Implementation research and practice最新文献

Background: Traumatic brain injury (TBI) is common among individuals seeking treatment for substance use disorders in behavioral healthcare settings, but evidence-based TBI screening methods are underutilized. We investigated provider perceptions of the acceptability, feasibility, and appropriateness of TBI screening, and whether these perceptions influenced the relationships between screening intentions and behaviors. Understanding how these implementation outcomes are interrelated can help clarify the temporal sequencing of implementation processes and lead to more precise and cost-effective dissemination and implementation (D&I) strategies.

Method: In Phase 1 of this explanatory sequential mixed methods study, 215 behavioral healthcare providers completed an electronic survey assessing their intentions to screen for TBI using the Ohio State University TBI Identification Method (OSU TBI-ID). After 1-month, a second survey assessed the number of screens conducted, and perceptions of the acceptability, feasibility, and appropriateness of the OSU TBI-ID. Binary logistic regressions were used to examine whether acceptability, feasibility, and appropriateness moderated the relationship between screening intentions and behaviors. In Phase 2, 20 providers participated in an interview to contextualize the quantitative results. Qualitative data were analyzed thematically and integrated with the quantitative results.

Results: The mean acceptability, feasibility, and appropriateness scores were 4.12, 4.02, and 3.69, respectively. Acceptability (OR = 0.80, p = .29), feasibility (OR = 0.93, p = .88), and appropriateness (OR = 0.97, p = .65) of TBI screening did not moderate the relationship between intentions and behaviors. Providers endorsed the OSU TBI-ID as easy to use and integrate into practice, relevant to clients, and helpful in guiding referrals and treatment decision-making.

Conclusions: Positive perceptions of an intervention are important but insufficient for shaping the transition from intentions to behavior. This study begins to disentangle interrelationships between early-phase implementation outcomes, which can help guide more precise D&I strategy development to enhance implementation efficiency and effectiveness.

Background: Strategies to implement evidence-based practices often require modifications. A systematic approach to documenting these changes was not widely adopted until the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS) emerged in 2021, enabling researchers to characterize both proactive and reactive implementation changes. While publications demonstrating the FRAME-IS's application are emerging, few have reflected on the use of the tool itself. The National Institutes of Health-funded Deidentified Opioid Initiative R01 trial, testing strategies to implement the Centers for Disease Control and Prevention guidelines on opioid prescribing, offered a timely chance to assess the FRAME-IS's utility in a multisite, hybrid type-3 trial.

Method: An interdisciplinary team of researchers, clinicians, and implementers documented modifications using the FRAME-IS across four implementation strategies that comprise an implementation package called systems consultation: (1) audit and feedback, (2) educational meetings, (3) practice facilitation, and (4) prescriber peer consulting. Modifications were needed due to COVID-19, the rise in telemedicine, changes in opioid prescribing, and healthcare system variations.

Results: The Deidentified Opioid Initiative was implemented in 32 clinics within two Midwestern healthcare systems using a sequential, multiple-assignment randomized trial. The implementation team completed the FRAME-IS's seven modules for each strategy's modifications and reflected on the process of using the tool, strengths, and limitations.

Conclusions: The team found the FRAME-IS is practical, comprehensive, and user-friendly. It effectively documents modifications and fosters reflection, raising critical questions about implementation. Challenges included role blurring (i.e., researcher/implementer/coordinator), capturing the complexity of cascading modifications (i.e., how one modification leads to another), and a lack of reporting options to capture modifications in a clustered, multisite trial (i.e., clinical staff nested in clinics nested in healthcare systems). Considerations and recommendations from this case study can enhance the FRAME-IS, guide other scholars in its use, and improve the research community's ability to measure the dynamic evolution of implementation strategies systematically. Future research should explore how documented modifications impact implementation outcomes.

Background: To help improve the implementation of evidence-based substance use disorder (SUD) treatment in practice settings, the United States funds a support system called the Addiction Technology Transfer Center (ATTC) network. Prior implementation research in HIV care found the team-focused Implementation and Sustainment Facilitation (ISF) strategy as an effective addition to the ATTC's staff-focused training, feedback, and consultation (TFC) strategy. Using the ISF + TFC strategy as the control, this type-3 hybrid trial tested the effectiveness of adding a staff-focused incentivization (INC) strategy (ISF + TFC + INC vs. ISF + TFC). Staff-focused incentivization was selected because prior implementation research found it to be highly effective and cost-effective for improving SUD treatment implementation.

Methods: Twenty-six HIV service organizations (HSOs), their staff participants (N = 87), and their client participants (N = 341) were cluster-randomized to either the ISF + TFC control condition or ISF + TFC + INC experimental condition. The INC strategy rewarded/reinforced motivational interviewing brief intervention (MIBI) implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined.

Results: The addition of the INC strategy had a large and significant (p < .05) effect on the number of MIBIs implemented (d = 1.30) and reduction in anxiety (d = -1.54). There was no significant impact on days of substance use.

Conclusions: The addition a staff-focused INC strategy improved implementation of an evidence-based brief intervention for adults with comorbid HIV and SUD, and also reduced anxiety. To help improve the integration of evidence-based SUD services in HSOs across the United States, use of the ISF + TFC + INC strategy by the ATTC network and/or the AIDS Education and Training Center (AETC) network is recommended.

Introduction: Front-line implementers report that selecting an evidence-based practice is the most challenging aspect of supporting Autistic students, which may contribute to the long-standing implementation gap. There is a need to understand educators' (special education teachers', general education teachers', and paraeducators') decision-making and determinants of their evidence-based practice (EBP) selection. Method: This study aimed to identify educators' decision-making factors, focusing on (a) information sources and (b) factors within the student, intervention, educator, and classroom levels. Eighty-one educators (general education teachers, special education teachers, and paraeducators) participated in semistructured interviews regarding their EBP selection for a specific student they served in inclusive classrooms. Results: General and special education teachers cited EBP sources from their teacher preparation and colleagues with autism expertise, while paraeducators relied on existing classroom practices and guidance from other educators. EBP decision-making frequently revolved around student and intervention characteristics, focusing less on educator, environment, and resource determinants. Educators made individualized EBP decisions for each student, selecting EBPs that served all students. They also shared that their decision-making was most supported through collaboration, despite limited opportunity. Conclusion: The study provides insights into key team members' EBP selection for Autistic students to aid in the development of implementation supports.

Background: In South Africa, rates of HIV and alcohol use are among the highest globally, with a detrimental synergistic relationship. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, cost-effective approach to identifying people at risk of alcohol-related problems to deliver early intervention. We developed and deployed a cascading train-the-trainer model to promote SBIRT implementation in a large nongovernmental organization offering HIV services across South Africa.

Method: Between 2021 and 2022, we completed preparatory activities including designing scalable training resources prior to rolling out the train-the-trainer model across two South African provinces. We conducted a comprehensive assessment of outcomes at the trainer- (knowledge, fidelity), provider- (attitudes, confidence, perceived implementation potential, adoption), and client-encounter (reach) levels over approximately one year.

Results: We trained 12 novice trainers who then trained 206 providers to implement SBIRT. Trainer SBIRT knowledge increased pre- to posttraining, and fidelity of training delivery was high (99.0% of elements covered across sessions). Provider attitudes, confidence, and perceived implementation potential increased over time, and 64% of providers adopted SBIRT. Reach of the model varied by component, with 41,793 clients screened by trained providers. Of those screening positive for risky alcohol use, 86% received brief intervention (BI) and 53% received referral to treatment (RT). Additionally, 15,353 clients who did not screen as having risky alcohol use received BI and 1,122 received RT.

Conclusion: Results indicated that the cascading training model was delivered with high fidelity, associated with improvements in all provider outcomes, and reached high numbers of clients for the screening component of the model. Rates of BI and RT delivery were moderate to high, though data suggested over-application of these elements with some clients, highlighting the tension between reach and fidelity. Lessons learned will inform future scale-out of this model in HIV service settings in low- and middle-income countries.

Background: Chronic insomnia disorder affects 10-15% of adults, causing significant individual and societal burden. Despite Cognitive Behavioral Therapy for Insomnia (CBT-I) being the recommended first-line, sleep medications remain more common due to limited access to trained providers. Digital CBT-I offers a scalable solution, but evidence of its real-world impact in U.S. clinical settings is lacking. Method: This study evaluates real-world implementation and impact of digital CBT-I in U.S. clinical settings, using Normalization Process Theory (NPT) to guide integration at Henry Ford Health, Detroit, Michigan. Implementation success was assessed through order rates, patient sign-ups and workflow acceptability. We assess the effect on healthcare utilization through a propensity-matched observational treatment-control design. Results: Implementation was successful, with 1,162 patients offered digital CBT-I. From this cohort, we analyzed a sample of 340 patients with sufficient chart data and established care (120 days) who utilized digital CBT-I, comparing them to 340 matched standard care controls. Patients who used digital CBT-I had a 64% reduction in the odds of any medication fill during the postwindow period (p < .001) and were 53% less likely to fill insomnia medication prescriptions compared with the preperiod (p = .013). Controls did not have any significant reductions in medication fill rates. Time-varied analysis showed digital CBT-I patients had transiently higher outpatient visit odds at 30-60 days, followed by sustained reductions of 28% (120-150 days) and 31% (150-180 days). After covariate adjustment, early differences were nonsignificant while later reductions remained significant. Conclusions: NPT facilitated integration of digital CBT-I into existing workflows, allowing immediate access while minimizing disruption to routine practice. Provider training sessions and reminders effectively promoted suitable patient uptake. Digital CBT-I was associated with reduced medication fills pre-to-post with an initial rise and then sustained reduction in outpatient service utilization patterns over time. A key limitation is the use of individuals who declined digital CBT-I as comparators, which may introduce selection bias. Generalizability may be limited as the study was conducted within a single healthcare system. Trial Registration: Not applicable-the assignment of the medical intervention to patients was not at the discretion of the investigators.

Background: School-based health promotion is a key public health strategy to reduce disease burden and health inequalities. School-based interventions with local evidence of effectiveness need to be scaled up to maximize their benefits. A Project Promoting healthy Living for Everyone in Schools (APPLE Schools) is a health promoting school (HPS) intervention that targets schools in disadvantaged settings and has been shown to be effective in promoting children's healthy lifestyle behaviors and reducing health inequalities. To support its scale-up, we aimed to identify core functions (basic purposes driving intervention's effectiveness) and forms (specific content and delivery strategies implemented to achieve core functions). Method: We extracted 5,301 action items from 191 annual action plans written between 2011 and 2021 in 70 APPLE Schools. We followed an implementation science approach and used supervised machine learning algorithms to classify 2,683 unique action items into intervention activities and implementation strategies. Core functions were drawn from theoretical frameworks; forms were identified through thematic analysis. Results: We identified 55 forms and mapped them to 17 core functions of intervention activities and implementation strategies. The most common core functions of intervention activities were enablement (96%), modeling (66%), and education (54%); the most common core functions of implementation strategies were relational and organizational support context (86%), partnerships and networking (84%), student participation (78%), and professional development and learning (73%). The remaining core functions were identified in <50% of the schools. Forms included a broad range of activities, with a greater variety of those that addressed the most common core functions. Conclusions: We created matrices of core functions and forms of intervention activities and implementation strategies to inform the successful scale-up of APPLE Schools, an effective and cost-effective HPS intervention. These matrices can be used as a guide to improving existing HPS interventions and scaling them up to new settings.

Background: Smoke-free policies are often poorly implemented in schools. The Smoke-Free Vocational Schools intervention aimed to support the routine implementation of a comprehensive school tobacco policy at Danish vocational schools and took place across seven schools. This study aimed to assess and understand the mechanisms-that is, reasoning and behavior change-that shaped if and how policy implementation outcomes occurred.

Method: We applied a convergent mixed-methods design informed by Normalization Process Theory (NPT). The quantitative strand employed a repeated cross-sectional design, assessing implementation mechanisms-Coherence, Cognitive Participation, Collective Action, Reflexive Monitoring-and implementation outcomes at two time points: 5+ months post-policy (T1) and 14+ months post-policy (T2). Additional mechanisms-Change Commitment and Change Efficacy-were surveyed among subsamples who completed questionnaires pre-policy (T0) and at the follow-ups (i.e., T0-T1 and T0-T2). The qualitative strand involved interviews and focus groups with 40 participants to explore the mechanisms and their connections to intervention activities. Integration of qualitative and quantitative findings was achieved through joint displays.

Results: Quantitative analyses included responses from N = 419 participants at T1, N = 452 at T2, N = 209 at T0-T1, and N = 182 at T0-T2. All implementation mechanisms were significantly and consistently associated with the total implementation outcomes score. Coherence encompassed the perceived meaningfulness of the policy, for example, believing the policy was a school responsibility. Cognitive Participation was related to policy legitimacy, for example, enforcement legitimacy beliefs. Collective Action involved practical implementation efforts, for example, enforcement and communication strategies. Reflexive Monitoring encompassed perceived policy impacts, for example, reduced smoking visibility. Change Commitment and Change Efficacy were found to be closely interrelated with the other mechanisms. Moreover, qualitative analysis revealed plausible connections between intervention activities and mechanisms.

Conclusions: This study identified critical mechanisms for implementing school tobacco policies and demonstrated how specific intervention activities can activate these mechanisms, offering guidance for future research and practice development.

Background: Cognitive behavioral therapy (CBT), an umbrella term for therapeutic techniques guided by cognitive behavioral theory, is an evidence-based approach for many psychiatric conditions in youth. A stronger dose of CBT delivery is thought to improve youth clinical outcomes. While a critical indicator of care quality, measuring the use of CBT techniques feasibly and affordably is challenging. Certain CBT techniques (e.g., more concrete and observable) may be easier to measure than others using low-cost methods, such as clinician self-report; however, this has not been studied.

Method: To assess the concordance of three methods of measuring CBT technique use with direct observation (DO), clinicians from 27 community agencies (n = 126; M _age = 37.7 years, SD = 12.8; 76% female) were randomized 1:1:1 to a self-report, chart-stimulated recall (CSR; semistructured interviews with the chart available), or behavioral rehearsal (BR; simulated role-plays) condition. In previous work using a global score aggregating 12 CBT techniques, only BR produced scores that did not differ from DO. This secondary analysis examined the concordance of these alternate methods with DO for each discrete CBT technique, testing for differential concordance across cognitive techniques (e.g., cognitive education) compared to behavioral techniques (e.g., behavioral activation).

Results: Results of three-level mixed effects regression models indicated that BR scores did not differ significantly from DO for any techniques, and for nine techniques, neither did CSR (all ps > .05). Contrastingly, self-report scores differed from DO for all but one technique, with greater concordance for behavioral than cognitive techniques (z = -3.29, p < .001).

Conclusions: Unlike previous findings using an aggregate score, we found that both BR and CSR did not differ significantly from DO for most techniques tested. These findings have implications within implementation research and usual care settings; they support multiple viable measurement methods that are less resource-intensive than DO.

Background: Qualitative methods are essential for providing an in-depth understanding of "why" and "how" evidence-based interventions are successfully implemented-a key area of implementation science (IS) research. A systematic synthesis of the applications of qualitative methods is critical for understanding how qualitative methods have been used to date and identifying areas of innovation and optimization. This scoping review explores which qualitative data collection and analytic methods are used in IS research, what and how frameworks and theories are leveraged using qualitative methods, and which implementation issues are explored with qualitative implementation research.

Method: We conducted a systematic scoping review of articles in MEDLINE and Embase using qualitative methods in IS health research. We systematically extracted information including study design, data collection method(s), analytic method(s), implementation outcomes, and other domains.

Results: Our search yielded a final dataset of 867 articles from 76 countries. Qualitative study designs were predominantly single elicitation (67.7%) and longitudinal (20.3%). In-depth interviews were the most common data collection method (84.3%), followed by focus group discussions (FGDs) (34.5%), and nearly 25% used both. Sample sizes were, on average, 40 in-depth interviews (range: 1-1,131) and nine FGDs (range: 1-46). The most common analytic approaches were thematic analysis (45.3%) and content analysis (18.5%) with substantial variation in analytic conceptualization. Nearly one-quarter (23.2%) of articles used one or more TMF to conceptualize the study, and less than half (40.9%) of articles used a TMF to guide both data collection and analysis.

Conclusions: We highlight variation in how qualitative methods were used, as well as detailed examples of data collection and analysis descriptions. By reviewing how qualitative methods have been used in well-described and innovative ways, and identifying important gaps, we highlight opportunities for strengthening their use to optimize IS research.

Registration: The protocol can be found 10.11124/JBIES-20-00120.