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Implementation Science at UW

Keywords: Scale-Up

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

Authors:

John A.Naslund, Jasmine Kalha, Juliana L. Restivo, Ishmael Amarreh, Tamora Callands, Hongtu Chen, Carlos Gomez-Restrepo, Hesham M. Hamoda, Arjun Kapoor, Sue Levkoff, Jones Masiye, Maria A. Oquendo, Vikram Patel, Inge Petersen, Ozge Sensoy Bahar, Laura Shields-Zeeman, Fred M. Ssewamala, Deepak Tugnawat, José Miguel Uribe-Restrepo, Lakshmi Vijayakumar, Bradley H. Wagenaar, Milton L.Wainberg, Larry Wissow, Haja Ramatulai Wurie, Chifundo Zimba, & Soumitra Pathare

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: January 2021

Read the full text in the subscription access journal Asian Journal of Psychiatry

✪ Evaluating the implementation of cervical cancer screening programs in low-resource settings globally: a systematized review

Authors:

J. Andrew Dykens, Jennifer S. Smith, Margaret Demment, E. Marshall, Tina Schuh, Karen Peters, Tracy Irwin, Scott McIntosh, Angela Sy & Timothy Dye

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2020

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

Abstract:

Purpose

Cervical cancer disproportionately burdens low-resource populations where access to quality screening services is limited. A greater understanding of sustainable approaches to implement cervical cancer screening services is needed.

Methods

We conducted a systematized literature review of evaluations from cervical cancer screening programs implemented in resource-limited settings globally that included a formal evaluation and intention of program sustainment over time. We categorized the included studies using the continuum of implementation research framework which categorizes studies progressively from “implementation light” to more implementation intensive.

Results

Fifty-one of 13,330 initially identified papers were reviewed with most study sites in low-resource settings of middle-income countries (94.1%) ,while 9.8% were in low-income countries. Across all studies, visual inspection of the cervix with acetic acid (58.8%) was the most prevalent screening method followed by cytology testing (39.2%). Demand-side (client and community) considerations were reported in 86.3% of the articles, while 68.6% focused scientific inquiry on the supply side (health service). Eighteen articles (35.3%) were categorized as “Informing Scale-up” along the continuum of implementation research.

Conclusions

The number of cervical cancer screening implementation reports is limited globally, especially in low-income countries. The 18 papers we classified as Informing Scale-up provide critical insights for developing programs relevant to implementation outcomes. We recommend that program managers report lessons learnt to build collective implementation knowledge for cervical cancer screening services, globally.

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

The impact of localized implementation: Determining the cost-effectiveness of HIV prevention and care interventions across six United States cities

Authors:

Emanuel Krebs, Xiao Zang, Benjamin Enns, Jeong E. Min, Czarina N. Behrends, Carlos del Rio, Julia C. Dombrowski, Daniel J. Feaster, Kelly A. Gebo, Matthew Golden, Brandon D.L. Marshall, Lisa R. Metsch, Bruce R. Schackman, Steven Shoptaw, Steffanie A. Strathdee, Bohdan Nosyk on behalf of the Localized Economic Modeling Study Group

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: March 2020

Read the full text in the subscription access journal AIDS

✪ Capturing the patient voice: implementing patient-reported outcomes across the health system

Authors:

Elizabeth Austin, Cynthia LeRouge, Andrea L. Hartzler, Courtney Segal, & Danielle C. Lavallee

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: October 2019

Read the full text provided with open access, by the hybrid subscription journal Quality of Life Research
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Abstract:

Purpose

Supporting the capture and use of patient-reported outcomes (PROs) at the point-of-care enriches information about important clinical and quality of life outcomes. Yet the ability to scale PROs across healthcare systems has been limited by knowledge gaps around how to manage the diversity of PRO uses and leverage health information technology. In this study, we report learnings and practice insights from UW Medicine’s practice transformation efforts to incorporate patient voice into multiple areas of care.

Methods

Using a participatory, action research approach, we engaged with UW Medicine clinical and administrative stakeholders experienced with PRO implementation to inventory PRO implementations across the health system, characterize common clinical uses for PROs, and develop recommendations for system-wide governance and implementation of PROs.

