Sustainability Archives - Implementation Science at UW

✪ Targeted social and behavior change communication (SBCC) in a high adolescent pregnancy setting of Bangladesh: a cluster-randomized study protocol engaging key family members

Abstract:

Background

Maternal health service utilization remains low in Bangladesh, while maternal health outcomes are poor and adolescent pregnancy rates are high. In this context, targeted social and behavior change communication (SBCC) can be an effective approach. This targeted SBCC research was participatorily designed in collaboration with Bangladesh local partners and was funded as part of the 2023–27 KOICA Strategic Partnership Program (SPP)- Strengthening Maternal and Neonatal Health System in Rangpur, Bangladesh (No. 2023–0515). The study was informed by implementation and behavior change theories, engaging key family members in the intervention.

Methods

A hybrid effectiveness-implementation type II cluster-randomized study was designed to measure key maternal health service utilization outcomes as well as implementation outcomes. A total of 750 participants classified into four targeted groups-1) adolescent pregnant women, 2) adult pregnant women, 3) husbands and 4) mothers-in-law, will be invited to participate in group-based interactive community courtyard sessions. These 5-month curriculum targeted SBCC sessions cover maternal and newborn health topics such as antenatal care (ANC), safe delivery, postnatal care (PNC), and neonatal care. The primary outcomes include four or more ANC visits, facility delivery, Postnatal Care (PNC) and neonatal care within 48 h after delivery. Secondary outcomes are perceptions on early marriage, maternal health-seeking behaviors, family support, decision making, and satisfaction with the information gained from the targeted SBCC sessions. To assess the effectiveness, baseline and endline surveys, along with endline focus group discussions (FGDs) will be conducted before and after the 5-month curriculum. Additionally, implementation outcomes such as adoption, penetration, acceptability, coverage, feasibility, fidelity, and sustainability will be measured.

Discussion

This study engages key decision-makers such as pregnant women, their husbands, and mothers-in-law, to enhance maternal health service utilization. As Bangladesh is a patriarchal society, men within households are often the primary decision-makers regarding marriage and reproductive matters. Moreover, the child marriage and adolescent pregnancy rates remain high, contributing to persistently elevated maternal and neonatal mortality. By applying implementation science frameworks and behavior change theories, this study aims to generate evidence to inform future scale-up efforts in similar contexts.

Trial registration

The protocol was registered with ISRCTN registry under registration ISRCTN12515877.

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

Implementing Payer Partnerships for Patient Care Programs within Clinically Integrated Networks of Community Pharmacies: A Qualitative Study

✪ Environmental sustainability, an essential outcome for implementation scientists to improve health

Abstract:

While there is evidence of humans' harmful impact on the environment, translating such evidence into changes is challenging. Implementation science can facilitate a shift from a reactive to proactive approach in tackling environmental sustainability. This article aims to spur further discussion among implementation scientists to incorporate environmental sustainability within their research, while also offering concepts relevant to environmental science researchers seeking to apply implementation science principles.

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

✪ Characterizing screening champions in the Center for Disease Control and Prevention’s Colorectal Cancer Control Program (CRCCP)

Abstract:

Background

CDC’s Colorectal Cancer Control Program (CRCCP) aims to increase colorectal cancer (CRC) screening prevalence by implementing evidence-based interventions (EBIs) in health system clinics partnering with the program. Program champions, as one of the key program components, are expected to facilitate the implementation of EBIs and support desired changes in many ways. Given limited information about the champions in clinical systems, this study investigated champion types, roles, and sustainability within the CRCCP.

Methods

This mixed methods, cross-sectional study included a survey of 205 respondents (health system and clinic staff) representing 303 clinics and 12 qualitative interviews of CRCCP award recipients and partnering clinics. The survey assessed clinic characteristics, EBI implementation, information about program champions, and sustainability. Interview topics included champion roles, benefits, turnover, and maintenance.

Findings

Champions worked at either the health system or clinic level. Among health systems, champions were quality improvement (QI) managers (48.5%), physicians (36.4%), or high-level administrators (27.3%). In clinics, champions were physicians (37.0%), QI managers (26.1%) or medical assistants (23.9%). Champions in both health systems and clinics were most often assigned the role (45.5% and 45.7%, respectively); yet clinic champions were more likely to naturally emerge than health system champions (26.1% vs. 15.2%). Among naturally emerging champions, 64.3% experienced zero turnover, more than for assigned champions. While champions in both groups received training, more champions in health systems reported being trained than those in clinics (75.8% vs 52.2%). No significant differences in EBIs implemented were observed between those clinics with and without a champion. Zero champion turnover was associated with great or very great leadership support (68.9%), program adaptation (60.7%) and organizational capacity (54.1%). Interviews found that champions’ roles included advocating for CRC screening, providing technical assistance for EBI implementation, creating organizational policies for CRC screening, and overseeing QI. Interviewees reported a desire to address champion sustainability.

Conclusion

These findings inform the use of program champions for clinic-based public health programs. Naturally emerging champions were more stable than those assigned the role.

Contributions to the literature

Research has demonstrated that program champions can assist in the implementation of evidence-based interventions; however, there is limited understanding of the types of champions, their roles, and turnover.
These findings contribute to this gap by describing the types of program champions, their training and major roles in implementing evidence-based interventions for colorectal cancer screening.
Common roles for champions were implementers, advocates, connectors, motivators, changemakers, data wranglers, educators, and sustainability resource.

