Open Access Archives - Page 5 of 35 - Implementation Science at UW

✪ Evaluating behavioral intervention technologies: Integrating human-centered design and implementation science outcomes

Abstract:

Background

Behavioral intervention technologies (BITs) offer scalable, cost-effective healthcare solutions but often show reduced impacts in community settings and are rarely sustained. Human-centered design (HCD) enhances usability by tailoring BITs to stakeholder needs, while implementation science (IS) identifies contextual barriers and strategies to promote uptake and sustainability. Both HCD and IS aim to improve BIT usability and implementation through iterative, user-focused processes but are rarely integrated.

Objective

We introduced the user-centered and sustainable implementation science (USIS) model, a novel and systematic framework that combines HCD and IS principles to enhance BIT effectiveness and sustainability. We aimed to (1) synthesize the HCD and IS outcomes and integrate them into a USIS framework; (2) apply USIS to a case study: the sleep shared-management intervention for children with juvenile idiopathic arthritis and their parents (SLEEPSMART).

Methods

We conducted a narrative literature review on HCD and IS outcomes for BITs from the PubMed, CINAHL, and Web of Science databases. Articles were selected based on their focus on usability, implementation outcomes, and evidence-based healthcare practices. This synthesis informed the development of the USIS model.

Results

The USIS model incorporates five domains: (1) user-centeredness (empathy, engagement, and equity), (2) efficiency (cost, timeliness, and rapidity), (3) feasibility (learnability, memorability, error reduction, and low cognitive load), (4) satisfaction (acceptability and appropriateness), and (5) fidelity (adoption, penetration, and sustainability). We applied the USIS model to evaluate the SLEEPSMART project to demonstrate the application of the USIS model in guiding BIT design and refinement. Insights from the review informed the design principles applied during the development and testing stages of SLEEPSMART.

Conclusion

The USIS model serves as a practical and theoretical guide to improve BIT design and evaluation. By emphasizing implementation considerations early and centering user needs, USIS provides a pathway to bridge HCD and IS approaches to enhance the real-world impact and sustainability of digital health innovations.

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✪ When evidence is not enough: A qualitative exploration of healthcare workers’ perspectives on expansion of two-way texting (2wT) for post- circumcision follow-up in South Africa

Abstract:

As per South African national guidelines, in-person follow-up visits after voluntary medical male circumcision (VMMC) are required but may be unnecessary. Two-way texting (2wT), an mHealth platform, engages clients in post-operative care and triages those with complications to in-person review. 2wT was found to be safe, effective, and efficient. In South Africa, to understand provider perspectives on 2wT and potential for expansion, 20 key informant interviews were conducted with management, clinicians, data officials and support staff involved in 2wT scale-up. Interviews were analyzed using rapid qualitative methods and informed by two implementation science frameworks: the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework and the Pragmatic, Robust, Implementation and Sustainability Model (PRISM). Participants shared mixed and multi-faceted feedback, including that 2wT improves monitoring and evaluation of clients and clinical outcomes while also reducing follow-up visits. Challenges included duplicative routine and 2wT reporting systems and perceptions that 2wT increased workload. To improve the likelihood of successful 2wT scale-up in routine VMMC settings, participants suggested: further 2wT sensitization to ensure clinician and support staff buy-in; a dedicated clinician or nurse to manage telehealth clients; improved dashboards to better visualize 2wT client data; mobilizing 2wT champions at facilities to garner support for 2wT as routine care; and updating VMMC guidelines to support VMMC telehealth. As attendance at follow-up visits may not be as high as reported, implementing 2wT may require more effort but also brings added benefits of client verification and documented follow-up. The transition from research to routine practice is challenging, but use of RE-AIM and PRISM indicate that it is not impossible. As VMMC funding is decreasing, more effort to share the evidence base for 2wT as a safe, cost-effective, high-quality approach for VMMC follow-up is needed to encourage widespread uptake and adoption.

Author summary

South Africa has a high prevalence of HIV, and voluntary medical male circumcision is a prevention method recommended by the World Health Organization. Two-way texting (2wT) is a digital health intervention that allows males to receive educational messages after circumcision about healing and send messages directly to a provider via SMS or WhatsApp. This system detects as many complications as routine follow-up care, though is more efficient. As we scale up to new locations in South Africa, we wanted to ensure the approach is well-adapted for health workers. Through 20 interviews with health workers, we found that it saves clients in-person visits and helps with data collection. However, more effort is needed to introduce the intervention to clinicians, including providing better training and appointing champions to help motivate clinicians. Funding for HIV and VMMC programs is decreasing, so it is important to find tools such as digital health to reduce the burden on facilities while maintaining quality client care.

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✪ Building the Plane as We Fly: Considerations for Scaling Out Coordinated Specialty Care for Early Psychosis in the Rural United States

Abstract:

Coordinated specialty care (CSC) programs for early psychosis have expanded rapidly in the United States in recent years due to evidence supporting early intervention and subsequent federal funding. The majority of CSC programs are located in major urban and surrounding suburban areas, although many states are expanding or planning to expand CSC services to rural and remote areas. Despite ongoing implementation efforts, little is known about effective implementation of CSC in rural and remote communities. The present article uses the “scale out” model as a guiding framework to consider how CSC can be implemented in rural areas and describes considerations relevant to infrastructure for rural CSC: defining rurality, priority population, workforce, financing, telehealth, strengths of rural communities, culture, and social determinants of health. We then discuss two overarching challenges of (a) integrating alternative bottom-up, community partnership approaches, such as community-based participatory research, into the scale out model and (b) using the scale out model for an implementation effort that is already underway. We argue that successful rural CSC implementation will involve integrating the scale out model with rigorous community-based participatory research to incorporate theory with real-world needs and learn in real-time from ongoing implementation efforts.

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✪ What do women want in pharmacy-based HIV prevention services during pregnancy? Developing attributes and levels for a discrete choice experiment in Western Kenya

Abstract:

Background

The delivery of HIV prevention services (e.g., HIV testing, pre-exposure prophylaxis (PrEP) initiation and refills, and STI testing) in community pharmacies could address clinic barriers faced by pregnant women such as extended travel and wait times. We conducted a qualitative study in Western Kenya to select and prioritize attributes and levels for a discrete choice experiment (DCE) to design pharmacy-based HIV prevention services for pregnant women.

Methods

We began by identifying a comprehensive list of attributes and levels relevant to women considering HIV prevention during pregnancy. This list was informed by recommended HIV prevention interventions for pregnant women, our objective to design services for pharmacy settings, and attributes identified in the literature as important for other populations when choosing HIV and pharmacy-based services. From March to November 2022, we recruited participants using stratified purposeful sampling and collected qualitative data through seven focus group discussions with women, four with health providers, and eight individual interviews with technical experts. Interviews were audio-recorded, translated, transcribed, and summarized in debrief reports. We conducted debriefing meetings and analyzed these reports to identify and refine the essential attributes that would influence decisions to access HIV prevention services from a pharmacy during pregnancy.

Results

We initially identified twelve potential attributes that were evaluated during the focus groups. Five attributes were eliminated based on ranking exercises with women and health providers. Additional attributes suggested during the focus groups were ranked low by participants or not mentioned frequently enough and, therefore, not included. We finalized and refined levels for each attribute using insights from the literature, participant feedback, and design considerations. The study identified seven attributes: service location, type of HIV test, STI testing availability, partner HIV testing availability, PrEP availability, service access methods (e.g., appointment versus walk-ins), and service fee.

Conclusions

This study was the first step in data collection toward defining attributes and levels for a DCE survey and successfully identified seven preliminary attributes and levels. Pre-testing and pilot testing activities further explored the feasibility and understanding of the attributes and levels.

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✪ Getting to Implementation for HIV Pre-Exposure Prophylaxis (GTI-PrEP): A data-driven approach to PrEP prescribing

Abstract:

Background

Pre-Exposure Prophylaxis (PrEP) dramatically reduces the likelihood of acquiring human immunodeficiency virus (HIV), yet it remains under-prescribed, particularly for people in communities with high HIV incidence. While implementation science and health services researchers aim to address disparities in care, few interventions have proven effective in doing so. We aimed to identify implementation strategies associated with higher PrEP prescribing rates and pilot test a tailored intervention as a proof-of-concept in a single Veterans Health Administration (VA) facility.

