UW Articles Archive - Page 7 of 60 - Implementation Science at UW

✪ “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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✪ Impact of a stakeholder selected implementation strategy package – fast tracking, provider re-training, and co-location – on PrEP implementation for pregnant women in antenatal care clinics in western Kenya

Abstract:

Background

Pre-exposure prophylaxis (PrEP) is recommended for HIV prevention in pregnant and postpartum women at substantial ongoing risk for HIV. In resource-limited settings, there exist gaps in the integration of PrEP into antenatal care.

Methods

We conducted a difference-in-differences analytic approach (3 months pre- and 3 months post) between January 2022 and July 2022 in 8 facilities (4 intervention and 4 comparison) in western Kenya. During the 6-month period, we tested a combination of 2 stakeholder selected implementation strategies – retraining health providers and fast tracking PrEP clients– to improve PrEP delivery. All study facilities dispensed PrEP in the Maternal and Child health clinics (MCH). We evaluated absolute changes in: PrEP penetration, PrEP fidelity, client PrEP knowledge, client satisfaction, and client waiting and service times as outcomes specified a priori while PrEP offer and HIV testing were outcomes specified post hoc. We measured acceptability and appropriateness by providers of the implementation strategies using AIM and IAM respectively.

Results

We observed statistically significant improvements in PrEP penetration and PrEP offer (p < 0.05) and non-significant improvements in fidelity. PrEP penetration increased 6 percent points (p = 0.002), PrEP offer increased nearly 6 percentage points (p = 0.002), and PrEP fidelity increased 4 percentage points (p = 0.202) in intervention vs comparison facilities. Client PrEP knowledge increased 0.45 out of 7 total points (p < 0.001) and PrEP screening increased 13 percentage points (p = 0.001). We observed no significant changes in service time (0.13-min increase; p = 0.249), waiting time (0.03-min decrease; p = 0.796), or client satisfaction (0.04/24 total point decrease; p = 0.849) in intervention vs comparison facilities. HIV testing did not significantly change (7 percentage point decrease, p = 0.305). The implementation strategy bundle was deemed appropriate and acceptable by the providers (appropriateness: 18.5/20; acceptability: 18.5/20). Overall, the implementation strategy bundle was associated with larger increases in implementation outcomes among women receiving a visit other than their first ANC visit, as well as among sites without stockouts of HIV test kits.

Conclusions

A stakeholder-selected implementation strategy bundle that included retraining healthcare workers, fast tracking PrEP clients to reduce waiting time, and PrEP dispensing in MCH improved several implementation outcomes without significantly affecting waiting time or reducing service time.

Contributions to the literature

Evidence is sparse on effective implementation strategies that focus on structural- and provider-level barriers to enhance delivery of integrated care in resource-limited settings.
Stakeholder-selected strategies are hypothesized to have a better fit to local context and potentially be more effective than externally selected strategies.
We tested a package of two stakeholder-selected implementation strategies – retraining health providers, fast tracking PrEP clients in a difference-in-differences study in 8 clinics in Kenya.
The package was associated with significant improvements in PrEP penetration, PrEP offer, PrEP knowledge, and PrEP screening. It was not associated with significant changes in PrEP fidelity, HIV testing, service time, waiting time, or client satisfaction.
The improvement associated with the package was most pronounced among clinics that did not experience substantial stockouts of supplies, suggesting that implementation strategies are not sufficient to overcome gaps in basic resourcing in the presence of critical events.

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✪ Can audit and feedback improve health service readiness and delivery outcomes in a low-resource setting? Effectiveness results of the IDEAs strategy from central Mozambique

Abstract:

Limited evidence exists on audit and feedback (A&F) in low-resource contexts. We tested the Integrated District Evidence-to-Action (IDEAs), a multicomponent A&F strategy in Mozambique’s maternal and child health (MCH) services. IDEAs include A&F meetings, readiness assessments, and facility support. We report the effectiveness results. IDEAs were implemented in 2016–2020 across two provinces, 12 districts, and 154 primary health facilities in Mozambique. We assessed 1) ten service delivery outcomes across antenatal, maternity, postpartum, childcare, and reproductive health services and 2) five service readiness outcomes (medicines, infrastructure, equipment, care, and staffing availability). We used propensity score matching to minimize bias and a controlled interrupted time series with a negative binomial mixed effects model for service delivery analysis, presenting incidence rate ratios (IRR) with 95% confidence intervals (95% CI). For service readiness outcomes, we created composite scores for each domain and a difference-in-difference analysis using an ordinal mixed effects model, reporting odds ratios (OR) and 95% CI. Significant associations were found with first at-risk child appointments (IRR = 1.06 [1.04, 1.07]), first polymerase chain reaction tests for HIV-exposed children (IRR = 1.02 [1.01, 1.03]), new contraceptive users (IRR = 0.95 [0.94, 0.96]), women starting long-lasting contraceptives (IRR = 0.94 [0.93, 0.95]), availability of infrastructure (OR = 5.84 [1.32, 25.88]) and essential care (OR = 0.13 [0.03, 0.54]). No significant associations were found between IDEAs and six of 10 service delivery outcomes (women with a fourth dose of preventive malaria treatment; women protected with tetanus vaccine; women with four+ antenatal visits; deliveries with active management of the third stage of labor; first postpartum consultations and fully vaccinated children) and on medicine, equipment, and staffing availability. We observed mixed effectiveness in implementing IDEAs, with null and sub-optimal effects suggesting the need to refine and adapt strategy components to more effectively address clinical and readiness outcomes.

