Skip to content

✪ Grounding implementation science in health equity for cancer prevention and control

Authors:

Prajakta Adsul, David Chambers, Heather M. Brandt, Maria E. Fernandez, Shoba Ramanadhan, Essie Torres, Jennifer Leeman, Barbara Baquero, Linda Fleischer, Cam Escoffery, Karen Emmons, Montserrat Soler, April Oh, Ariella R. Korn, Stephanie Wheeler & Rachel C. Shelton

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: June 2022

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

Abstract:

Background

The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute’s Consortium for Cancer Implementation Science convened an action group focused on ‘health equity and context’ to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions.

Discussion

In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity.

Summary

To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Contributions to the literature
  • This paper presents a narrative review and synthesis of the conceptual and empirical literature at the intersection of implementation science and health equity research.
  • We highlight opportunities identified at the health equity and context working group at the Consortium for Cancer Implementation Science to make a focus on health equity in IS foundational and explicit.
  • Informed by the narrative review and identified opportunities by the action group, we offer recommendations that reflect the essential groundwork needed to promote bi-directional learning and synergy between the fields of implementation science and health equity research.

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

✪ Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics

Authors:

Sarah D. Hohl, Stephanie Melillo, Thuy T. Vu, Cam Escoffery, Amy DeGroff, Dara Schlueter, Leslie W. Ross, Annette E. Maxwell, Krishna P. Sharma, Jennifer Boehm, Djenaba Joseph, Peggy A. Hannon

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: May 2022

Read the full text in the open access journal Preventing Chronic Disease: Public Health Research, Practice, and Policy

Abstract:

Evidence-based interventions, including provider assessment and feedback, provider reminders, patient reminders, and reduction of structural barriers, improve colorectal cancer screening rates. Assessing primary care clinics’ readiness to implement these interventions can help clinics use strengths, identify barriers, and plan for success. However, clinics may lack tools to assess readiness and use findings to plan for successful implementation. To address this need, we developed the Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions (Field Guide) for the Centers for Disease Control and Prevention’s (CDC’s) Colorectal Cancer Control Program (CRCCP).

We conducted a literature review of evidence and existing tools to measure implementation readiness, reviewed readiness tools from selected CRCCP award recipients (n = 35), and conducted semi-structured interviews with key informants (n = 8). We sought feedback from CDC staff and recipients to inform the final document. The Field Guide, which is publicly available online, outlines 4 assessment phases: 1) convene team members and determine assessment activities, 2) design and administer the readiness assessment, 3) evaluate assessment data, and 4) develop an implementation plan. Assessment activities and tools are included to facilitate completion of each phase. The Field Guide integrates implementation science and practical experience into a relevant tool to bolster clinic capacity for implementation, increase potential for intervention sustainability, and improve colorectal cancer screening rates, with a focus on patients served in safety net clinic settings. Although this tool was developed for use in primary care clinics for cancer screening, the Field Guide may have broader application for clinics and their partners for other chronic diseases.

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

✪ A pragmatic approach to identifying implementation barriers and facilitators for a novel pre-exposure prophylaxis (PrEP) delivery model at public facilities in urban Uganda

Authors:

Dorothy Thomas, Andrew Mujugira, Katrina Ortblad, Sylvia Namanda, Joseph Kibuuka, Mai Nakitende, Florence Nambi, Lylianne Nakabugo, Caitlin Scoville, Timothy Muwonge, Renee Heffron

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2022

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

Abstract:

Background

Scalable HIV pre-exposure prophylaxis (PrEP) delivery models for resource-limited settings are critical for improving PrEP coverage and interrupting HIV transmission. This research uses technical assistance (TA) reports to evaluate implementation barriers and facilitators for a novel delivery model integrating PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples in public health facilities in Kampala, Uganda.

Methods

We used data from the Partners PrEP Program (PPP)—a stepped-wedge cluster randomized trial that is launching PrEP delivery through an integrated model of oral PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples at public health facilities in Kampala and Wakiso, Uganda (NCT03586128). Technical assistance teams, comprised of PPP program staff, conducted monthly TA visits to implementing facilities where they identified and addressed implementation challenges in collaboration with health facility staff. Findings were recorded in TA reports, a standardized form structured using the Consolidated Framework for Implementation Research (CFIR). We used a conceptual content analysis approach to evaluate TA reports completed from January to December 2019 and identify implementation barriers and facilitators.

Results

Among 39 reports from the 8 implementing facilities (~ 5 per facility), we identified 11 CFIR constructs. Key implementation facilitators included sensitizing and educating facility staff about PrEP (knowledge and beliefs about the innovation); establishing formal and informal feedback and accountability mechanisms (reflecting and evaluating); and empowering facility staff to address implementation challenges (self-efficacy). Key implementation barriers were related to ineffective recruitment and referral of sero-different couples to and from nearby facilities (cosmopolitanism) as well as stockouts of laboratory resources and testing supplies (available resources).