Methods

VA clinicians were surveyed using an instrument derived from the Evidence-based Recommendations for Implementing Change taxonomy to assess the use of various strategies for PrEP in fiscal years 2019–2021. Correlational analyses identified the strategies associated with the frequency of PrEP prescribing and semi-structured interviews with personnel from 11 VA medical facilities with high PrEP prescribing refined and manualized these strategies into the Getting to Implementation (GTI)-PrEP playbook. The playbook was subsequently pilot tested in a VA facility with high new HIV diagnosis rates and low PrEP prescribing rates.

Results

The clinician survey collected 157 responses from 95 unique VA facilities on implementation strategy use. Analysis identified eight strategies significantly associated with PrEP prescribing, including: networking, clinician education, clinical support tools, dashboard utilization, telehealth, pharmacist involvement, direct patient engagement, and enhanced sexual health history taking. In the pilot study, the site completed the GTI-PrEP Playbook with high fidelity and newly implemented seven of the eight strategies, achieving a 363% increase in PrEP prescribing rates among Black Veterans over the one-year period.

Conclusions

This multi-year national evaluation identified a core subset of effective implementation strategies for increasing PrEP prescribing. The process of empirically specifying these strategies and pilot testing them through the GTI-PrEP playbook demonstrates a promising, data-driven approach to improve PrEP prescribing rates and reduce racial disparities in HIV prevention.

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✪ “If he returns, receive him because he has realized that he needs assistance”: A qualitative study exploring preferences for retention on antiretroviral therapy support in Malawi among Lighthouse Clinic clients

Abstract:

Introduction

Retention of people living with HIV (PLHIV) on antiretroviral therapy (ART) is critical. Retention is not static: clients cycle in and out of care over the course of treatment. Retention support is also evolving, with interventions like mobile health (mHealth) gaining traction. We aimed to explore ART clients’ perspectives and recommend strategies for improved retention support including a two-way-texting (2wT) mHealth intervention in two clinics in Malawi.

Materials and methods

We conducted focus group discussions (FGDs) with PLHIV on ART receiving 2wT or standard of care (SoC) retention support to understand client perspectives. FGDs were audio-recorded in Chichewa, translated and transcribed into English. We used the RE-AIM implementation science framework to report findings on the reach, effectiveness, adoption, implementation, and maintenance potential of retention interventions considering individual, clinic/organization, and community factors. Through rapid qualitative analysis, we identified key themes and subthemes.

Results

Ten FGDs were conducted with 89 ART clients (aged ≥18 years; 55% female): four FGDs among 2wT participants and six among SoC participants. Few differences were observed between 2wT and SoC clients. All clients appreciated accessing at least one form of support and recommended continuous assistance, regardless of age, sex, or duration on ART. Clients wished to be encouraged by other PLHIV to allay common fears. Groups discussed the need for intensified support to retain young clients or those out of care longer. Individual responsibility was identified as necessary, but insufficient, to improve retention: respondents desired a more positive clinic environment to encourage persistence in care. Fear of stigma, unintended status disclosure, and negative interactions with clinic staff prevent some clients from returning to care.

Conclusion

PLHIV want differentiated, continuous retention support from other PLHIV coupled with a positive clinic environment to promote retention and reengagement in care. As differentiated retention support is expensive, consideration of cost, feasibility, and sustainability is needed.

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✪ “Going above and beyond” for implementation in the education sector: extension and validation of the School Implementation Citizenship Behavior Scale (SICBS)

Abstract:

Background

Employee behaviors that strategically support implementation (i.e., implementation citizenship behavior [ICB]) theoretically promote the adoption and high-fidelity use of evidence-based practices (EBPs). ICB (e.g., helping colleagues overcome implementation barriers) may vary across contexts, including schools where children are most likely to access and receive mental and behavioral health services. Pragmatic measures are needed to advance nascent research on school-based ICB and inform how these behaviors can be used to support successful implementation. The current study expanded the Implementation Citizenship Behavior Scale (ICBS) to create and validate the School Implementation Citizenship Behavior Scale (SICBS) in a sample of elementary school teachers implementing evidence-based prevention programs to support children’s mental and behavioral health.

