in bold.}

Subscription Required for Full Text Access

Published: October 2025

Authors:

✪ Open Access

Read the full text in the open access Journal of Climate Change and Health

Abstract:

Introduction

Methods

Results

Conclusion

Highlights

Authors:

✪ Open Access

Read the full text in the open access journal Journal of Cancer Survivorship: Research and Practice

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Science

Abstract:

Background

Method

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal European Urology Open Science

Abstract:

Background and objective

Methods

Key findings and limitations

Conclusions and clinical implications

Authors:

✪ Open Access

Read the full text in the open access journal BMJ Open

Abstract:

Introduction

Methods and analysis

Authors:

✪ Open Access

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

Abstract:

Introduction

Method

Results

Conclusion

Authors:

✪ Open Access

Read the full text in the open access journal Global Health

Abstract:

Background

Methods

Results

Conclusion

Authors:

✪ Open Access

Read the full text in the open access journal Journal of the American Pharmacy Association

Abstract:

Background

Objective

Methods

Results

Conclusion

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Results

Conclusions

Authors:

Subscription Required for Full Text Access

Read the full text in the subscription access journal Journal of Anxiety Disorders