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✪ Advancing implementation of single session interventions in schools: a protocol for a qualitative study

Abstract:

Background

Schools are one of the most common settings in which youth seek mental health services, yet existing school-based mental health interventions are often difficult to implement due to time, cost, and staffing limitations. Digital, self-administered Single Session Interventions (SSIs) are evidence-based supports that are intentionally structured to deliver a clinically-meaningful dosage of evidence-based content within one session. Although multiple studies have demonstrated the clinical effectiveness of school-based SSIs, there have been no systemic efforts to understand how SSIs can be practically implemented in schools. The goal of this project is to partner with students, parents, and school staff to identify factors that impact the implementation of SSIs and understand how SSIs can be sustainably integrated as mental health supports into school mental health infrastructure.

Methods

We will conduct focus groups (five groups, total n = 35–45) among community members (i.e., students, parents/caregivers, teachers, school administrators, and school mental health providers) to assess perceived facilitators and barriers to the effective implementation of evidence-based SSIs in schools (Aim 1). We will then work in partnership with community members (n = 10–15) to co-design multi-level implementation strategies (i.e., student-directed, staff-directed, system-directed) for increasing uptake and promoting sustainability of school-based SSIs (Aim 2). We will use inductive coding to thematically analyze qualitative data from group sessions. This study is being conducted within the Lake Washington School District in the Seattle, Washington region.

Discussion

The proposed project will be the first to investigate facilitators and barriers to real-world implementation of SSIs in schools and strategies to improve implementation. Future studies may test the effectiveness of the generated implementation strategies on outcomes such as SSI uptake over time.

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✪ Integrating behavioral health care into a low-barrier HIV clinic using the Collaborative Care Model: a mixed methods evaluation of patient care cascade outcomes and determinants

Abstract:

Background

Low-barrier HIV care is an evidence-based intervention to improve HIV outcomes among those who have complex barriers to care, but the walk-in model poses challenges to integrating behavioral health services. We evaluated the acceptability and feasibility of a Collaborative Care Model (CoCM) for treatment of depression and opioid use disorder in a low-barrier clinic.

Methods

In a sequential explanatory mixed methods pilot study, we accessed data from patient records to generate a care cascade for the number of patients enrolled in the first six months of the program and conducted individual interviews with patients and staff to interpret the care cascade findings.

Results

Among 175 patients who visited the clinic, 36% were screened for, 24% were referred to, 15% completed an intake for, and 9% engaged in CoCM. The interviews revealed that screening was limited by a lack of clarity among staff about services offered in CoCM, staff forgetting the screening process, and limited time during patent visits. Referrals were limited by low buy-in among staff and patient complexity. Intakes were limited by time and space constraints in the care setting and competing acute patient needs. The care manager’s ability to embody the clinic’s culture facilitated engagement among patients who completed intakes.

Conclusions

Staff perceived CoCM to be acceptable and feasible to implement, but only in the context of multiple barriers to implementation and challenges to systematic screening and measurement-based care.

Trial registration

Not applicable.

Contributions to the literature

We evaluated implementation of the Collaborative Care Model, an evidence-based model for integrating behavioral healthcare into primary care settings, for treating depression and opioid-use disorder in a low-barrier HIV clinic. To our knowledge, this is the first implementation of the Collaborative Care Model in a low-barrier HIV clinic.
By specifying a multi-component implementation strategy, our evaluation provides a foundation for selecting and tailoring implementation strategies for use with integrated behavioral healthcare interventions.
Through use of a joint visual display showing a care cascade with illustrative quotes, our evaluation demonstrates a novel approach to using explanatory mixed methods in implementation science.

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✪ Partnering with Policymakers to Design Suicide Care Research: Maximizing Impact in Adolescent Mental Health Policy

Abstract:

Outpatient medical settings are a critical source of mental health care for adolescents and young adults. This is due to the familiarity and accessibility of those settings and challenges accessing mental health care elsewhere. Adolescents and young adults who die by suicide are more likely to have seen a medical provider in the prior month than a mental health specialist, but few suicide care interventions have been developed to specifically address the challenges of working in these outpatient medical settings. This paper provides the perspective of the University of Washington Suicide Care Research Center on the importance of incorporating evidence into public policy decisions regarding workforce development and standards of care for adolescents and young adults experiencing suicidal thoughts and behaviors, their families, and their outpatient medical setting providers; and the equal importance of integrating policy and funding perspectives in clinical services and implementation science. The paper will review the trends in suicide care policy and funding structures as relevant to adolescents and young adults in outpatient medical settings, provide recommendations to advance the translation of research into evidence-based policy decisions for adolescents and young adults at risk of suicide, and recommendations for researchers on incorporating policy perspectives in the development and evaluation of evidence-based interventions. We will share how the University of Washington Suicide Care Research Center is operationalizing these recommendations.

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Authors:

✪ Open Access

Read the full text in the open access journal PLOS One

Abstract:

Introduction

Materials and methods

Results

Conclusion

Authors:

✪ Open Access

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

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Background

Methods

Results

Conclusion

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

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

Abstract:

Background

Method

Results

Conclusions

Trial Registration

Plain Language Summary

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Results

Conclusions

Trial registration

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Results

Conclusions

Contributions to the literature

Authors:

✪ Open Access

Read the full text in the open access journal PLOS Global Public Health

Abstract:

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Discussion

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Results

Conclusions

Trial registration

Contributions to the literature

Authors:

✪ Open Access

Read the full text in the open access journal Evidence-Based Practice in Child and Adolescent Mental Health

Abstract: