UW Articles Archive - Page 18 of 60 - Implementation Science at UW

✪ A Community-Partnered Research Process for Implementation Strategy Design: Developing Resources to Support Behavioral Classroom Interventions

Abstract:

Schools need effective, sustainable implementation strategies to support teachers in using effective Tier 1 (i.e., whole class) and Tier 2 (i.e., targeted) behavioral interventions in the classroom. This paper describes an iterative, community-partnered process of developing implementation resources to support teachers in using Tier 1 and 2 positive behavior management interventions; we call these resources the Positive Behavior Management Toolkit (PBMT). There were two key aspects to the iterative development process: 1) working with a Program Development Team of district—and school-employed partners to identify priorities, interpret data, provide feedback on resources, and plan for sustainment; and 2) conducting a series of tryouts in which teachers used a version of the PBMT in their classrooms and provided quantitative and qualitative feedback on acceptability, appropriateness, feasibility, and recommendations for improvement. In partnership with the Program Development Team, we used data from the tryouts to inform revisions to the PBMT. This paper presents quantitative and qualitative data from the tryouts and describes how these data informed revisions to the PBMT. We also describe the processes by which we engaged the team, considerations related to contextual appropriateness, and lessons learned related to community-engaged intervention development research.

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

✪ Adapting and testing measures of organizational context in primary care clinics in KwaZulu-Natal, South Africa

Abstract:

Background

Implementation science frameworks situate intervention implementation and sustainment within the context of the implementing organization and system. Aspects of organizational context such as leadership have been defined and measured largely within US health care settings characterized by decentralization and individual autonomy. The relevance of these constructs in other settings may be limited by differences like collectivist orientation, resource constraints, and hierarchical power structures. We aimed to adapt measures of organizational context in South African primary care clinics.

Methods

We convened a panel of South African experts in social science and HIV care delivery and presented implementation domains informed by existing frameworks and prior work in South Africa. Based on panel input, we selected contextual domains and adapted candidate items. We conducted cognitive interviews with 25 providers in KwaZulu-Natal Province to refine measures. We then conducted a cross-sectional survey of 16 clinics with 5–20 providers per clinic (N = 186). We assessed reliability using Cronbach’s alpha and calculated interrater agreement (awg) and intraclass correlation coefficient (ICC) at the clinic level. Within clinics with moderate agreement, we calculated correlation of clinic-level measures with each other and with hypothesized predictors – staff continuity and infrastructure – and a clinical outcome, patient retention on antiretroviral therapy.

Results

Panelists emphasized contextual factors; we therefore focused on elements of clinic leadership, stress, cohesion, and collective problem solving (critical consciousness). Cognitive interviews confirmed salience of the domains and improved item clarity. After excluding items related to leaders’ coordination abilities due to missingness and low agreement, all other scales demonstrated individual-level reliability and at least moderate interrater agreement in most facilities. ICC was low for most leadership measures and moderate for others. Measures tended to correlate within facility, and higher stress was significantly correlated with lower staff continuity. Organizational context was generally more positively rated in facilities that showed consistent agreement.

Conclusions

As theorized, organizational context is important in understanding program implementation within the South African health system. Most adapted measures show good reliability at individual and clinic levels. Additional revision of existing frameworks to suit this context and further testing in high and low performing clinics is warranted.

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

✪ Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): a modified Delphi study

Abstract:

Background

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

Method

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability and inclusion (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

Results

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

Discussion

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

Contributions to the literature

Adaptation of evidence-based practices, programs, and treatments is often needed to ensure successful implementation. However, existing theories/models/frameworks do not outline concrete adaptation steps that are feasible for real-world settings.
We created a resource-efficient method (MODIFI) for developing and assessing intervention adaptations in local settings. This method was iteratively developed through a mixed-methods modified Delphi process, which resulted in consensus among experts in implementation science and practice.
MODIFI leverages human centered design techniques and is tailored to the needs of intervention implementers in applied settings, filling a crucial gap in the research to practice pipeline.

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

✪ Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): a modified Delphi study

Abstract:

Background

Method

Results

Discussion

Contributions to the literature

Adaptation of evidence-based practices, programs, and treatments is often needed to ensure successful implementation. However, existing theories/models/frameworks do not outline concrete adaptation steps that are feasible for real-world settings.
We created a resource-efficient method (MODIFI) for developing and assessing intervention adaptations in local settings. This method was iteratively developed through a mixed-methods modified Delphi process, which resulted in consensus among experts in implementation science and practice.
MODIFI leverages human centered design techniques and is tailored to the needs of intervention implementers in applied settings, filling a crucial gap in the research to practice pipeline.