Methods

Based on subject matter expert feedback, items were refined from the original ICBS and items for two new subscales (taking initiative, advocacy) were created for the SICBS. A sample of 441 public school teachers from 52 elementary schools in the Midwest and Western United States of America completed a survey that included the SICBS and additional measures to assess convergent and divergent validity. SICBS was refined and validated via examination of item characteristics curves to reduce items and develop a pragmatic instrument, confirmatory factor analyses to evaluate the hypothesized measurement structure, and assessment of convergent and divergent validity.

Results

The original two ICBS subscales (helping others, keeping informed) were retained, and two new three-item subscales resulted from item reduction analyses (taking initiative, advocacy). The hypothesized second-order factor model was generally well fit to the data (CFI = .99, TLI = .99, RMSEA = .09), all first- (λs = .85-.96) and second-order factor loadings (λs = .93-.95) were high. All SICBS subscales demonstrated acceptable reliability (αs = .88-.92). Convergent validity was evidenced by moderate correlations with organizational citizenship behavior items (rs = .42-.49). Divergent validity was demonstrated by weak correlations with teachers’ beliefs about teaching (rs = .31-.38) and null correlations with most school demographics.

Conclusion

Results support the structural, convergent, and divergent validity of the 12-item, 4-factor SICBS. The SICBS provides a deeper understanding of individual implementer actions that may serve as implementation mechanisms or outcomes.

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✪ Acceptability, feasibility, and factors affecting implementation of a gender-sensitivity training for HIV providers and staff in Uganda: a mixed methods, quasi-experimental controlled pilot trial

Abstract:

Background

Health workers play a critical role in providing gender-sensitive HIV care. However, without adequate training, they may inadvertently reinforce negative gender norms that hinder engagement in care. To improve ART services in sub-Saharan Africa, effective implementation strategies, including trainings, are essential.

Methods

This study evaluated the feasibility and acceptability of a novel 4-session, gender-sensitivity training for HIV health and lay workers in rural and peri-urban Uganda. We conducted a pilot quasi-experimental controlled trial in 2022–23, utilizing data from three sources: process data from 144 providers and 238 clients, qualitative post-intervention focus groups and interviews with 53 training attendees, and stakeholder interviews with 12 community leaders and facilitators. We employed thematic analysis guided by the Consolidated Framework for Implementation Research (CFIR).

Results

The training was highly rated by attendees via brief post-session surveys, with 99% of sessions deemed satisfactory. Qualitative feedback indicated that the sessions were perceived as appropriate for addressing providers’ gaps in delivering gender-sensitive care and as beneficial for participants. High feasibility was evidenced by 100% of intervention steps delivered (fidelity checklists), 86% attendance (attendance logs), and 98.6% and 94.8% recruitment of eligible providers and clients (study records), respectively. Through qualitative exit focus groups, factors that positively affected acceptability and feasibility included tactics to gain support from supervisors, the use of experienced facilitators and active learning approaches, and the consideration of the health system context in delivery (e.g., cadre mix, location). Suggested improvements encompassed addressing interpersonal and structural barriers to client-centered care, incorporating community sensitization, streamlining content, and enhancing mentorship follow-ups. Stakeholders recognized the training’s alignment with national health priorities and emphasized the need for clarity regarding its integration with existing training curricula and ongoing stakeholder engagement.

Conclusions

This study underscores the acceptability and feasibility of a gender-sensitivity training program for HIV providers; further evaluation of the program is warranted. Identified factors influencing implementation can inform enhancements to gender-focused training initiatives to improve the quality of HIV services and enhance client engagement and health outcomes.

