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Implementation Science at UW

Keywords: CFIR

✪ Study protocol for a hybrid type 3 effectiveness-implementation trial of a team-based implementation strategy to support educators’ use of a social engagement intervention

Authors:

Jill Locke, Aksheya Sridhar, Wendy Shih, Stephanie Shire, Andria B. Eisman, Emily Kim, Adora Du, Christine Espeland, & Connie Kasari

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2025

Read the full text in the open access journal Implementation Science

Abstract:

Background

Remaking Recess (RR) is a school-based evidence-based peer social engagement intervention for autistic students. RR involves direct training and coaching with educators; however, educators face several barriers to implementation at both the individual- and organizational-levels. This protocol paper describes a multi-site study that will test whether an educator-level implementation strategy, coaching, with or without a school-level implementation strategy, school-based teams, will maximize educators’ use (fidelity and sustainment) of RR for autistic students and their peers who are socially-isolated, rejected, or peripheral and may need additional support during recess.

Methods

This study will employ a hybrid type-3 effectiveness-implementation trial. Fifty-five elementary schools will be recruited as well as 121 educators (e.g., classroom assistants, aides), 55 general and special educator teachers, and 83–138 other school personnel (e.g., administrators). Additionally, at least 118 autistic students and allistic or non-autistic classmates will be recruited as RR recipients. Participants will complete baseline assessments at the beginning of the year, and all schools will be provided RR training. Schools will be randomized to coaching with or without school-based teams. This study will measure RR fidelity (primary outcome), RR sustainment, as well as peer engagement, social network inclusion, and social skills (secondary outcomes). It is expected that coaching with school-based teams will improve both RR fidelity and social network inclusion, while coaching with and without school-based teams will result in improved peer engagement and social skills.

Discussion

Previous research has documented barriers to RR implementation at both the individual- (provider) and organization-level (school). Using multi-level implementation strategies such as coaching with school-based teams may address these barriers and support RR implementation in schools. Findings from this study may guide future efforts to scale up tailored implementation strategies for use in public school districts, with the ultimate goal of increasing intervention access and improving student outcomes.

Trial registration

Name of the Registry: clinicaltrials.gov.
Trial Registration: Clinical Trials ID: NCT06559267.
Date of Registration: August 15, 2024. Prospectively registered.

Contributions to the literature

Remaking Recess (RR) is an intervention that improves peer engagement and classroom inclusion in autistic students. Educators, who play an important role in supporting autistic youth and their peers who are socially-isolated, rejected, or peripheral during the school day and at recess, can deliver RR.
Schools face many challenges, at both the individual- (i.e., educator) and organizational-levels (i.e., school), when implementing new interventions.
This study will evaluate the impact of two implementation strategies on the fidelity and sustainment of RR: (a) individual direct coaching for educators (coaching), and (b) supporting a team of school personnel (school-based teams) in addition to coaching.

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

✪ Implementation research logic model in the design and execution of eHealth innovations for maternal and newborn healthcare in Ethiopia

Authors:

Dabere Nigatu, Muluken Azage, Eyaya Misgan, Daniel A. Enquobahrie, Tegegn Kebebaw, Enyew Abate, Esubalew Alemneh, Mirkuzie Woldie & Tsinuel Girma

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2025

Read the full text open access in the journal Health Research Policy and Systems

Abstract:

Background

The use of eHealth innovations is becoming increasingly important in improving health outcomes, especially for maternal and newborn health. However, planning and executing these innovations can be challenging due to their complex nature. To provide guidance and clarity on implementation approaches, researchers need to use implementation research (IR) tools. We conducted IR to recognize the challenges in implementing eHealth innovations in the context of maternal and newborn healthcare using the implementation research logic model (IRLM). Therefore, this paper aims to describe the practical application of IRLM to design, execute and evaluate eHealth innovations that improve maternal and newborn care in public facilities in Ethiopia.

Methods

We employed rapid review, formative assessment and process evaluation of an eHealth innovation in selected healthcare facilities serving maternal and newborn care. The eHealth innovation we developed and deployed was named ‘ADHERE’ (Antenatal Care, ChilDbirtH CarE and Postnatal CaRE), representing the continuum of maternal care. The rapid review was conducted as an initial step using the Consolidated Framework for Implementation Research (CFIR). We employed a mix of data collection methods: interview/discussion, eHealth system or document review and direct observation. Furthermore, we executed various stakeholder engagement activities: two co-creation workshops and on-site iterative discussions. We applied the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) to capture ongoing implementation learnings.

Results

We developed IRLM of the eHealth innovation implementation for three contexts: urban, peri-urban and remote public healthcare facilities. The model depicted the mechanism of interaction between implementation determinants and implementation strategies to produce the intended implementation outcomes. The IRLM helped to identify more than 35 implementation barriers or facilitators for eHealth interventions and to develop over 17 mitigation strategies for the study contexts. The initial IRLM was refined through ongoing implementation learnings and the mitigation strategies that were executed.

