Implementation research and practice最新文献

Background: This study assessed the feasibility and acceptability of a multilevel, multi-component implementation strategy for measurement-based care (MBC) called Feedback and Outcomes for Clinically Useful Student Services (FOCUSS). FOCUSS includes six components selected in our prior work with a national sample of school mental health stakeholders. This is among the first demonstrations of MBC with school-employed clinicians. We explored proof of concept by observing MBC adoption rates achieved by the end of the school year and other related implementation outcome data.

Method: A mixed-method, single-arm pilot study was conducted during one academic year with 10 school-employed mental health clinicians in two K-12 public school districts in Connecticut. Clinician adoption was assessed by monthly fidelity monitoring of measures clinicians entered in the feedback system. Clinician self-reported practices, attitudes, feasibility, acceptability, and appropriateness of using MBC with K-12 students was assessed by pre-training, 3-, 6-, and 9-month surveys. School year-end qualitative interviews explored clinician implementation experiences using MBC and FOCUSS implementation supports to inform future changes to FOCUSS in a district-wide trial.

Results: Clinicians were asked to implement MBC with five students; 60% of the clinicians achieved or exceeded this target, and MBC was adopted with 65 students. Other implementation outcomes were comparable to related studies. Qualitative feedback indicated that MBC is clinically valuable in schools by providing consistency and structure to sessions, is compatible with school mental health, and well regarded by students and parents. FOCUSS implementation supports were regarded as helpful, and individual performance feedback emails appeared to be a necessary component of FOCUSS to boost post-training implementation.

Conclusion: This is among the first studies of MBC implementation with school-employed mental health professionals in the United States. Results demonstrate proof of concept for MBC implementation with school social workers, psychologists and counselors and support subsequent district-wide use of FOCUSS to install MBC in schools.

Background: The science of intervention adaptation is rapidly expanding, yet there has been limited research evaluating how context affects intervention fidelity and adaptation. The current study sought to address this gap by closely characterizing the delivery of an autism evidence-based practice (EBP), Project ImPACT, within an Early Intervention (EI) system to understand how context shaped both intervention adaptation and providers' coaching fidelity.

Method: Twenty-one EI providers were trained in Project ImPACT. Following training, providers submitted videos of each of their Project ImPACT sessions, which were scored for Project ImPACT coaching fidelity, Project ImPACT adaptation, and the presence and quantity of supplemental therapeutic content. After each session, EI providers also completed a brief survey about how they delivered Project ImPACT and adaptations they made.

Results: Mixed methods data from 100 sessions demonstrated that how providers reported delivering Project ImPACT was misaligned from adaptations that were observed within the same session. Overall, providers' Project ImPACT fidelity was variable and driven by the integration of other content areas within the confines of relatively short therapy sessions. EI providers adapted Project ImPACT in approximately half of their sessions and spent about 17% of their recorded session time covering other therapeutic content. Spending a greater percentage of session time integrating other content areas was significantly associated with dropping core Project ImPACT coaching activities and having lower Project ImPACT fidelity within that same session.

Conclusion: The current study highlights the critical role of context in shaping providers' Project ImPACT coaching fidelity. Fidelity outcomes in this study were consistent with other EI implementation trials and raise questions about fidelity benchmarks and normative delivery within community settings. Findings also highlight the need for holistic fidelity tools and training models that support the delivery of core intervention functions in relationship to child-, family-, and system-level factors.

Background: This study explored the feasibility, acceptability, and Māori cultural responsivity of study methods and components of an intervention to support clinicians to resume implementation of Parent-Child Interaction Therapy (PCIT), an evidence-based treatment for disruptive behavior in young children.

Method: This pragmatic, parallel-arm, randomized, controlled pilot trial ran for a 6-month period and included PCIT-trained clinicians who were not delivering, or only rarely using PCIT in their work. Re-implementation strategies were systematically developed and theory-driven and included a mobile co-worker, a portable time-out space, audio-visual equipment, weekly consultation groups, and 2-day targeted PCIT refresher training.

Results: Pre-specified progression criteria included enrolling 20 clinicians, a maximum of 20% attrition, and a monthly survey response rate of at least 80%. Fourteen clinicians enrolled in the trial, there was no attrition, and an 89.8% average survey response rate was achieved. Secondary outcomes included clinician ratings of the usefulness and acceptability of intervention components. The time-out cubicle was considered relatively less useful and acceptable, while the refresher training and manuals were preferred. Study methods and intervention components were considered acceptable by the small proportion of Māori participants. Clinician self-reported Capability, Opportunity, and Motivation to implement PCIT fluctuated monthly across both groups. Pre-/post-changes in each domain within the Theoretical Domains Framework generally showed similar improvement from baseline to follow-up in both groups. There was no observable difference in PCIT adoption in either group.

Conclusion: To the best of our knowledge, this is the first study to pragmatically attempt to re-implement a parent training intervention in a community setting, several years after clinicians' initial training in the approach (here, an average of 5.36 years). Low attrition and high survey response rates highlighted the feasibility of the data collection methodology. Important opportunities to improve the design of an adequately powered definitive trial are highlighted to minimize future resource waste.

Background: Despite the efficacy of lifestyle interventions for the physical and mental health of people with mental illness, there is little change in clinical care. Understanding barriers and facilitators of implementation can help interpret intervention effectiveness and aid implementation. This cross-sectional study identifies barriers and facilitators before implementing a multidisciplinary lifestyle approach in the treatment of inpatients with mental illness (MULTI+). Additionally, we analyze associations between barriers and facilitators, and recipients' health and demographic characteristics.

Method: This study used baseline data from an open cohort stepped wedge cluster randomized trial. The Measurement Instrument for Determinants of Innovations was used to investigate barriers and facilitators associated with the innovation (MULTI+), user (recipients and deliverers), and organization. Data was collected through semi-structured interviews for recipients and an online survey for deliverers. We explored associations between barriers and facilitators, and recipients' health and demographic characteristics through multiple regression models.

Results: We included 134 recipients and 125 deliverers. Perceived barriers to implementing MULTI+ included complexity, incomplete information, and incompatibility with current treatment. Recipients and deliverers reported personal barriers, including a lack of personal benefits, potential drawbacks, and insufficient knowledge. Facilitators such as the recognized importance of lifestyle-focused care, social support, and organizational commitment could enhance implementation. Being hospitalized for more than a year was negatively associated with determinants such as compatibility, patient relevance, and satisfaction (range between β = -.25 and β = -.45). Regression models indicated few other associations. Suggestions to address barriers were made.

Conclusions: This study is one of the first to analyze barriers and facilitators before the large-scale implementation of a multicomponent lifestyle-focused approach in mental healthcare. Recipients and deliverers experience barriers and facilitators across all domains. Addressing these factors through patient-level tailoring, structured training, the use of champions, and sustained organizational support may enhance implementation and sustainability.

Trial registration: ClinicalTrials.gov registration. Identifier: NCT04922749. Retrospectively registered 3rd of June 2021.

Background: Most research on appropriate, feasible, and effective suicide screening has excluded research conducted in non-Western and low-income settings. This study explores preparedness and co-designing a suicide screening and referral intervention in a Nepali emergency department (ED) using the Consolidated Framework for Implementation Research (CFIR).

Method: To assess implementation readiness and context, we conducted eight key informant interviews and four focus-group discussions with clinical staff along with 3 months of embedded ethnography. We also assessed clinical staff (n = 26) knowledge, attitudes, current practices, confidence, and institutional priorities surrounding implementing suicide screening using structured questionnaires. Qualitative analysis used CFIR to assess feasibility, acceptability, and necessary implementation strategies for a suicide screening intervention within the context of this resource-strained ED. We report descriptive statistics of quantitative findings using a convergent analytic mixed-methods approach.

Results: Qualitatively, clinicians expressed hopelessness and reservations surrounding ED programs to prevent suicide given important system and social barriers. Additionally, they doubted their ability to meaningfully overcome broader structural issues in their patients' lives (e.g., poverty and family tension) that they believed more directly determined suicidal behavior and thwarted help seeking. They discussed practical and emotional motivators for doing suicide prevention work, which highlighted departmental leadership and deep teamwork that motivated action despite wider societal myths that suicide cannot easily be prevented. Quantitative assessments largely supported these findings, indicating shared beliefs that suicide prevention was important and supported by leadership. However, providers frequently endorsed suicide myths and noted barriers including difficult interdepartmental collaboration, limited confidence in suicide prevention communication and suicide screening.

Conclusions: In under-resourced settings, staff must contend with competing responsibilities and complex structural causes of suicide and barriers to treatment. These can impede implementation of suicide screening interventions and must be integrated into the co-design of implementation strategy selection and deployment.

Trial registration: NCT06094959 clinicaltrials.gov.

Background: People with HIV are more likely than the general population to have a substance use disorder (SUD), which can impact the HIV care continuum. HIV service organizations (HSOs) can implement SUD interventions but may need assistance from support systems like the AIDS Education and Training Center (AETC) network. We assess the fit of strategies AETCs may use to help HSOs integrate SUD interventions.

Method: We invited 74 of 91 AETCs (81.3%) to participate. Using a real-time Delphi approach, 64 AETCs (86.5% of those invited) rated the (a) importance of, (b) feasibility of, (c) readiness to offer, (d) scalability of, (e) pressure to offer, and (f) current need for 10 strategies their AETC could use to help HSOs integrate SUD interventions. Items were examined via confirmatory factor analyses. Responses were summed to create the Setting-Strategy Fit index score. We conducted pairwise t-tests to examine differences in scores between strategies, plotted the mean importance ratings for each strategy against the mean ratings for other criteria to review the strategies' relative viability, and conducted bivariate and multiple regression analyses to examine correlates of the scores.