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

✪ High acceptability, feasibility and sustainability of a direct-to-pharmacy differentiated PrEP delivery model in public health HIV clinics in Kenya: perspectives of PrEP clients and healthcare providers

Abstract:

Introduction

High client opportunity costs and a burdened healthcare system limit oral pre-exposure prophylaxis (PrEP) delivery in Kenyan public HIV clinics. We conducted a qualitative study among PrEP clients and providers to understand the acceptability, feasibility and willingness to implement a client-centred, differentiated direct-to-pharmacy (DTP) PrEP refill visits intervention aimed at improving the efficiency of PrEP implementation in real-world clinics.

Methods

From March 2021 to March 2022, we conducted in-depth interviews with clients and healthcare providers participating in an individual facility pharmacy-based PrEP delivery model for PrEP refills among clients in the continuation phase at two public HIV clinics in central Kenya. The core components of the DTP model included directed-to-PrEP pharmacy refill visits conducted by facility pharmacy staff and client HIV self-testing (HIVST) while waiting for services at the pharmacy. We used semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR). We analysed data using thematic content analysis and organised findings by CFIR constructs.

Results

We interviewed 20 PrEP clients and 20 healthcare providers. PrEP clients included 15 females and had a median age of 39 years (interquartile range [IQR]: 33–48). Providers included 13 females, had a median age of 32 years (IQR: 30–41), and included 10 HIV counsellors, 5 pharmacy and 3 clinical providers. Both providers and clients reported high satisfaction with DTP PrEP refill visits derived from improved clinic flow and quality of service. Among clients, shorter waiting times and less movement between multiple clinic rooms reduced delays, improved privacy and reduced stigma associated with visiting HIV clinics. Furthermore, shorter waiting times and infrequent clinic visits reduced loss of working hours and income among clients, motivating PrEP continuation. Providers reported improved clinic flow, reduced work burden among non-pharmacy providers, improved knowledge and ease of implementing DTP refill visits. However, providers expressed concerns about the potential loss of roles among HIV counsellors and the shifting of workload burden to pharmacy providers.

Conclusions

Differentiated DTP refill visits with HIVST were highly acceptable and feasible among PrEP clients and providers. Context-specific modifications and scale-up of the intervention could improve the efficiency of PrEP delivery within public HIV clinics in Kenya and similar settings.

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

Barriers and facilitators to implementing enteral resuscitation for major burn injuries: Reflections from Nepalese care providers

✪ Training and Support Practices and Insights in the Sustainability of mHealth Implementations in Sub-Saharan Africa

Abstract:

We conducted an interview-based study to understand the training and support practices and insights that influence sustainable implementations of mHealth projects of varying mHealth technologies. The qualitative assessment was inspired by the Consolidated Framework for Implementation Research adapted with the recommended questions for guiding the implementation of training programs. Participants in the study (N = 16) were both international and in-country researchers managing projects in sub-Saharan Africa. We chose to focus on training and support, as it is often the interface between international and in-country components of these projects. Participants agreed on the central role of training in the implementation of mHealth projects and are following best practices. There was often a division in the responsibility of training between international and in-country researchers reflecting the distinction between project management and local implementation adaptions. One of the main findings is the importance of individualized continuous retraining to make deployments robust with respect to changing conditions with technology and personnel, an aspect that has been managed a bit differently with varying mHealth technologies as presented in this article.

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

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

Abstract:

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

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

✪ Study protocol for a hybrid type 3 effectiveness-implementation trial of a team-based implementation strategy to support educators’ use of a social engagement intervention

Abstract:

Background

Remaking Recess (RR) is a school-based evidence-based peer social engagement intervention for autistic students. RR involves direct training and coaching with educators; however, educators face several barriers to implementation at both the individual- and organizational-levels. This protocol paper describes a multi-site study that will test whether an educator-level implementation strategy, coaching, with or without a school-level implementation strategy, school-based teams, will maximize educators’ use (fidelity and sustainment) of RR for autistic students and their peers who are socially-isolated, rejected, or peripheral and may need additional support during recess.

Methods

This study will employ a hybrid type-3 effectiveness-implementation trial. Fifty-five elementary schools will be recruited as well as 121 educators (e.g., classroom assistants, aides), 55 general and special educator teachers, and 83–138 other school personnel (e.g., administrators). Additionally, at least 118 autistic students and allistic or non-autistic classmates will be recruited as RR recipients. Participants will complete baseline assessments at the beginning of the year, and all schools will be provided RR training. Schools will be randomized to coaching with or without school-based teams. This study will measure RR fidelity (primary outcome), RR sustainment, as well as peer engagement, social network inclusion, and social skills (secondary outcomes). It is expected that coaching with school-based teams will improve both RR fidelity and social network inclusion, while coaching with and without school-based teams will result in improved peer engagement and social skills.

Discussion

Previous research has documented barriers to RR implementation at both the individual- (provider) and organization-level (school). Using multi-level implementation strategies such as coaching with school-based teams may address these barriers and support RR implementation in schools. Findings from this study may guide future efforts to scale up tailored implementation strategies for use in public school districts, with the ultimate goal of increasing intervention access and improving student outcomes.

Trial registration

Name of the Registry: clinicaltrials.gov.
Trial Registration: Clinical Trials ID: NCT06559267.
Date of Registration: August 15, 2024. Prospectively registered.

Contributions to the literature

Remaking Recess (RR) is an intervention that improves peer engagement and classroom inclusion in autistic students. Educators, who play an important role in supporting autistic youth and their peers who are socially-isolated, rejected, or peripheral during the school day and at recess, can deliver RR.
Schools face many challenges, at both the individual- (i.e., educator) and organizational-levels (i.e., school), when implementing new interventions.
This study will evaluate the impact of two implementation strategies on the fidelity and sustainment of RR: (a) individual direct coaching for educators (coaching), and (b) supporting a team of school personnel (school-based teams) in addition to coaching.

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

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