Conclusions

The IRLM is a comprehensive and effective guiding tool for the development, implementation and evaluation of innovations in various low- and middle-income contexts. Researchers and implementing partners should adapt and use it.

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

✪ Systems analysis and improvement to optimize opioid use disorder care quality and continuity for patients exiting jail (SAIA-MOUD)

Authors:

Sarah Gimbel, Anirban Basu, Emily Callen, Abraham D. Flaxman, Omeid Heidari, Julia E. Hood, Anna Kellogg, Eli Kern, Judith I. Tsui, Ericka Turley, and Kenneth Sherr

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2024

Read the full text in the open access journal Implementation Science

Abstract:

Background

Between 2012–2022 opioid-related overdose deaths in the United States, including Washington State, have risen dramatically. Opioid use disorder (OUD) is a complex, chronic, and criminalized illness with biological, environmental, and social causes. One-fifth of people with OUD have recent criminal-legal system involvement; > 50% pass through WA jails annually.

Medications for Opioid Use Disorder (MOUD) can effectively treat OUD. WA has prioritized improving access to MOUD, including for those in jails. As patients in jail settings are systematically marginalized due to incarceration, it is critical to foster connections to MOUD services upon release, an acknowledged period of high overdose risk. Currently, there is insufficient focus on developing strategies to foster linkages between jail-based MOUD and referral services.

The Systems Analysis and Improvement Approach (SAIA), an evidence-based implementation strategy, may optimize complex care cascades like MOUD provision and improve linkages between jail- and community-based providers. SAIA bundles systems engineering tools into an iterative process to guide care teams to visualize cascade drop-offs and prioritize steps for improvement; identify modifiable organization-level bottlenecks; and propose, implement, and evaluate modifications to overall cascade performance. The SAIA-MOUD study aims to strengthen the quality and continuity of MOUD care across jail and referral clinics in King County, WA, and ultimately reduce recidivism and mortality.

Methods

We will conduct a quasi-experimental evaluation of SAIA effectiveness on improving MOUD care cascade quality and continuity for patients receiving care in jail and exiting to referral clinics; examine determinants of SAIA-MOUD adoption, implementation, and sustainment; and determine SAIA-MOUD’s cost and cost-effectiveness. Clinic teams with study team support will deliver the SAIA-MOUD intervention at the jail-based MOUD program and three referral clinics over a two-year intensive phase, followed by a one-year sustainment phase where SAIA implementation will be led by King County Jail MOUD staff without study support to enable pragmatic evaluation of sustained implementation.

Discussion

SAIA packages user-friendly systems engineering tools to guide decision-making by front-line care providers to identify low-cost, contextually appropriate health care improvement strategies. By integrating SAIA into MOUD care provision in jail and linked services, this pragmatic trial is designed to test a model for national scale-up.

Trial registration

ClinicalTrials.gov NCT06593353 (registered 09/06/2024).

Contributions to the literature
  • Our study examines whether the introduction of an evidence-based, user-friendly, low-cost package of systems engineering tools can optimize investments in providing medications for opioid use disorder for individuals during the high-risk period immediately after exiting jail.
  • This is the first application of the Systems Analysis and Improvement Approach (SAIA) across health system levels to optimize both care delivery and continuity of care.
  • Our study is designed to provide decision-makers with evidence they need to decide whether to invest in systems engineering approaches during the expansion of MOUD in jail settings, including information on acceptability, feasibility, effectiveness and cost.

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

Peer Review reports

✪ A Team Coaching Intervention for Dementia Care: Acceptability and Feasibility Study in Care Communities

Authors:

Jessica Welsch, Boeun Kim, Lorna Prophater, Basia Belza, & Sam Fazio

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2024

Read the full text open access in the Journal of the American Medical Directors Association

Abstract:

Objectives

In 2018, the Alzheimer's Association published the Dementia Care Practice Recommendations (DCPR) to provide guidance on quality care for professionals. This study aimed to examine the feasibility and acceptability of a consultative coaching program to increase adoption of the DCPR.

Design

A single-group pre-post design was employed. A 6-month team coaching intervention was implemented to make organization-wide and measurable changes in the areas of (1) policies and procedures, (2) education and training, or (3) care practices to increase person-centered care practices.

Setting and Participants

A total of 36 care communities in Washington and Montana states were enrolled in this program.

Methods

Focus groups were conducted with participants to explore the acceptability and feasibility of the program. A 35-item employees satisfaction survey was administered both before and after the program.

Results

The findings offer preliminary evidence that implementing a coaching program is desired by care community staff and has a positive impact on staff job satisfaction and the use of person-centered care. The coaching model was received by staff as a supportive and affirming program.

Conclusions and Implications

The team coaching intervention, designed to improve person-centered care and employee satisfaction, is acceptable. However, its efficacy needs to be tested with a larger sample using a randomized controlled design.