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

✪ Scaling up a brief alcohol intervention to prevent HIV infection in Vietnam: a cluster randomized, implementation trial

Authors:

Sophia M. Bartels, Huong T. T. Phan, Heidi E. Hutton, Do T. Nhan, Teerada Sripaipan, Jane S. Chen, Sarah L. Rossi, Olivia Ferguson, Ha T. T. Nong, Ngan T. K. Nguyen, Le Minh Giang, Hao T. M. Bui, Geetanjali Chander, Hojoon Sohn, Sol Kim, Ha V. Tran, Minh X. Nguyen, Byron J. Powell, Brian W. Pence, William C. Miller & Vivian F. Go

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: June 2024

Read the full text in the open access journal Implementation Science

Abstract:

Background

Evidence-based interventions (EBIs) often address normative behaviors. If a behavior is also common among clinicians, they may be skeptical about the necessity or effectiveness of an EBI. Alternatively, clinicians’ attitudes and behaviors may be misaligned, or they may lack the knowledge and self-efficacy to deliver the EBI. Several EBIs address unhealthy alcohol use, a common and often culturally acceptable behavior. But unhealthy alcohol use may be particularly harmful to people with HIV (PWH). Here, we present an implementation trial using an experiential implementation strategy to address clinicians’ knowledge, attitudes, and behaviors. Clinicians receive the experiential intervention before they begin delivering an evidence-based brief alcohol intervention (BAI) to PWH with unhealthy alcohol use.

Methods

Design: In this hybrid type 3 implementation-effectiveness cluster randomized controlled trial, ART clinics (n = 30) will be randomized 1:1 to facilitation, a flexible strategy to address implementation barriers, or facilitation plus the experiential brief alcohol intervention (EBAI). In the EBAI arm, clinicians, irrespective of their alcohol use, will be offered the BAI as experiential learning. EBAI will address clinicians’ alcohol-related attitudes and behaviors and increase their knowledge and confidence to deliver the BAI.

Participants: ART clinic staff will be enrolled and assessed at pre-BAI training, post-BAI training, 3, 12, and 24 months. All PWH at the ART clinics who screen positive for unhealthy alcohol use will be offered the BAI. A subset of PWH (n = 810) will be enrolled and assessed at baseline, 3, and 12 months.

Outcomes: We will compare implementation outcomes (acceptability, fidelity, penetration, costs, and sustainability) and effectiveness outcomes (viral suppression and alcohol use) between the two arms. We will assess the impact of site-level characteristics on scaling-up the BAI. We will also evaluate how experiencing the BAI affected clinical staff’s alcohol use and clinic-level alcohol expectations in the EBAI arm.

Discussion

This trial contributes to implementation science by testing a novel strategy to implement a behavior change intervention in a setting in which clinicians themselves may engage in the behavior. Experiential learning may be useful to address normative and difficult to change lifestyle behaviors that contribute to chronic diseases.

Trial Registration

NCT06358885 (04/10/2024), https://clinicaltrials.gov/study/NCT06358885.

Contributions to the literature

This study tests a novel implementation strategy to educate ART providers and address their attitudes and knowledge about alcohol use and treatment in Vietnam. Few implementation strategies are grounded in an experiential approach to changing provider attitudes and behaviors in contexts where these behaviors are pervasive.
It uses mixed-methods to determine mechanisms influencing scale-up of the brief alcohol intervention (BAI) to inform future implementation of alcohol interventions for people with HIV across settings where alcohol is normalized.
It assesses resource-related costs associated with the experiential BAI (EBAI) and EBAI implementation, which can inform policymakers working to prevent HIV transmission.

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

✪ Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers

Abstract:

Rationale & Objective

Developing strategies to improve home dialysis use requires a comprehensive understanding of barriers. We sought to identify the most important barriers to home dialysis use from the perspective of patients, care partners, and providers.

Study Design

This is a convergent parallel mixed-methods study.

Setting and Participants

We convened a 7-member advisory board of patients, care partners, and providers who collectively developed lists of major patient/care partner-perceived barriers and provider-perceived barriers to home dialysis. We used these lists to develop a survey that was distributed to patients, care partners, and providers—through the American Association of Kidney Patients and the National Kidney Foundation. The surveys asked participants to (1) rank their top 3 major barriers (quantitative) and (2) describe barriers to home dialysis (qualitative).

Analytic Approach

We compiled a list of the top 3 patient/care partner-perceived and top 3 provider-perceived barriers (quantitative). We also conducted a directed content analysis of open-ended survey responses (qualitative).

Results

There were 522 complete responses (233 providers; 289 patients/care partners). The top 3 patient/care partner-perceived barriers were fear of performing home dialysis; lack of space; and the need for home-based support. The top 3 provider-perceived barriers were poor patient education; limited mechanisms for home-based support staff, mental health, and education; and lack of experienced staff. We identified 9 themes through qualitative analysis: limited education; financial disincentives; limited resources; high burden of care; built environment/structure of care delivery that favors in-center hemodialysis; fear and isolation; perceptions of inequities in access to home dialysis; provider perspectives about patients; and patient/provider resiliency.

Limitation

This was an online survey that is subject to nonresponse bias.

Conclusions

The top 3 barriers to home dialysis for patient/care partners and providers incompletely overlap, suggesting the need for diverse strategies that simultaneously address patient-perceived barriers at home and provider-perceived barriers in the clinic.

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

✪ Inter-organizational alignment and implementation outcomes in integrated mental healthcare for children and adolescents: a cross-sectional observational study

Abstract:

Background

Integrated care involves care provided by a team of professionals, often in non-traditional settings. A common example worldwide is integrated school-based mental health (SBMH), which involves externally employed clinicians providing care at schools. Integrated mental healthcare can improve the accessibility and efficiency of evidence-based practices (EBPs) for vulnerable populations suffering from fragmented traditional care. However, integration can complicate EBP implementation due to overlapping organizational contexts, diminishing the public health impact. Emerging literature suggests that EBP implementation may benefit from the similarities in the implementation context factors between the different organizations in integrated care, which we termed inter-organizational alignment (IOA). This study quantitatively explored whether and how IOA in general and implementation context factors are associated with implementation outcomes in integrated SBMH.

Methods

SBMH clinicians from community-based organizations (CBOs; nclinician = 27) and their proximal student-support school staff (nschool = 99) rated their schools and CBOs (clinician only) regarding general (organizational culture and molar climate) and implementation context factors (Implementation Climate and Leadership), and nine common implementation outcomes (e.g., treatment integrity, service access, acceptability). The levels of IOA were estimated by intra-class correlations (ICCs). We fitted multilevel models to estimate the standalone effects of context factors from CBOs and schools on implementation outcomes. We also estimated the 2-way interaction effects between CBO and school context factors (i.e., between-setting interdependence) on implementation outcomes.

Results

The IOA in general context factors exceeded those of implementation context factors. The standalone effects of implementation context factors on most implementation outcomes were larger than those of general context factors. Similarly, implementation context factors between CBOs and schools showed larger 2-way interaction effects on implementation outcomes than general context factors.

Conclusions

This study preliminarily supported the importance of IOA in context factors for integrated SBMH. The findings shed light on how IOA in implementation and general context factors may be differentially associated with implementation outcomes across a broad array of integrated mental healthcare settings.

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

✪ Implementation of Obesity Science into Clinical Practice: A Scientific Statement from the American Heart Association

Abstract:

Background

Effective implementation strategies are needed to enhance the success of evidence-based prevention programs. The current study evaluates the effects of two implementation strategies on teachers’ implementation of an evidenced-based HIV intervention

Methods

Using our 7-item pre-implementation school screening tool, we identified teachers who were at-risk for not implementing the Focus on Youth HIV-risk reduction intervention curriculum which targets grade six through grade 8 students. After completing a two-day curriculum workshop, 81 low- and moderate-performing teachers were randomly assigned to one of four experimental conditions and were asked to teach the two-month intervention curriculum. This optimization trial examines the impact of two implementation strategies: biweekly monitoring/feedbacks (BMF) and site-based assistance/mentorship (SAM). The primary outcome is implementation fidelity defined as number of core activities taught. Linear mixed-effects model was used to examine the association of the implementation strategies with implementation fidelity.

Results

BMF and SAM were significantly associated with teachers’ implementation fidelity. Teachers who received both BFM and SAM taught the greatest numbers of core activities (15 core activities on average), followed by teachers who received either BMF (6.9 activities) or SAM (7.9 activities). Teachers who did not receive BMF or SAM taught the lowest numbers (4.1 activities). Teachers’ sustained implementation of FOYC in the prior school year was related to increased implementation fidelity during the optimization trial. Teachers’ confidence in implementing five core activities, attitudes toward sex education in schools, and perceived principal support were significantly related to increased self-efficacy, which in turn was related to teachers’ fidelity of implementation before the optimization trial.

