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Implementation Science at UW

Archives: UW Articles

✪ 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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✪ Costs of implementing and sustaining enhanced collaborative care programs involving community partners

Authors:

Theresa J. Hoeft, Heather Wilcox, Ladson Hinton & Jürgen Unützer

University of Washington affiliated authors are displayed in bold.

Published: April 2019

Read the full text in the open access journal Implementation Science

 

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Abstract:

Background

Collaborative care is an evidence-based program for treating depression in primary care. We sought to expand this model by recruiting clinics interested in incorporating community partners (i.e., community-based organizations (CBO) and/or family members) in the care team. Seven sites implemented evidence-based collaborative care programs with community partners while collecting information on costs of implementing and sustaining programs.

Methods

Sites retrospectively collected data on planning and implementation costs with technical assistance from study researchers. Sites also prospectively collected cost of care activities over a 1-month period once the program was implemented to determine resources needed to sustain programs. Personnel salary costs were adjusted, adding 30% for benefits and 30% for administrative overhead.

Results

The programs implemented varied considerably in staffing, involvement of care partners, and allocation of costs. Total planning and implementation costs varied from $39,280 to $60,575. The largest implementation cost category involved workflow development and ranged from $16,325 to $31,375 with the highest costs in this category attributed to the most successful implementation among clinic-CBO programs. Following implementation, cost per patient over the 1-month period ranged from $154 to $544. Ongoing strategic decision-making and administrative costs, which were included in cost of care, ranged from $284 to $2328 for the month.

Conclusions

Sites implemented collaborative care through differing partnerships, staffing, and related costs. Costs to implement and sustain programs developed in partnership are often not collected but are crucial to understanding financial aspects of developing sustainable partnerships. Assessing such costs is feasible and can inform future partnership efforts.

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

Discrepancies and Agreement in Perceptions of Implementation Leadership: Associations with Dosage of School-Based Evidence-Based Practices for Children with Autism

Authors:

Rosemary D. Meza, Rinad S. Beidas, Mark G. Ehrhart, David S. Mandell, Shannon Dorsey, Lindsay Frederick, Cristine Oh, & Jill Locke

University of Washington affiliated authors are displayed in bold.

Published: April 2019

Read the full text in the subscription access journal Administration and Policy in Mental Health and Mental Health Services Research
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✪ Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design

Authors:

Richard R. Owen, Eva N. Woodward, Karen L. Drummond, Tisha L. Deen, Karen Anderson Oliver, Nancy J. Petersen, Scott S. Meit, John C. Fortney, & JoAnn E. Kirchner

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2019

Read the full text in the open access journal Implementation Science

Abstract:

Background

Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics.

Methods

This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation.

Discussion

This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics.

Trial registration

ClinicalTrials.gov registration number NCT02713217. Registered on 18 March 2016.

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

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✪ Individual and organizational factors that affect implementation of evidence-based practices for children with autism in public schools: a cross-sectional observational study

Authors:

Jill Locke, Gwendolyn M. Lawson, Rinad S. Beidas, Gregory A. Aarons, Ming Xie, Aaron R. Lyon, Aubyn Stahmer, Max Seidman, Lindsay Frederick, Cristine Oh, Christine Spaulding, Shannon Dorsey & David S. Mandell

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2019

Read the full text in the open access journal Implementation Science

Abstract:

Background

Children with autism receive most of their intervention services in public schools, but implementation of evidence-based practices (EBPs) for autism varies. Studies suggest that individual (attitudes) and organizational characteristics (implementation leadership and climate) may influence providers’ use of EBPs, but research is relatively limited in this area. This study examined individual and organizational factors associated with implementation of three EBPs—discrete trial training, pivotal response training, and visual schedules—for children with autism in special education classrooms in public elementary schools.

Methods

Participants included 67 autism support teachers and 85 other classroom staff from 52 public elementary schools in the northeastern United States. Participants reported their attitudes toward EBPs (e.g., intuitive appeal, willingness if required, openness, and divergence), implementation leadership and climate of their school, and the frequency with which they deliver each of three EBPs. Linear regression was used to estimate the association of attitudes about EBPs with organizational characteristics and intensity of EBP use. Demographic covariates with a bivariate association with EBP use significant at p < .20 were entered into the adjusted models.

Results

There were significant findings for only one EBP, discrete trial training. Teachers who reported higher perceived divergence (perceived difference of usual practice with academically developed or research-based practices) between EBPs and current practices used less discrete trial training (ƒ² = .18), and teachers who reported higher appeal (willingness to adopt EBPs given their intuitive appeal) of EBPs used more discrete trial training (ƒ² = .22). No organizational factors were significantly associated with implementation with any of the three EBPs.

Conclusions

Attitudes toward EBPs may affect teachers’ decisions to use EBPs; however, implementation leadership and climate did not predict EBP use. Future implementation efforts ought to consider the type of EBP and its fit within the context in terms of the EBP’s similarities to and differences from existing practices and programs in the setting. Implementation strategies that target individual attitudes about EBPs may be warranted in public schools.

**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**

Understanding the processes that Federally Qualified Health Centers use to select and implement colorectal cancer screening interventions: A qualitative study

Authors:

Jennifer Leeman, Natoshia Askelson, Linda K Ko, Catherine L Rohweder, Jade Avelis, Alicia Best, Daniela Friedman, Karen Glanz, Laura Seegmiller, Lindsay Stradtman, & Robin C Vanderpool

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: February 2019

Read the full text in the subscription access journal Translational Behavioral Medicine
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✪ Implementation science and stigma reduction interventions in low- and middle-income countries: A systematic review

Authors:

Christopher G. Kemp, Brooke A. Jarrett, Churl-Su Kwon, Lanxin Song, Nathalie Jetté, Jaime C. Sapag, Judith Bass, Laura Murray, Deepa Rao & Stefan Baral

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: February 2019

Read the full text in the open access journal BMC Medicine

Abstract:

Background

Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions.

Methods

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR).

Results

A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven.

Conclusion

Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.

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

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