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

Dissemination and Implementation – A Primer for Accelerating “Time to Translation” in Radiation Oncology

Authors:

Patricia Mae G. Santos, Sierra Silverwood, Gita Suneja, Eric C. Ford, Nikhil G. Thaker, Jamie S. Ostroff, Bryan J. Weiner, and Erin F. Gillespie

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: December 2024

Read the full text in the subscription access International Journal of Radiation Oncology - Biology - Physics

Barriers and facilitators to implementing enteral resuscitation for major burn injuries: Reflections from Nepalese care providers

Authors:

Raslina Shrestha, Kajal Mehta, Aldina Mesic, Dinasha Dahanayake, Manish Yadav, Shankar Rai, Kiran Nakarmi, Pariwesh Bista, Tam Pham, & Barclay T Stewart

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: October 2024

Read the full text in the subscription access journal Burns

✪ Digital communication between mothers and community health workers to support neonatal health (CHV-NEO): study protocol for a randomized controlled trial

Authors:

Keshet Ronen, Lincoln C. Pothan, Violet Apondi, Felix A. Otieno, Daniel Mwakanema, Felix O. Otieno, Lusi Osborn, Julia C. Dettinger, Priyanka Shrestha, Helena Manguerra, Ferdinand Mukumbang, Millicent Masinde, Evelyn Waweru, Mercy Amulele, Christine Were, Beatrice Wasunna, Grace John-Stewart, Bryan Weiner, Arianna Rubin Means, Barbra A. Richardson, Anna B. Hedstrom, Jennifer A. Unger & John Kinuthia

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: October 2024

Read the full text in the open access journal Trials

Abstract:

Background

Provision of essential newborn care at home, rapid identification of illness, and care-seeking by caregivers can prevent neonatal mortality. Mobile technology can connect caregivers with information and healthcare worker advice more rapidly and frequently than healthcare visits. Community health workers (CHWs) are well-suited to deliver such interventions. We developed an interactive short message service (SMS) intervention for neonatal health in Kenya, named CHV-NEO. CHV-NEO sends automated, theory-based, actionable, messages throughout the peripartum period that guide mothers to evaluate maternal and neonatal danger signs and facilitate real-time dialogue with a CHW via SMS. We integrated this intervention into Kenya’s national electronic community health information system (eCHIS), which is currently used at scale to support CHW workflow.

Methods

The effect of CHV-NEO on clinical and implementation outcomes will be evaluated through a non-blinded cluster randomized controlled trial. Twenty sites across Kisumu County in Western Kenya were randomized 1:1 to provide either the national eCHIS with integrated CHV-NEO messaging (intervention) or standard of care using eCHIS without CHV-NEO (control). We will compare neonatal mortality between arms based on abstracted eCHIS data from 7200 pregnant women. Secondary outcomes include self-reported provision of essential newborn care (appropriate cord care, thermal care, and timely initiation of breastfeeding), knowledge of neonatal danger signs, and care-seeking for neonatal illness, compared between arms based on questionnaires with a subgroup of 2000 women attending study visits at enrollment in pregnancy and 6 weeks postpartum. We will also determine CHV-NEO’s effect on CHW workflows and evaluate determinants of intervention acceptability, adoption, and fidelity of use through questionnaires, individual interviews, and messaging data.

Discussion

We hypothesize that the CHV-NEO direct-to-client communication strategy can be successfully integrated within existing CHW workflows and infrastructure, improve the provision of at-home essential newborn care, increase timely referral of neonatal illness to facilities, and reduce neonatal mortality. The intervention’s integration into the national eCHIS tool will facilitate rapid scale-up if it is clinically effective and successfully implemented.

Trial registration

ClinicalTrials.gov, NCT05187897. The CHV-NEO study was registered on January 12, 2022.

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

✪ Implementation of a bilingual and bicultural navigation program for Hispanic children with traumatic brain injuries

Authors:

Celeste N. Garcia, Magaly Ramirez, Tasnia Alam, Linda K. Ko & Nathalia Jimenez

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: August 2024

Read the full text in the open access journal Brain Injury

Abstract:

Background

Traumatic brain injury (TBI) disproportionately affects Hispanic children, with higher rates of severe injuries and worse outcomes compared to non-Hispanic White children. Patient navigation has shown effectiveness in improving health outcomes among Hispanic populations. However, culturally tailored navigation programs for pediatric TBI are lacking, and knowledge gaps remain regarding contextual factors influencing the implementation of these programs. This study examined factors that facilitate or hinder the implementation of a bilingual and bicultural navigation program for caregivers of Hispanic children with TBIs.

Methods

In-depth interviews were conducted with 12 personnel involved in implementing the 1st Brain Injury Education and Outpatient Navigation (1st BIEN) program across four states. Directed content analysis was used based on the Consolidated Framework for Implementation Research (CFIR) to guide the development of the interview guide and data analysis.

Results

Key facilitators included the program’s adaptability to patient needs, bilingual/bicultural patient navigator’s skills, and alignment with organizational values. Barriers included restrictive healthcare regulatory policies hindering interinstitutional work, incomplete medical records, and gaps in behavioral support training.

Discussion

These findings offer insights for optimizing the implementation of patient navigation programs in pediatric TBI care, potentially improving access to care and reducing disparities for Hispanic children with brain injuries.

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