Mixed-Methods Archives - Page 5 of 8 - Implementation Science at UW

✪ Enhancing the Introduction and Scale Up of Self-Administered Injectable Contraception (DMPA-SC) in Health Systems (the EASIER Project): Protocol for Embedded Implementation Research

Abstract:

Background

The introduction of self-administered injectable contraception presents an opportunity to address the unmet need for family planning. As ministries of health scale up self-administered injectable contraception, there is a scarcity of knowledge on the implementation practices and contextual conditions that help and hinder these efforts. The World Health Organization has launched the “enhancing self-administered family planning through embedded research project” (EASIER) to address this challenge.

Objective

EASIER’s objectives are to: (1) assess the coverage of self-injectable contraception, and the readiness of health systems to integrate it into the contraceptive method mix; (2) document strategies used to introduce and scale up self-injectable contraception and understand practices that have led to success and challenges; (3) identify the contextual factors that affect the adoption and implementation of self-injectable contraception throughout health systems; (4) understand whether implementation addresses users’ preferences and needs; (5) strengthen collaboration between decision makers, researchers, and implementers; support and build capacity to use evidence.

Methods

EASIER developed a global protocol that implementation research (IR) teams in Burkina Faso, Ghana, and Kenya adapted into country-level embedded IR projects. In all countries (1) at the national level, IR teams evaluate the policy environment for scaling up by conducting a desk review and in-depth interviews; (2) at the local level, IR teams implement quantitative questionnaires on structural and organizational readiness to integrate self-injection into the method mix; (3) in “case study” localities, IR teams conduct in-depth interviews and focus group discussions with implementers, method users, and community members; and (4) IR teams use participatory action research to elicit stakeholder participation and translate findings into programmatic decisions.

Results

EASIER has been launched in all 3 countries. Preliminary findings are available from Burkina Faso and Kenya. In Burkina Faso, IR teams identified the need to strengthen health worker training approaches to ensure that family planning providers at primary health care facilities are adequately oriented to depo-medroxyprogesterone acetate subcutaneous (DMPA-SC) and self-injection and capacitated to initiate women to the method. In addition, they report the need for service communication strategies that reach potential users of the method with knowledge about self-injection and how to initiate the practice. In Kenya, the findings illuminate the need for practice guidelines that county health teams can use to coordinate the rollout of self-administered DMPA-SC. In addition, Kenya’s findings underscore the importance of addressing logistical bottlenecks to help avoid stock-outs.

Conclusions

EASIER presents a strategy to embed IR in contraceptive method introduction and scale-up, address local knowledge needs, devise ways to maximize the impact of new technologies in health systems, and build capacity for using evidence in programmatic decisions. Adaptation and implementation of country-level IR studies will advance the use of IR to strengthen family planning programs.

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

✪ Organizational contexts, implementation processes, and capacity outcomes of multicultural, multilingual Home-Based Programs in public initiatives: A Mixed-Methods study

Abstract:

Aims

The study aim was to examine the impact of a home-based programme intervention on organizational contexts, implementation processes and organizational capacity outcomes from multicultural, multilingual participants working at community-based organizations.

Design

This was a sequential exploratory, mixed-methods longitudinal study using community-based participatory research principles.

Sample

Twenty participants from nine multicultural, multilingual community-based organizations were in this public health initiative's intervention to develop community-designed, home-based programmes.

Methods

Capacity building providers delivered the intervention selected by the funders. Workshop outcomes were descriptively measured in April/May 2019. In April/May and November 2019, participants completed surveys about organizational contexts, implementation processes and organizational capacity outcomes, which were analysed with t-tests using the organization as the unit of analysis. Qualitative data were analysed using content analysis.

Results

Seven programmes were new and two were modified. As workshop outcomes, 59% of participants reported increased overall implementation knowledge and 74% reported capacity building providers as the most helpful resource. After 6 to 7 months, no statistically significant changes were noted in organizational contexts, implementation processes or organizational capacity outcomes. Participants benefited from capacity building because they had programmes developed, formed partnerships with capacity building providers, gained implementation knowledge, and engaged in networking.

Conclusion

Participants reported excellent individual and organizational strengths. Many Initiative factors contributed to no statistical changes. Namely, there was no opportunity for baseline data; limited community-based organization engagement in the intervention model selection, timeline and processes; the Initiative's timeline did not fit participants' timeline; insufficient time to develop culturally and linguistically appropriate programmes; late literature review abstracts; lack of adequate, planful and paid capacity building time; and a contract requirement to have the programme due when it was not implementable. These Initiative design factors, as reported by participants, limited the Initiative's home-based programme development.