Results

We identified a wide breadth of PRO implementations (n = 14) in practice and found that nearly half (47%) of employed PRO measures captured shared clinical domains (e.g., depression). We developed three vignettes (use cases) that illustrate how users interact with PROs, characterize common ways PRO implementations support clinical care across the health system (1) Preventive care, (2) Chronic/Specialty care, and (3) Surgical/Interventional care), and elucidate opportunities to enhance efficient PRO implementations through system-level standards and governance.

Conclusions

Practice transformation efforts increasingly require integration of the patient voice into clinical care, often through the use of PROs. Learnings from our work highlight the importance of proactively considering how PROs will be used across the layers of healthcare organizations to optimize the design and governance of PROs.

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

✪ Scaling-up the Systems Analysis and Improvement Approach for prevention of mother-to-child HIV transmission in Mozambique (SAIA-SCALE): a stepped-wedge cluster randomized trial

Authors:

Kenneth Sherr, Kristjana Ásbjörnsdóttir, Jonny Crocker, Joana Coutinho, Maria de Fatima Cuembelo, Esperança Tavede, Nélia Manaca, Keshet Ronen, Felipe Murgorgo, Ruanne Barnabas, Grace John-Stewart, Sarah Holte, Bryan J. Weiner, James Pfeiffer & Sarah Gimbel

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2019

Read the full text in the open access journal Implementation Science

Abstract:

Background

The introduction of option B+ — rapid initiation of lifelong antiretroviral therapy regardless of disease status for HIV-infected pregnant and breastfeeding women — can dramatically reduce HIV transmission during pregnancy, birth, and breastfeeding. Despite significant investments to scale-up Option B+, results have been mixed, with high rates of loss to follow-up, sub-optimal viral suppression, continued pediatric HIV transmission, and HIV-associated maternal morbidity. The Systems Analysis and Improvement Approach (SAIA) cluster randomized trial demonstrated that a package of systems engineering tools improved flow through the prevention of mother-to-child HIV transmission (PMTCT) cascade. This five-step, facility-level intervention is designed to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). This protocol describes a novel model for SAIA delivery (SAIA-SCALE) led by district nurse supervisors (rather than research nurses), and evaluation procedures, to serve as a foundation for national scale-up.

Methods

The SAIA-SCALE stepped wedge trial includes three implementation waves, each 12 months in duration. Districts are the unit of assignment, with four districts randomly assigned per wave, covering all 12 districts in Manica province, Mozambique. In each district, the three highest volume health facilities will receive the SAIA-SCALE intervention (totaling 36 intervention facilities). The RE-AIM framework will guide SAIA-SCALE’s evaluation. Reach describes the proportion of clinics and population in Manica province reached, and sub-groups not reached. Effectiveness assesses impact on PMTCT process measures and patient-level outcomes. Adoption describes the proportion of districts/clinics adopting SAIA-SCALE, and determinants of adoption using the Organizational Readiness for Implementing Change (ORIC) tool. Implementation will identify SAIA-SCALE core elements and determinants of successful implementation using the Consolidated Framework for Implementation Research (CFIR). Maintenance describes the proportion of districts sustaining the intervention. We will also estimate the budget and program impact from the payer perspective for national scale-up.

Discussion

SAIA packages user-friendly systems engineering tools to guide decision-making by frontline health workers, and to identify low-cost, contextually appropriate PMTCT improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial is designed to test a model for national intervention scale-up.

Trial Registration

ClinicalTrials.gov NCT03425136 (registered 02/06/2018).

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

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✪ Scaling-up PrEP Delivery in Sub-Saharan Africa: What Can We Learn from the Scale-up of ART?

Authors:

Gabrielle O’Malley, Gena Barnabee, & Kenneth Mugwanya

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: February 2019

Read the full text open access from subscription journal Current HIV/AIDS Reports

Abstract:

Purpose of Review

Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020.

Recent Findings

Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence.

Summary

Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.

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