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Implementation Science at UW

Keywords: Interview

✪ How integrated knowledge translation worked to reduce federal policy barriers to the implementation of medication abortion in Canada: a realist evaluation

Authors:

Sarah Munro, Kate Wahl, Sheila Dunn, Courtney Devane, Linda C. Li, & Wendy V. Norman

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: February 2025

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

Abstract:

Background

Initial Canadian federal regulations for the abortion pill, mifepristone, had the potential to impede safe and equitable access to this medication. To catalyze evidence-based regulatory change, we engaged health policy, health system, and health services decision makers, and health professional organizations in integrated knowledge translation (iKT), a research approach that engages the users of research as equal partners.

Methods

We conducted a realist evaluation of what iKT strategies worked, for whom, and in what context to impact federal mifepristone regulations. We constructed initial program theories (if–then statements about how iKT worked). We tested the initial program theories using interviews with researchers and knowledge partners and triangulated with analysis of research programme documents. We configured the evidence in relation to the initial program theories, and refined program theories into causal explanatory configurations.

Results

We analyzed 38 interviews with researchers, health professional leaders, advocacy group leaders, and administrative government policy makers, as well as 49 program documents. Our results indicated that researcher partnerships with stakeholders had a meaningful impact on the removal of restrictions. We found key components of the causal explanatory configurations included: researcher motivation to move evidence into action, trusted reputations as credible sources of evidence, strategic partnerships, understanding of health policy processes, and researcher roles as a trusted convenor between key groups and decision makers.

Conclusions

Our study identifies several practical and transferable approaches to impactful iKT. The findings may be of relevance to researchers focused on public health topics subject to stigma.

Contributions to the literature
  • The effect of integrated knowledge translation (iKT) on public health policy is ambiguous, especially for issues that may be stigmatized, like abortion.
  • To bridge this knowledge gap, we evaluated the iKT used to support Canadian federal drug regulatory decisions to remove restrictions for the medication abortion pill, mifepristone.
  • Our realist evaluation identified several practical and transferable approaches to impactful iKT in complex policy systems that comprise an ‘iKT mindset’.
  • Key approaches for researchers include acting on motivations to move evidence into policy, building trusted reputations as credible sources of evidence, understanding and targeting policy levers, acting as a source of strategic evidence, and acting as a trusted convenor between key groups and decision makers.
  • Our use of realist methodology contributes to theoretical and empirical understandings of iKT with policy makers and has relevance for other stigmatized topics including opioid safe supply, vaccination, and climate change.

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

✪ Human-Centered Design of an mHealth Tool for Optimizing HIV Index Testing in Wartime Ukraine: Formative Research Case Study

Authors:

Nancy Puttkammer, Elizabeth Dunbar, Myroslava Germanovych, Mariia Rosol, Matthew Golden, Anna Hubashova, Vladyslav Fedorchenko, Larisa Hetman, Liudmyla Legkostup, Jan Flowers, and Olena Nesterova

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2025

Read the full text in the open access journal JMIR Formative Research

Abstract:

Background

Assisted partner services (APSs; sometimes called index testing) are now being brought to scale as a high-yield HIV testing strategy in many nations. However, the success of APSs is often hampered by low levels of partner elicitation. The Computer-Assisted Self-Interview (CASI)–Plus study sought to develop and test a mobile health (mHealth) tool to increase the elicitation of sexual and needle-sharing partners among persons with newly diagnosed HIV. CASI-Plus provides client-facing information on APS methods and uses a standardized, self-guided questionnaire with nonjudgmental language for clients to list partners who would benefit from HIV testing. The tool also enables health care workers (HCWs) to see summarized data to facilitate partner tracking.

Objective

The formative research phase of the CASI-Plus study aimed to gather client and HCW input on the design of the CASI-Plus tool to ensure its acceptability, feasibility, and usability.

Methods

This study gathered input to prioritize features and tested the usability of CASI-Plus with HCWs and clients receiving HIV services in public health clinics in wartime Ukraine. The CASI-Plus study’s formative phase, carried out from May 2023 to July 2024, adapted human-centered design (HCD) methods grounded in principles of empathy, iteration, and creative ideation. The study involved 3 steps: formative HCD, including in-depth individual interviews with clients, such as men who have sex with men and people who inject drugs, and internet-based design workshops with HCWs from rural and urban HIV clinics in Chernihiv and Dnipro; software platform assessment and heuristic evaluation, including assessment of open-source mHealth platforms against CASI-Plus requirements, prototype development, and testing of the REDCap (Research Electronic Data Capture) prototype based on usability heuristics; and usability walk-throughs, including simulated cases with HCWs and clients.

Results:

The formative phase of the CASI-Plus study included in-depth individual interviews with 10 clients and 3 workshops with 22 HCWs. This study demonstrated how simplified HCD methods, adapted to the wartime context, gathered rich input on prioritized features and tool design. The CASI-Plus design reflected features that are both culturally sensitive and in alignment with the constraints of Ukraine’s wartime setting. Prioritized features included information about the benefits of HIV index testing; a nonjudgmental, self-guided questionnaire to report partners; client stories; and bright images to accompany the text. Two-way SMS text messaging between clients and HCWs was deemed impractical based on risks of privacy breaches, national patient privacy regulations, and HCW workload./p>

Conclusions

It was feasible to conduct HCD research in Ukraine in a wartime setting. The CASI-Plus mHealth tool was acceptable to both HCWs and clients. The next step for this research is a randomized clinical trial of the effect of the REDCap-based CASI-Plus tool on the number of partners named and the rate of partners completing HIV testing.

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

✪ Sustainability of an evidence-based intervention supporting transition to independent care for youth living with HIV in Kenya

Authors:

Alina Metje, Sarah Shaw, Cyrus Mugo, Mercy Awuor, Annabell Dollah, Hellen Moraa, Christine Kundu, Dalton Wamalwa, Grace John-Stewart, Kristin Beima-Sofie, and Irene Njuguna

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2025

Read the full text in the open access journal PLOS Global Public Health

Abstract:

Integrating and sustaining evidence-based interventions (EBIs) in routine care is crucial to improving HIV treatment outcomes among youth living with HIV (YLH). However, EBIs are often not sustained post clinical trial. An Adolescent Transition Package (ATP) delivered by health care workers (HCWs) and tested in Kenya in 2021 significantly improved YLH readiness to transition to independent care. Post-trial, participating clinics could continue using the ATP. We conducted 30 in-depth interviews with health care workers to evaluate determinants of continued ATP implementation one-year post-trial. Interviews used semi-structured guides, informed by the Consolidated Framework for Implementation Research version 2.0 (CFIR v2.0). Transcripts were analyzed thematically to identify key influences of ATP sustainment and fidelity post-trial. Effective training during and after the trial, and continued internal and external support for implementation, were crucial for sustained acceptability and feasibility. In contrast, staff shortages and high turnover, lack of integration into the existing electronic medical system, and maintaining staff motivation were barriers to ATP sustainment. Implementation fidelity was limited by workforce constraints and HCW beliefs about the importance of individualizing content and delivery to be responsive to individual client needs. ATP adaptability afforded optimization of delivery to overcome workforce constraints and meet client needs, increasing HCW perceptions of feasibility and motivating continued use. Alignment between observed impact and care provision goals further motivated ongoing ATP utilization. Strategies to ensure continued training and integration of tools into existing systems have the potential to further enhance ATP sustainability.

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

✪ VA’s EHR transition and health professions trainee programs: Findings and impacts of a multistakeholder learning community

Authors:

Julian Brunner, Ellen A. Ahlness, Ekaterina Anderson, Brianne K. Molloy-Paolillo, Alexandre Braga, Sarah L. Cutrona, Christian D. Helfrich, Deborah Levy, Erin Matteau, Edward Walton, George Sayre, Seppo T. Rinne

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: October 2024

Read the full text in the open access journal Learning Health System

Abstract:

Introduction

The Department of Veterans Affairs (VA) is undergoing an unprecedented electronic health record (EHR) transition, switching from its homegrown EHR to a commercial system. The transition affects nearly every clinical employee but is particularly disruptive to health professions trainees (HPTs)—an often-overlooked population in EHR transitions. To better understand and address trainee challenges with the EHR transition, we formed a multistakeholder learning community. In this study, we describe the findings of this learning community and the practices and policies developed in response.

Methods

In the qualitative study designed and executed by our learning community, we conducted 51 interviews with HPTs, program leaders, and preceptors before and multiple times after an EHR transition site's go-live (February 16, 2022 to April 7, 2023). We merged interview transcripts with 125 survey free-text responses from a survey conducted with preceptors 2 months post-go-live and conducted thematic analysis to identify key themes. To complement qualitative findings, we also include a quantitative survey finding, and, where applicable, we note policy and practice responses spurred by our learning community.

Results

Interviews yielded six key themes: (1) High satisfaction with HPT programs, despite negative impacts of the EHR transition; (2) early delays, then substantial improvements, in HPTs' EHR access; (3) persistent challenges with HPTs' EHR training and support, mitigated by local and national efforts; (4) the challenge of learning to use a rapidly evolving EHR during clinical training; (5) reduced visit volume as a continuing barrier to education; and (6) an impression that HPTs' relative lack of exposure to the prior EHR facilitated their proficiency with the new EHR.

Conclusions

Findings highlighted challenges for HPT programs related to the EHR transition, which spurred important changes including the creation of a national VA council to represent the needs of HPTs in the EHR transition, and improvements to HPTs' EHR training and access.

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

✪ The pathway to delivering injectable CAB for HIV prevention: strategies from global PrEP leaders leveraging an adapted version of the Intervention Scalability Assessment Tool (ISAT)

Authors:

Lauren R. Violette, Kidist Zewdie, Nyawira Gitahi, Kristin Beima-Sofie, & Renee Heffron

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: September 2024

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

Abstract:

Background

Longer-acting cabotegravir (CAB) is a novel, safe, and efficacious pre-exposure prophylaxis (PrEP) for HIV prevention. As we near a time for CAB scale-up, the experience of global leaders in PrEP research and implementation can be leveraged to identify optimal strategies for scaling and integrating CAB into existing PrEP infrastructure worldwide.

Methods

We recruited leaders of HIV prevention clinical trials and large PrEP programs through a combination of purposive and snowball sampling for participation in individual interviews. We conducted interviews using a semi-structured guide that compared CAB to oral PrEP and sought perspectives on barriers and strategies for CAB scale-up. Interviews were conducted virtually, audio recorded, and transcribed. We used thematic analysis, grounded in an adapted version of the Intervention Scalability Assessment Tool (ISAT), to identify critical elements for optimizing delivery of CAB.

Results

From October 2021 to April 2022, we interviewed 30 participants with extensive experience in PrEP research, care, and programming. Participants worked in all seven WHO regions and reported a median of 20 years working in HIV and 10 years in PrEP. Participants agreed that CAB was efficacious and discrete, therefore having the potential to address current concerns about oral PrEP adherence and stigma. Participants indicated direct and indirect costs for provider training, expansion of existing medical infrastructure, and the current medication cost of CAB as major concerns for roll out. The true cost to the end-user and health system were unknown. There were some conflicting strategies on how to best address product targeting, presentation of efficacy, and timing of product availability with scale-up. Some thought that targeting CAB for the general population could normalize PrEP and decrease stigma, while others thought that prioritizing key populations could optimize impact by targeting those with highest risk. Overall, participants emphasized that to ensure successful CAB scale-up, communities and stakeholders must be involved at every stage of planning and implementation.

Conclusions

Our evaluation found that although there is a clear and urgent need for additional HIV PrEP options beyond daily oral PrEP, CAB scale-up must be thoughtful, flexible, and based in lessons learned from oral PrEP rollout.

Contributions to the literature
  • We used the Intervention Scalability Assessment Tool (ISAT), a quantitative tool used to inform decision-making for the scale-up of health interventions, as a framework for a qualitative analysis.
  • To our knowledge, this is the first use of the ISAT to assess scalability of injectable cabotegravir (CAB) for HIV pre-exposure prophylaxis (PrEP).
  • Our findings offer a summary of perspectives from global HIV PrEP leaders, experts, and advocates that can be used to map the process of CAB implementation using existing HIV prevention infrastructure.

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

✪ Are we being equitable enough? Lessons learned from sites lost in an implementation trial

Authors:

Elizabeth J Austin, Jessica Chen, Lori Ferro, Andrew J Saxon, John C Fortney, Geoffrey M Curran, Anna D Ratzliff, & Emily C Williams

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: August 2024

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

Abstract:

Background

There is a growing interest in practice-based implementation research, yet too often research prioritizes and is most successful in academic settings. During a national implementation trial to evaluate the effectiveness of Collaborative Care for co-occurring opioid use and mental health disorders, we lost three of our 11 participating implementation sites, all representing community sites.

Method

To better understand needed supports for implementation trial participation, we conducted exit interviews (n = 5) with key staff at these community sites. Interview transcripts were double-coded and analyzed using Rapid Assessment Process. Qualitative themes were iteratively reviewed by the study team.

Results

Three themes emerged characterizing challenges for community sites, including that: (1) research threatens sites’ most precious resource—staff; (2) staff lack comfort with and skills for research; and (3) research participation in its current form does not offer a clear return on investment.

Conclusions

Learnings from this work illuminate some of the barriers community sites face when trying to participate in multisite implementation research. An undercurrent of participant perspectives was the belief that community sites like theirs are just not set up to successfully participate in clinical trial research, including population-based implementation trials. Future implementation trials should consider strategies that disrupt traditional approaches, increasing the equitable inclusion of diverse practice settings in implementation research.

Plain Language Summary

There is a growing interest in research that reflects community settings. Yet too often, research is most successful in academic settings. During a national implementation trial to evaluate the effectiveness of Collaborative Care for co-occurring opioid use and mental health disorders, we lost three of our 11 participating implementation sites, all representing community sites. To better understand their perspectives, we conducted exit interviews (n = 5) with staff at these community sites. Interview transcripts were double-coded and analyzed using thematic analysis. Analysis identified three themes: (1) research threatens sites’ most precious resource—staff; (2) staff lack comfort with and skills for research, and (3) research participation in its current form does not offer a clear return on investment. Community sites face many barriers to participating in implementation research trials. Future trials should consider ways to disrupt traditional approaches and increase the equitable inclusion of community settings in implementation research.

**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**