Conclusions

This analysis featured a robust implementation science framework to assess the relationship between early implementation determinants and outcomes of this innovative PrEP delivery model. Further, we have provided important descriptions of early implementation barriers and facilitators that will inform scale-up efforts for PrEP delivery within and beyond Uganda. Future work will refine the analysis of pragmatic program data, qualitatively investigate the identified key themes, and explore strategies for addressing implementation barriers.

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

✪ Comparing Patients’ Experiences in Three Differentiated Service Delivery Models for HIV Treatment in South Africa

Authors:

Ferdinand C. Mukumbang, Sibusiso Ndlovu, and Brian van Wyk

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2021

Read the full text in the open access journal Qualitative Health Research

Abstract:

Differentiated service delivery for HIV treatment seeks to enhance medication adherence while respecting the preferences of people living with HIV. Nevertheless, patients’ experiences of using these differentiated service delivery models or approaches have not been qualitatively compared. Underpinned by the tenets of descriptive phenomenology, we explored and compared the experiences of patients in three differentiated service delivery models using the National Health Services’ Patient Experience Framework. Data were collected from 68 purposively selected people living with HIV receiving care in facility adherence clubs, community adherence clubs, and quick pharmacy pick-up. Using the constant comparative thematic analysis approach, we compared themes identified across the different participant groups. Compared to facility adherence clubs and community adherence clubs, patients in the quick pharmacy pick-up model experienced less information sharing; communication and education; and emotional/psychological support. Patients’ positive experience with a differentiated service delivery model is based on how well the model fits into their HIV disease self-management goals.

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

✪ Adolescent girls and young women’s PrEP-user journey during an implementation science study in South Africa and Kenya

Authors:

Elzette Rousseau , Ariana W. K. Katz, Shannon O’Rourke, Linda-Gail Bekker, Sinead Delany-Moretlwe, Elizabeth Bukusi, Danielle Travill, Victor Omollo, Jennifer F. Morton, Gabrielle O’Malley, Jessica E. Haberer, Renee Heffron, Rachel Johnson, Connie Celum, Jared M. Baeten, & Ariane van der Straten

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: October 2021

Read the full text in the open access journal PLOS ONE

Abstract:

Successful scale-up of PrEP for HIV prevention in African adolescent girls and young women (AGYW) requires integration of PrEP into young women’s everyday lives. We conducted interviews and focus group discussions with 137 AGYW PrEP users aged 16–25 from South Africa and Kenya. Individual and relational enablers and disablers were explored at key moments during their PrEP-user journey from awareness, initiation and early use through persistence, including PrEP pauses, restarts, and discontinuation. PrEP uptake was facilitated when offered as part of an integrated sexual reproductive health service, but hampered by low awareness, stigma and misconceptions about PrEP in the community. Daily pill-taking was challenging for AGYW due to individual, relational and structural factors and PrEP interruptions (intended or unintended) were described as part of AGYW’s PrEP-user journey. Disclosure, social support, adolescent-friendly health counseling, and convenient access to PrEP were reported as key enablers for PrEP persistence.

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

✪ Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results From a Type 2 Hybrid Effectiveness-Implementation Pilot Study

Authors:

Sara J. Landes, Susan M. Jegley, JoAnn E. Kirchner, John P. Areno, Jeffery A. Pitcock, Traci H. Abraham, Sacha A. McBain, R. Sonia Singh, Mary J. Bollinger, Jacob Painter, Jack A. Woods, Nyssa D. Curtis, Donald E. Jones Jr, Bridget B. Matarazzo, Mark A. Reger, and Katherine Anne Comtois

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: October 2021

Read the full text in the open access journal Frontiers in Psychiatry

Abstract:

Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care.

Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.

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

✪ Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial

Authors:

Sara J. Becker, Cara M. Murphy, Bryan Hartzler, Carla J. Rash, Tim Janssen, Mat Roosa, Lynn M. Madden & Bryan R. Garner

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: October 2021

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

Abstract:

Background

Opioid-related overdoses and harms have been declared a public health emergency in the United States, highlighting an urgent need to implement evidence-based treatments. Contingency management (CM) is one of the most effective behavioral interventions when delivered in combination with medication for opioid use disorder, but its implementation in opioid treatment programs is woefully limited. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) was funded by the National Institute on Drug Abuse to identify effective strategies for helping opioid treatment programs improve CM implementation as an adjunct to medication. Specific aims will test the impact of two different strategies on implementation outcomes (primary aim) and patient outcomes (secondary aims), as well as test putative mediators of implementation effectiveness (exploratory aim).