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✪ A randomized controlled trial testing supervision strategies in community mental health

Abstract:

Background

Clinicians need supports beyond training to deliver evidence-based treatments with fidelity. Workplace-based clinical supervision often is a commonly provided support in community mental health, yet too few studies have empirically examined supervision and its impact on clinician fidelity and treatment delivery.

Method

Building on a Washington State-funded evidence-based treatment initiative (CBT+), we conducted a randomized controlled trial (RCT), testing two supervision conditions delivered by workplace-based supervisors (supervisors employed by community mental health organizations). The RCT followed a supervision-as-usual (SAU) phase for comparison. The treatment of focus was trauma-focused cognitive behavioral therapy (TF-CBT). Clinicians (N = 238) from 25 organizations participated in the study across the SAU baseline and RCT phases. In the RCT phase, clinicians were randomized to either symptom and fidelity monitoring (SFM) or SFM and behavioral rehearsal (SFM + BR). For BR, clinicians engaged in a short role play of an upcoming treatment element. Supervisors delivered both conditions, with regular study monitoring for drift. Clinicians audiorecorded therapy sessions with enrolled clients, and masked coders coded a subset of recordings for adherence to TF-CBT. One hundred and thirty-three clinicians had recorded TF-CBT session data for 258 youth. We examined six adherence outcomes, including potential moderators.

Results

Results of generalized estimating equations indicated that there were no real differences on adherence outcomes for experimental conditions (SFM, SFM + BR) compared to SAU. Adherence scores in the baseline SAU phase and the RCT conditions were high. Only one interaction was significant.

Conclusions

Contrary to our hypotheses, we did not see improvements in adherence with the RCT conditions. However, nonsignificant findings seem best explained by clinicians’ acceptable/high adherence in SAU. This study was conducted within the context of a long-standing, state-funded EBT initiative, in which clinicians and their supervisors receive training and support, and in which participating community mental health organizations have adopted and supported TF-CBT.

Trial Registration

ClinicalTrials.gov ID: NCT01800266

Plain Language Summary

Clinicians often receive training in evidence-based treatments (EBTs), but training alone is not enough for clinicians to deliver EBTs well. They need other supports. One of the necessary supports is clinical supervision. In public community mental health organizations, which are often resource-constrained, routine clinical supervision is a commonly available support. However, its potential for supporting high-quality EBT delivery is not well understood. This study looked at supervision and clinicians’ delivery of trauma-focused cognitive behavioral therapy (TF-CBT), an EBT for youth who have mental health problems subsequent to trauma. We found that clinicians who received workplace-based supervision on TF-CBT from TF-CBT-trained supervisors, within the context of a state-funded EBT initiative, delivered TF-CBT well. This initiative supported delivery by providing training and supervisor-specific supports. In a second phase of the study, we rigorously tested supervisors’ use of two specific technique packages. These packages included having supervisors review: (a) graphed client mental health symptoms across treatment and clinicians’ report of TF-CBT elements delivered each session or (b) these plus having clinicians do a brief demonstration of how they would deliver an upcoming TF-CBT element to their client, so supervisors could “see” clinicians’ skill and provide feedback. Contrary to expectations, we did not see important differences in clinicians’ TF-CBT delivery. This may be because the clinicians enrolled in our study were already delivering TF-CBT well and, therefore, there was less opportunity for changes. Future studies should explore if these techniques are more helpful for specific situations or clinicians.

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✪ 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.

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Authors:

✪ Open Access

Read the full text in the open access journal Digital Health

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Background

Objective

Methods

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Conclusion

Authors:

✪ Open Access

Read the full text in the open access journal PLOS Digital Health

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Author summary

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✪ Open Access

Read the full text in the open access journal Rural Mental Health

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✪ Open Access

Read the full text in the open access journal AIDS Research and Therapy

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✪ Open Access

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

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Background

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✪ Open Access

Read the full text in the open access journal PLOS One

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Introduction

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✪ Open Access

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

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✪ Open Access

Read the full text in the open access journal BMC Public Health

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✪ Open Access

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

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Background

Method

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Authors:

✪ Open Access

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

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Background

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Results

Conclusions

Trial registration