Conclusions

BMF and SAM are effective in promoting teachers’ implementation of youth evidence-based interventions. Researchers and future program implementers should consider teacher training, teachers’ attitudes toward sex education, perceived principal support, and self-efficacy when attempting to maintain the effects of teacher-delivered interventions in schools.

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

✪ A formative mixed methods evaluation of a new Ross program: Why context matters

Abstract:

Background

The Ross procedure is a technically complex operation to address the pathology of the aortic valve. Prior attempts at widespread implementation have been plagued with variations in effectiveness. We report our initial programmatic outcomes using dissemination and implementation (D&I) science frameworks, with an aim to define both programmatic efficacy and effectiveness. The study design was a single center, explanatory sequential mixed methods evaluation of a Ross surgery program from June 2020 to April 2023. Quantitative measures for baseline patient characteristics and postoperative outcomes were summarized. Qualitative measures were obtained using semi-structured interviews and characterized using implementation science frameworks.

Results

A total of 71 patients underwent the Ross procedure at a single academic center. Mean age was 40 years (± 13). There were no perioperative deaths or valve-related reinterventions (0%). During the follow-up period, 2 (2.8%) patients required re-operation and 2 (2.8%) required balloon dilation of the pulmonary homograft. Qualitative measures noted communication and prospective self-audit facilitated measures of effectiveness, as dichotomy within expected vs. observed outcomes led to program modifications. Collaboration across hospital systems promoted adoption and implementation, which led to the incorporation of the Ross procedure into accepted organizational practice.

Conclusions

In this formative evaluation, limited-efficacy outcomes demonstrated similar programmatic success to data from other established centers. With the prerequisite center volume and case selection, the Ross procedure is a safe and efficacious treatment for aortic valvular disease. Implementation science can be used both in real-time and retrospectively to guide organizational efforts to improve outcomes and to improve the translation of results across centers.

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

✪ “A problem shared is a problem solved:” integrating human-centered design and implementation science to optimize lay counselor supervision in Western Kenya

Abstract:

Implementation science and human-centered design (HCD) offer useful frameworks and methods for considering and designing for individuals' needs and preferences when implementing new interventions or technologies in global health. When used in tandem, the two approaches may blend creative and partnered research methods with a focus on the factors necessary to design, implement, and sustain interventions. However, research is needed that describes the process of blending these two approaches and explores the experiences of community partners. This study builds from a stepped-wedge cluster-randomized trial in Western Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy (TF-CBT). Mobile phones emerged as a tool to supervise lay counselors from afar; however, their use was characterized by unique challenges. Informed by human-centered design and implementation science, we first engaged lay counselors (n = 24) and supervisors (n = 3) in individual semi-structured interviews then hosted an in-person participatory workshop to “co-design” solutions to optimize the use of mobile phone supervision. Lay counselors participated in focus group discussions regarding their experiences in the workshop. Focus group transcripts were analyzed using thematic analysis. We describe our approach as well as focus group discussion results. Counselors felt the workshop was a valuable experience to learn new strategies from their colleagues, and they enjoyed the “collaborative spirit” that emerged as they worked together. Counselors felt that varying small and large group discussions fostered participation by creating opportunities for more people to engage and share their thoughts. Counselors suggested the approach be improved by providing more tangible materials (e.g., hand-outs) and more closely following a schedule of activities. It is important to also center stakeholders’ experiences as partners in the research process. Though counselors largely expressed positive sentiments, they also shared valuable suggestions for how to improve participatory research practices in the future.

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

Authors:

✪ Open Access

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

Abstract:

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

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

Abstract:

Background

Method

Results

Discussion

Contributions to the literature

Authors:

✪ Open Access

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

Abstract:

Background

Method

Results

Discussion

Contributions to the literature

Authors:

✪ Open Access

Read the full text in the open access journal Implementation Science

Abstract:

Background

Methods

Discussion

Trial Registration

Contributions to the literature

Authors:

✪ Open Access

Read the full text in the open access journal American Journal of Kidney Disease

Abstract:

Rationale & Objective

Study Design

Setting and Participants

Analytic Approach

Results

Limitation

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Implementaion Science

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Circulation

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal The Cardiothoracic Surgeon

Abstract:

Background

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Social Science and Medicine - Mental Health

Abstract: