Inner Setting Archives - Implementation Science at UW

✪ 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**}

✪ Optimizing healthcare for blood donors at risk of transfusion-transmissible infections: pre-implementation mixed methods protocol

Abstract:

In the Peruvian Amazon, a significant proportion of replacement blood donors test reactive for HIV, HTLV-1/2, and other transfusion-transmissible infections but often receive no subsequent care. Optimizing healthcare for these individuals can mitigate adverse outcomes by enabling early diagnosis and management. Effective coordination between Blood Bank and Infectious Diseases services is essential to provide comprehensive care. To address this challenge, this study applies an Implementation Science approach to design and assess an innovation that enhances healthcare for blood donors affected by transfusion-transmissible infections. A pre-implementation mixed methods study will be conducted at two hospitals in the Peruvian Amazon, employing the Consolidated Framework for Implementation Research (CFIR) and a systems engineering tool (mapping). The study will focus on the inner setting domain of CFIR and map the care continuum to identify contextual determinants that may influence implementation. It has three specific aims planned for the future: first, to use a convergent mixed methods approach to examine the care continuum of blood donors and the inner settings; second, to co-design an innovation through qualitative and participatory methods, integrating Blood Bank and Infectious Diseases services via the hospital information management system; and third, to evaluate the feasibility, appropriateness, and acceptability of the co-designed innovation through a pilot. Replacement blood donation and fragmented healthcare systems are common challenges in other low- and middle-income countries. The findings of this study can inform future implementation research and policy in similar settings.

Paper context

Main findings: This study will co-design and pilot an innovation to improve how blood donors at risk of transfusion-transmissible infections receive screening results, confirmatory testing, and care, by integrating Blood Bank and Infectious Diseases services through digital tools.

Added knowledge: This study employs a participatory, mixed-methods implementation science approach to systematically assess and address gaps in blood donor healthcare, providing a scalable methodology while ensuring context-specific, actionable interventions for resource-limited settings.

Global health impact for policy and action: This study will drive digital innovations in blood donor healthcare to strengthen blood safety and infectious disease control, while framing a pragmatic, adaptable approach for integrating fragmented healthcare systems in resource-limited settings.

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

✪ Determinants of implementation of a stepped care intervention for adolescents and youth living with HIV in Kenya: a qualitative evaluation

Abstract:

Background

Differentiation of HIV services, a client-centered strategy, may improve care outcomes among adolescents and youth living with HIV (AYLHIV). Understanding health provider perceptions of barriers and facilitators that influence implementation can optimize adoption and sustainment of health systems interventions.

Methods

The Data-informed Stepped Care (DiSC) study was a cluster randomized controlled trial of a stepped care intervention in 24 HIV care facilities in Kenya. At each visit, providers used an assessment tool to allocate AYLHIV to services according to level of need. Stable clients were allocated to differentiated service delivery (DSD) with less frequent visits. Intensified services, including behavioral counseling, were provided for those with greater likelihood of loss to follow-up, mental health issues, or viral non-suppression. We conducted focus group discussions (FGDs) with providers across 12 intervention sites between January-February 2023. FGDs used a semi-structured interview guide, grounded in the Consolidated Framework for Implementation Research, which were audio-recorded and transcribed. Transcripts were analyzed using a team-based rapid turnaround approach to characterize key determinants influencing adoption, reach, and fidelity.

Results

Providers were enthusiastic about, and quick to adopt, the DiSC intervention. They found the DiSC tool easy to use and felt it provided a relative advantage by improving service delivery efficiency and prioritizing time with higher need AYLHIV. Providers noted the importance of tool flexibility to align with changing national guidelines. They expressed concerns about compatibility with existing workflows at facilities exclusively using electronic medical record (EMR) systems, suggesting EMR integration will be needed for intervention sustainment. AYLHIV eligible for DSD benefited from clinic visit intervals that aligned with the school calendar, which posed a challenge for reaching AYLHIV in more intensive steps. Provider collective efficacy was important in consistent implementation of DiSC and was facilitated by continuous quality improvement meetings, access to knowledge and information, and perceived intervention effectiveness. Supportive leadership was an important driver of implementation success, through availing space for mental health counseling sessions and time for client-provider interactions outside standard operating hours.

Conclusions

Consideration of alignment with national policy, integration into clinic workflows, school schedules, and leadership engagement, will be important for sustained use of differentiated care interventions.

Trial registration

ClinicalTrials.gov, NCT05007717. Registration date: July 13, 2021.

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

✪ Strengthening the US Health Workforce to End the HIV Epidemic: Lessons Learned From 11 Ending the HIV Epidemic Jurisdictions

Authors:

Phillip L Marotta, Debbie Humphries, Daniel Escudero, David A Katz, Joseph G Rosen, Samantha Veronica Hill, Jennifer L Glick, Dennis H Li, Latosha Elopre, Fatemeh Ghadimi, Rinad S Beidas, Jose Bauermeister, Stephen Bonett, Drew B Cameron, LaRon E Nelson, Serena Rajabiun, Larry R Hearld, Mansoorah Kermani, Sarah Stoltman, Darjai Payne, Tobeya Ibitayo, Faiad Alam, Amanda Williams, Corilyn Ott, Emma Kay, Sarah Chrestman, Scott Batey, Laramie R Smith, Robin Gaines Lanzi, Karen Musgrove, Mayra Malagon, Jeannette Bailey-Webb, Florence Momplaisir, Robert Gross, Gregory Gross, Taylor Kaser, Tawnya Brown, Chelsey R Carter, Michael Mugavero , Tequetta Valeriano, Sarah Shaw, Anjuli D Wagner, Bakari Atiba, & Russell A Brewer

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

✪ Open Access

Published: April 2025

Read the full text open access in the journal JAIDS: Journal of Acquired Immune Deficiency Syndrome

✪ Health Care Professional Adherence to Breast Cancer Management Guidelines in Nigeria

Authors:

Anya Romanoff, Olalekan Olasehinde, Kathleen Lynch, Sharif Folorunso, Oluwatosin Omoyiola, Betiku Omolade, Adeleye Omisore, Chukwuma Eze Okereke, Olayide Agodirin, Abubakar Bala Muhammad, Nuhu Ali, Omorodion Irowa, Nneka Sunday Nweke, Uchechukwu Emmanuel Nwokwu, Adewale Aderounmu, Funmilola Wuraola, Hannah L Kalvin, Rivka Kahn, Grace Fitzgerald, Cristina Olcese, Alexia Iasonos, Victoria L Mango, Jamie S Ostroff, Rachel Vreeman, Benjamin O Anderson, T Peter Kingha, and Olusegun Isaac Alatise

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

✪ Open Access

Published: February 2025

Read the full text in the open access journal JAMA Network Open

Abstract:

Importance

In Nigeria, 80% of breast cancer is diagnosed at an advanced stage, when clinical management is complex and necessitates multidisciplinary collaboration. The Nigerian Federal Ministry of Health promotes multidisciplinary tumor board (MDT) discussions and endorses the National Comprehensive Cancer Network Harmonized Guidelines for Sub-Saharan Africa (Harmonized Guidelines) to standardize breast cancer care, but the extent of their clinical utilization is not well understood.

Objective

To identify barriers to and facilitators of the standardization of breast cancer care in Nigeria as reflected by awareness and consultation of resource-adapted guidelines.

Design, Setting, and Participants

For this survey study, health care professionals (HCPs) involved in breast cancer care in Nigeria were recruited electronically through medical societies and snowball sampling from November 1, 2023, to January 31, 2024.

Exposure

Breast cancer care guidelines.

Main Outcomes and Measures

Current breast cancer guideline awareness, adherence among specialties, and multidisciplinary management in Nigeria were evaluated. A multinational, multidisciplinary team developed and distributed an HCP questionnaire. Cochran-Armitage trend tests and logistic regression assessed associations with guideline awareness and use.

Results

A total of 277 HCPs (median [IQR] age, 42 [38-48] years; 211 of 275 [77%] male), including 124 surgeons (45%), 59 radiologists (21%), 49 clinical oncologists (18%), and 45 pathologists (16%), responded to the survey. Of 274 HCPs, 253 (92%) believed that breast cancer guidelines contribute to better patient outcomes, and 100 of 195 (51%) routinely consulted guidelines. Of 273 HCPs, 103 (38%) had regular engagement in breast cancer MDT discussions. Only 93 of 277 HCPs (34%) were aware of resource-adapted Harmonized Guidelines; both guideline awareness and consultation increased with the frequency of MDT participation. Completing a cancer-related fellowship (OR, 14.56; 95% CI, 6.24-40.00; P < .001), clinical oncology specialization (OR vs surgery, 0.20 [95% CI, 0.09-0.42]; OR vs pathology, 0.05 [95% CI, 0.02-0.14]; OR vs radiology, 0.02 [95% CI, 0.01-0.06]; P < .001), devoting more time to breast health care delivery (OR, 1.04; 95% CI, 1.02-1.05; P < .001), and regular MDT engagement (OR for weekly vs none, 5.13; 95% CI, 1.69-17.35; P = .04) were associated with consulting guidelines regularly on univariable analysis. To improve guideline adherence, 230 of 277 HCPs (83%) reported needing regular MDT discussions.

Conclusions and Relevance

In this survey of HCPs across Nigeria, half reported routinely consulting guidelines and only one-third were aware of the Harmonized Guidelines, which are resource adapted and endorsed by the Nigerian Federal Ministry of Health. Approximately one-third of HCPs reported engaging in regular breast cancer MDT discussions; guideline awareness and consultation increased as frequency of MDT participation increased. Opportunities for disseminating knowledge, such as MDT discussions and fellowship training, are essential to standardize breast cancer care delivery in Nigeria.

^{**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

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**}

✪ Integrating a mental health intervention into PrEP services for South African young women: a human-centered implementation research approach to intervention development

Abstract:

Introduction

Adolescent girls and young women (AGYW) who may benefit from HIV pre-exposure prophylaxis (PrEP) face high levels of common mental disorders (e.g. depression, anxiety). Common mental disorders can reduce PrEP adherence and increase HIV risk, yet mental health interventions have not been well-integrated into PrEP delivery.

Methods

We conducted a four-phase human-centered design process, from December 2020 to April 2022, to understand mental health challenges among AGYW in Johannesburg, South Africa and barriers to integrated mental health and PrEP services. In the “Discover” phase, we conducted in-depth interviews with AGYW and key informants (KIs) in Johannesburg. We conducted a rapid qualitative analysis, informed by the Consolidated Framework for Implementation Research (CFIR), to identify facilitators and barriers of integrated mental health and PrEP services and mapped barriers to potential implementation strategies. In the “Design” and “Build” phases, we conducted stakeholder workshops to iteratively adapt an evidence-based mental health intervention, the Friendship Bench, and refine implementation strategies for South African PrEP delivery settings. In the “Test” phase, we piloted our adapted Friendship Bench package.

Results

Interviews with 70 Discover phase participants (48 AGYW, 22 KIs) revealed the importance of integrated mental health and PrEP services for South African AGYW. Interviewees described barriers and implementation strategies for mental health and PrEP services around the CFIR domains: intervention characteristics (e.g. challenges with AGYW “opening up”); outer Johannesburg setting (e.g. community stigma); inner clinic setting (e.g. judgmental healthcare providers); characteristics of counsellors (e.g. training gaps); and the implementation process (e.g. need for demand creation). The Design and Build workshops included 13 AGYW and 15 KIs. Implementation barriers related to the quality and accessibility of public-sector clinic services, lay counsellor training, and community education and demand creation activities were prioritized. This led to 12 key Friendship Bench adaptations and the specification of 10 implementation strategies that were acceptable and feasible in initial pilot testing with three AGYW.

Conclusions

Using a human-centered approach, we identified determinants and potential solutions for integrating mental health interventions within PrEP services for South African AGYW. This design process centered stakeholders’ perspectives, enabling rapid development of an adapted Friendship Bench intervention implementation package.

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

✪ How pharmacists would design and implement a community pharmacy-based colorectal cancer screening program

Abstract:

Background

Distributing CRC screening through pharmacies, a highly accessible health service, may create opportunities for more equitable access to CRC screening. However, providing CRC screening in a new context introduces a substantial implementation challenge.

Methods

We conducted 23 semi-structured interviews with community pharmacists practicing in Washington state and North Carolina about distributing fecal immunochemical tests (FIT) to patients in the pharmacy. The Consolidated Framework for Implementation Research (CFIR) was used to guide analysis.

Results

Pharmacists believed that delivering FITs was highly compatible with their environment, workflow, and scope of practice. While knowledge about FIT eligibility criteria varied, pharmacists felt comfortable screening patients. They identified standardized eligibility criteria, patient-facing educational materials, and continuing education as essential design features. Pharmacists proposed adapting existing pharmacy electronic health record systems for patient reminders/prompts to facilitate FIT completion. While pharmacists felt confident that they could discuss test results with patients, they also expressed a need for stronger communication and care coordination with primary care providers.

Discussion

When designing a pharmacy-based CRC screening program, pharmacists desired programmatic procedures to fit their current knowledge and context. Findings indicate that if proper attention is given to multi-level factors, FIT delivery can be extended to pharmacies.

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

✪ Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care

Abstract:

Background

Unhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention.

Methods

Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR.

Results

We interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics.

Conclusions

These findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.

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

✪ Disruptions to and Innovations in HPV Vaccination Strategies within Safety-Net Healthcare Settings Resulting from the COVID-19 Pandemic

Abstract:

Abstract

The COVID-19 pandemic disrupted healthcare delivery within safety-net settings. Barriers to and facilitators of human papillomavirus (HPV) vaccination during the pandemic can inform future HPV vaccine strategies for underserved communities. Qualitative interviews (n = 52) between December 2020 and January 2022 in Los Angeles and New Jersey were conducted with providers, clinic leaders, clinic staff, advocates, payers, and policy-level representatives involved in the HPV vaccine process. Using the updated Consolidated Framework for Implementation Research we identified (1) outer setting barriers (i.e., vaccine hesitancy driven by social media, political views during the pandemic) and facilitators (e.g., partnerships); (2) inner setting clinic facilitators (i.e., motivation-driven clinic metrics, patient outreach, vaccine outreach events); (3) individual characteristics such as patient barriers (i.e., less likely to utilize clinic services during the pandemic and therefore, additional outreach to address missed vaccine doses are needed); (4) innovations in HPV vaccination strategies (i.e., clinic workflow changes to minimize exposure to COVID-19, leveraging new community partnerships (e.g., with local schools)); and (5) implementation strategies (i.e., multisectoral commitment to HPV goals). Pandemic setbacks forced safety-net settings to develop new vaccine approaches and partnerships that may translate to new implementation strategies for HPV vaccination within local contexts and communities.

^{**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 Journal of Cancer Survivorship: Research and Practice

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Global Health Action

Abstract:

Paper context

Authors:

✪ Open Access

Read the full text in the open access journal BMC Health Service Research

Abstract:

Background

Methods

Results

Conclusions

Trial registration

Authors:

✪ Open Access

Read the full text open access in the journal JAIDS: Journal of Acquired Immune Deficiency Syndrome

Authors:

✪ Open Access

Read the full text in the open access journal JAMA Network Open

Abstract:

Importance

Objective

Design, Setting, and Participants

Exposure

Main Outcomes and Measures

Results

Conclusions and Relevance

Authors:

✪ Open Access

Read the full text in the open access journal Brain Injury

Abstract:

Background

Methods

Results

Discussion

Authors:

✪ Open Access

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

Abstract:

Introduction

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Preventive Oncology & Epidemiology

Abstract:

Background

Methods

Results

Discussion

Authors:

✪ Open Access

Read the full text in the open access journal Addiction Science and Clinical Practice

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Healthcare

Abstract:

Abstract