Impact

This study highlights the strengths of participants, community-based organizations and capacity building providers. Model selection, timeline and budget were identified as key factors for equitable implementation in multicultural, multilingual organizations.

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

✪ Characterizing provider-led adaptations to mobile phone delivery of the Adolescent Transition Package (ATP) in Kenya using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS): a mixed methods approach

Abstract:

Background

The COVID-19 pandemic resulted in disruptions to routine HIV services for youth living with HIV (YLH), provoking rapid adaptation to mitigate interruptions in care. The Adolescent Transition to Adult Care for HIV-infected adolescents (ATTACH) study (NCT03574129) was a hybrid I cluster randomized trial testing the effectiveness of a healthcare worker (HCW)-delivered disclosure and transition intervention — the Adolescent Transition Package (ATP). During the pandemic, HCWs leveraged phone delivery of the ATP and were supported to make adaptations. We characterized real-time, provider-driven adaptations made to support phone delivery of the ATP.

Methods

We conducted continuous quality improvement (CQI) meetings with HCWs involved in phone delivery of the ATP at 10 intervention sites. CQI meetings used plan-do-study-act (PDSA) cycles and were audio-recorded. Adaptations were coded by two-independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Adaptation testing outcomes (adopt, retest, or abandon) and provider experience implementing the adaptations were also recorded. We summarized adaptation characteristics, provider experience, and outcomes.

Results

We identified 72 adaptations, 32 were unique. Overall, adaptations included modification to context (53%, n = 38), content (49%, n = 35), and evaluation processes (13%, n = 9). Context adaptations primarily featured changes to personnel, format, and setting, while content and evaluation adaptations were frequently achieved by simple additions, repetition, and tailoring/refining of the phone delivery strategy. Nine adaptations involved abandoning, then returning to phone delivery. HCWs sought to increase reach, improve fidelity, and intervention fit within their context. Most adaptations (96%, n = 69) were perceived to increase the feasibility of phone delivery when compared to before the changes were introduced, and HCWs felt 83% (n = 60) of adaptations made phone delivery easier. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%).

Conclusion

Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Adaptations were primarily context adaptions. While FRAME-IS was apt for characterizing adaptations, more use cases are needed to explore the range of its utility.

Trial registration

Trial registered on ClinicalTrial.gov as NCT03574129.

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

✪ Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation

Abstract:

Background

The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA’s Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation.
The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams.

Methods

The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation’s overall goal is to assess CRH’s return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners.

Discussion

Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

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

✪ Implementation and scale-up of a single-visit, screen-and-treat approach with thermal ablation for sustainable cervical cancer prevention services: a protocol for a stepped-wedge cluster randomized trial in Kenya

Abstract:

Background

An important cervical cancer prevention strategy in low- and middle-income countries (LMICs) has been single-visit screen-and-treat (SV-SAT) approach, using visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy to manage precancerous lesions. While SV-SAT with VIA and cryotherapy have established efficacy, its population level coverage and impact on reducing cervical cancer burden remains low. In Kenya, the estimated cervical cancer screening uptake among women aged 30–49 is 16% and up to 70% of screen-positive women do not receive treatment. Thermal ablation for treatment of precancerous lesions of the cervix is recommended by the World Health Organization and has the potential to overcome logistical challenges associated with cryotherapy and facilitate implementation of SV-SAT approach and increase treatment rates of screen-positive women. In this 5-year prospective, stepped-wedge randomized trial, we plan to implement and evaluate the SV-SAT approach using VIA and thermal ablation in ten reproductive health clinics in central Kenya.

Methods

The study aims to develop and evaluate implementation strategies to inform the national scale-up of SV-SAT approach with VIA and thermal ablation through three aims: (1) develop locally tailored implementation strategies using multi-level participatory method with key stakeholders (patient, provider, system-level), (2) implement SV-SAT approach with VIA and thermal ablation and evaluate clinical and implementation outcomes, and (3) assess the budget impact of SV-SAT approach with VIA and thermal ablation compared to single-visit, screen-and-treat method using cryotherapy.

Discussion

Our findings will inform national scale-up of the SV-SAT approach with VIA and thermal ablation. We anticipate that this intervention, along with tailored implementation strategies will enhance the adoption and sustainability of cervical cancer screening and treatment compared to the standard of care using cryotherapy.

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

✪ The special sauce of the Cancer Prevention and Control Research Network: 20 years of lessons learned in developing the evidence base, building community capacity, and translating research into practice

Abstract:

Purpose

The Cancer Prevention and Control Research Network (CPCRN) is a national network focused on accelerating the translation of cancer prevention and control research evidence into practice through collaborative, multicenter projects in partnership with diverse communities. From 2003 to 2022, the CPCRN included 613 members.

Methods

We: (1) characterize the extent and nature of collaborations through a bibliometric analysis of 20 years of Network publications; and (2) describe key features and functions of the CPCRN as related to organizational structure, productivity, impact, and focus on health equity, partnership development, and capacity building through analysis of 22 in-depth interviews and review of Network documentation.

Results

Searching Scopus for multicenter publications among the CPCRN members from their time of Network engagement yielded 1,074 collaborative publications involving two or more members. Both the overall number and content breadth of multicenter publications increased over time as the Network matured. Since 2004, members submitted 123 multicenter grant applications, of which 72 were funded (59%), totaling more than $77 million secured. Thematic analysis of interviews revealed that the CPCRN’s success—in terms of publication and grant productivity, as well as the breadth and depth of partnerships, subject matter expertise, and content area foci—is attributable to: (1) its people–the inclusion of members representing diverse content-area interests, multidisciplinary perspectives, and geographic contexts; (2) dedicated centralized structures and processes to enable and evaluate collaboration; and (3) focused attention to strategically adapting to change.

Conclusion

CPCRN’s history highlights organizational, strategic, and practical lessons learned over two decades to optimize Network collaboration for enhanced collective impact in cancer prevention and control. These insights may be useful to others seeking to leverage collaborative networks to address public health problems.

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

✪ Co-developed implementation guidelines to maximize acceptability, feasibility, and usability of mobile phone supervision in Kenya

Abstract:

Opportunities exist to leverage mobile phones to replace or supplement in-person supervision of lay counselors. However, contextual variables, such as network connectivity and provider preferences, must be considered. Using an iterative and mixed methods approach, we co-developed implementation guidelines to support the implementation of mobile phone supervision with lay counselors and supervisors delivering a culturally adapted trauma-focused cognitive behavioral therapy in Western Kenya. Guidelines were shared and discussed with lay counselors in educational outreach visits led by supervisors. We evaluated the impact of guidelines and outreach on the acceptability, feasibility, and usability of mobile phone supervision. Guidelines were associated with significant improvements in acceptability and usability of mobile phone supervision. There was no evidence of a significant difference in feasibility. Qualitative interviews with lay counselors and supervisors contextualized how guidelines impacted acceptability and feasibility – by setting expectations for mobile phone supervision, emphasizing importance, increasing comfort, and sharing strategies to improve mobile phone supervision. Introducing and discussing co-developed implementation guidelines significantly improved the acceptability and usability of mobile phone supervision. This approach may provide a flexible and scalable model to address challenges with implementing evidence-based practices and implementation strategies in lower-resourced areas.

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

✪ Implementation fidelity to HIV assisted partner services (aPS) during scale-up in western Kenya: a convergent mixed methods study

Abstract:

Background

HIV assisted partner services (aPS) is an intervention to improve HIV status awareness among sex and drug-injecting partners of people newly diagnosed with HIV (index clients). Implementation fidelity—the degree to which an intervention is conducted as intended – is critical to effectiveness, but there are limited data about aPS fidelity when delivered by HIV testing service (HTS) providers. We explored factors affecting implementation fidelity to aPS in two high-HIV prevalence counties in western Kenya.

Methods

We used convergent mixed methods adapting the conceptual framework for implementation fidelity within the aPS scale-up project. This was an implementation study examining scale-up of APS within HTS programs in Kisumu and Homa Bay counties that recruited male sex partners (MSPs) of female index clients. We defined implementation fidelity as the extent to which HTS providers followed the protocol for phone and in-person participant tracing at six expected tracing attempts. Quantitative data were collected from tracing reports in 31 facilities between November 2018 and December 2020, and in-depth interviews (IDIs) were conducted with HTS providers. Descriptive statistics were used to describe tracing attempts. IDIs were analyzed using thematic content analysis.

Results

Overall, 3017 MSPs were mentioned of whom 98% (2969/3017) were traced, with most tracing attempts being successful (2831/2969, 95%). Fourteen HTS providers participated in the IDIs—mostly females (10/14, 71%) with a median age of 35 years (range 25–52), who all had post-secondary education (14/14, 100%). The proportion of tracing attempts occurring by phone ranged from 47 to 66%, with the highest proportion occurring on the first attempt and lowest on the sixth attempt. Contextual factors either enhanced or impeded implementation fidelity to aPS. Positive provider attitudes towards aPS and conducive work environment factors promoted implementation fidelity, while negative MSP responses and challenging tracing conditions impeded it.

Conclusion

Interactions at the individual (provider), interpersonal (client—provider), and health systems (facility) levels affected implementation fidelity to aPS. As policymakers prioritize strategies to reduce new HIV infections, our findings highlight the importance of conducting fidelity assessments to better anticipate and mitigate the impact of contextual factors during the scale-up of interventions.

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

✪ Content validity of an item bank to assess intervention characteristic determinants of implementing evidence-based practices

Abstract:

Background

Barriers and facilitators, collectively called determinants, of evidence-based practice implementation are key to identifying the best strategies for promoting implementation. Assessing determinants before implementation can help tailor strategies to those that would be most effective. Current measures of determinants are not comparable across implementation settings and implementation scientists and practitioners often have to create their own measures. This study was the first step in creating determinants item banks that are usable across settings and focused on intervention characteristics. We aimed to establish the content validity of the item bank.

Method

This study used a concurrent mixed methods approach. Items for assessing intervention characteristic determinants were first identified through systematic reviews. Implementation scientists then completed a survey where they provided both quantitative and qualitative feedback on the items. Finally, three experts with both clinical and implementation experience provided feedback on redundancy and representativeness.

Results

The systematic reviews identified over 1,959 items so subsequent steps were limited to focus on intervention characteristic determinants (271 items) such as adaptability of the practice. Based on feedback from thirty implementation scientists, the items were reduced to 92 but an additional 53 were added, most due to qualitative feedback. Items were also rewritten based on qualitative results. Three experts reviewed the remaining 145 items. Based on their feedback, the number of items was reduced to 109.

Conclusions

Creating a determinants item bank was feasible and the final items had content validity. The next steps include testing reliability and validity in a larger sample of clinicians implementing evidence-based practices.

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

✪ A policy implementation study of earmarked taxes for mental health services: study protocol

Abstract:

Background

Insufficient funding is frequently identified as a critical barrier to the implementation and sustainment of evidence-based practices (EBPs). Thus, increasing access to funding is recognized as an implementation strategy. Policies that create earmarked taxes—defined as taxes for which revenue can only be spent on specific activities—are an increasingly common mental health financing strategy that could improve the reach of EBPs. This project’s specific aims are to (1) identify all jurisdictions in the USA that have implemented earmarked taxes for mental health and catalogue information about tax design; (2) characterize experiences implementing earmarked taxes among local (e.g., county, city) mental health agency leaders and other government and community organization officials and assess their perceptions of the acceptability and feasibility of different types of policy implementation strategies; and (3) develop a framework to guide effect earmarked tax designs, inform the selection of implementation strategies, and disseminate the framework to policy audiences.

Methods

The project uses the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to inform data collection about the determinants and processes of tax implementation and Leeman’s typology of implementation strategies to examine the acceptability and feasibility strategies which could support earmarked tax policy implementation. A legal mapping will be conducted to achieve aim 1. To achieve aim 2, a survey will be conducted of 300 local mental health agency leaders and other government and community organization officials involved with the implementation of earmarked taxes for mental health. The survey will be followed by approximately 50 interviews with these officials. To achieve aim 3, quantitative and qualitative data will be integrated through a systematic framework development and dissemination process.

Discussion

This exploratory policy implementation process study will build the evidence base for outer-context implementation determinants and strategies by focusing on policies that earmarked taxes for mental health services.

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

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✪ Open Access

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

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✪ Open Access

Read the full text in the open access Journal of Advanced Nursing

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✪ Open Access

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

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✪ Open Access

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

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✪ Open Access

Read the full text in the open access journal Implementation Science

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✪ Open Access

Read the full text in the open access journal Cancer Causes and Control

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✪ Open Access

Read the full text in the open access journal Cambridge Prisms: Global Mental Health

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✪ Open Access

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

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✪ Open Access

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

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Authors:

✪ Open Access

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

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Discussion