Methods

A 3-cohort, cluster-randomized, type 3 hybrid design is used with the opioid treatment programs as the unit of randomization. Thirty programs are randomized to one of two conditions. The control condition is the Addiction Technology Transfer Center (ATTC) Network implementation strategy, which consists of three core approaches: didactic training, performance feedback, and on-going consultation. The experimental condition is an enhanced ATTC strategy, with the same core ATTC elements plus two additional theory-driven elements. The two additional elements are Pay-for-Performance, which aims to increase implementing staff’s extrinsic motivations, and Implementation & Sustainment Facilitation, which targets staff’s intrinsic motivations. Data will be collected using a novel, CM Tracker tool to document CM session delivery, session audio recordings, provider surveys, and patient surveys. Implementation outcomes include CM Exposure (number of CM sessions delivered per patient), CM Skill (ratings of CM fidelity), and CM Sustainment (number of patients receiving CM after removal of support). Patient outcomes include self-reported opioid abstinence and opioid-related problems (both assessed at 3- and 6-months post-baseline).

Discussion

There is urgent public health need to improve the implementation of CM as an adjunct to medication for opioid use disorder. Consistent with its hybrid type 3 design, Project MIMIC is advancing implementation science by comparing impacts of these two multifaceted strategies on both implementation and patient outcomes, and by examining the extent to which the impacts of those strategies can be explained by putative mediators.

Trial registration

This clinical trial has been registered with clinicaltrials.gov (NCT03931174).

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

✪ Factors Affecting the Initiation of a Shared Decision Making Program in Obstetric Practices

Authors:

Deborah J. Bowen, Ann M. Nguyen, Cynthia LeRouge, Erin LePoire, & Tao Sheng Kwan-Gett

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: September 2021

Read the full text in the open access journal Healthcare

Abstract:

As healthcare systems progress toward initiatives that increase patient engagement, stakeholder hopes are that shared decision making (SDM) will become routine practice. Yet, there is limited empirical evidence to guide such SDM program implementations, particularly in obstetric practices. The first stage of any project implementation is the "initiation stage", in which project leaders define a project's purpose and stakeholders and structures are put in place to support the new initiative.

Our study's objective was to identify factors affecting the initiation stage of an SDM program implementation project for TOLAC, trial of labor after Cesarean. We conducted a multiple-case study of an SDM program implementation in three obstetric settings in Washington State. The research design and analysis were guided by implementation science frameworks and project management literature. Data sources included interviews with key informants from the State, SDM tool vendors, and three project sites, as well as implementation documents.

The study results provide insight into how the identified project implementation factors provide an essential foundation for informing project planning, execution, and reflection/evaluation. In this study, the State's decision aid certification program pressured the project sites to shape the project purpose and engage stakeholders that would meet immediate project requirements (specifically, state requirements).

The study reveals that external demands may not be in perfect alignment with the internal necessities required for an SDM program's long-term viability and sustainability. Findings may be used by implementers and researchers to model and strategize the early stages of SDM program implementation projects, particularly in the obstetric setting.

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

✪ Exploring the impact of workforce turnover on the sustainability of evidence-based programs: A scoping review

Authors:

Kelley M. Pascoe, Miruna Petrescu-Prahova, Lesley Steinman, Jennifer Bacci, Siobhan Mahorter, Basia Belza, & Bryan Weiner

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: September 2021

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

Abstract:

Background

Evidence-based programs (EBPs) are used across disciplines to integrate research into practice and improve outcomes at the individual and/or community level. Despite widespread development and implementation of EBPs, many programs are not sustained beyond the initial implementation period due to many factors, including workforce turnover. This scoping review summarizes research on the impact of workforce turnover on the sustainability of EBPs and recommendations for mitigating these impacts.

Methods

We searched 10 databases for articles that focused on an EBP and described an association between workforce turnover and the sustainment or sustainability of the program. We created a data abstraction tool to extract relevant information from each article and applied the data abstraction tool to all included articles to create the dataset. Data were mapped and analyzed using the program sustainability framework (PSF).

Results and Discussion

A total of 30 articles were included in this scoping review and mapped to the PSF. Twenty-nine articles described impacts of workforce turnover and 18 articles proposed recommendations to address the impacts. The most frequent impacts of workforce turnover included increased need for training, loss of organizational knowledge, lack of EBP fidelity, and financial stress. Recommendations to address the impact of workforce turnover included affordable and alternative training modalities, the use of champions or volunteers, increasing program alignment with organizational goals, and generating diverse funding portfolios.

Conclusion

The sustainment of EBPs is critical to ensure and maintain the short- and long-term benefits of the EBP for all participants and communities. Understanding the impacts of workforce turnover, a determinant of sustainability, can create awareness among EBP-implementing organizations and allow for proactive planning to increase the likelihood of program sustainability.

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