Results: The items of the Setting-Strategy Fit index showed good internal consistency and model fit. Generally, strategies were considered somewhat important but AETCs felt very little pressure to offer them. Two strategies (disseminating information, providing access to asynchronous training) exceeded the "important" threshold. One strategy (disseminating information) was considered viable for also having high feasibility. Overall, AETCs were only somewhat ready to provide the strategies, which were perceived as only somewhat feasible or currently needed.

Conclusions: Although AETCs recognized the importance of several strategies for helping HSOs integrate SUD interventions, their responses resulted in only one having good fit. These findings can guide efforts to further prepare AETCs to support HSOs and to end the HIV epidemic.

Plain language summary: Strategies AIDS Education and Training Centers Could Use to Help HIV Service Organizations Implement Substance Use Interventions. Why was the study done?: Having a substance use disorder (SUD) can complicate care for people with HIV by reducing their engagement in services. HIV service organizations (HSOs) serve people with HIV but not all of them offer services to address SUD. We assessed the fit of different strategies that AIDS Education and Training Centers (AETCs), which provide technical assistance to HSOs, could use to help HSOs implement SUD interventions.What did the researchers do?: We engaged 74 AETC representatives nationally to rate 10 strategies. They were asked about (a) the importance of the strategies, (b) the feasibility of offering them, (c) their readiness to off

Background: Clinicians, health care organizations, and families demand better and more accessible children's mental health services with greater patient engagement. The I-InTERACT-North program was developed for children following traumatic brain injury and adapted for a transdiagnostic neurological and neurodevelopmental focus, with a recent transition to a stepped-care model. To date, the program has been exclusively provided within research studies; however, demand for its clinical use is growing. Implementation frameworks provide essential guidance regarding facilitators and barriers of clinical implementation under real-world conditions. Similarly, intersectionality evaluation can provide insights to develop equitable and inclusive health care practices. Informed by the Consolidated Framework of Implementation Research 2.0 (CFIR) and recent intersectionality supplement, the objectives were to examine the perspectives of parents/caregivers and clinical partners involved in the I-InTERACT-North program to identify (a) facilitators and barriers to inform the scale and spread of the program, and (b) equity, diversity, and inclusion (EDI) considerations to integrate in future clinical implementation.

Method: This study used a qualitative descriptive design with focus group methodology. Participants included parents/caregivers and clinical partners. Semi-structured focus groups were conducted virtually. Focus group data were coded inductively and deductively using CFIR 2.0. The team reflected on intersectionality in the data, coding results, and broader context of the program's history.

Results: Positive perceptions of the innovation's relevance and adaptability were echoed across focus groups. Prominent facilitators included the program's adaptability, personalized, flexible format, and knowledge dissemination. Barriers included geography, technological accessibility, and workflow, with participants stressing the importance of tailoring to culture, language, and neurodiversity. Feedback from participants aligned with 10 reflective prompts highlighted within the CFIR intersectionality supplement pertaining to families' intersecting categories, diverse intervention experiences, and information access.

Conclusions: Identified facilitators of I-InTERACT-North implementation extended across program knowledge sharing and recruitment. Recommendations included directions for clinical and system integration to facilitate scalability.

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.

Clinicaltrialsgov id: NCT01800266.

Background: Organizational readiness for change (ORC), referring to psychological and behavioral preparedness of organizational members for implementation, is often cited in healthcare implementation research. However, evidence about whether and under which conditions ORC is relevant for positive implementation results remains ambiguous, with past studies building on various theories and assessing ORC with different measures. To strengthen the ORC knowledge base, we therefore identified factors investigated in the empirical literature alongside ORC, or as mediators and/or moderators of ORC and implementation.

Method: We conducted a systematic review of experimental, observational, and hybrid studies in physical, mental, and public health care that included a quantitative assessment of ORC and at least one other factor (e.g., ORC correlate, predictor, moderator, or mediator). Studies were identified searching five online databases and bibliographies of included studies, employing dual abstract and full text screening. The study synthesis was guided by the Consolidated Framework for Implementation Research integrated with the Theory of ORC. Study quality was appraised using the Mixed Methods Appraisal Tool.

Results: Of 2,907 identified studies, 47 met inclusion criteria, investigating a broad range of factors alongside ORC, particularly contextual factors related to individuals and the innovation. Various ORC measures, both home-grown or theory-informed, were used, confirming a lack of conceptual clarity surrounding ORC. In most studies, ORC was measured only once.

Conclusions: This systematic review highlights the broad range of factors investigated in relation to ORC, suggesting that such investigation may enhance interpretation of implementation results. However, the observed diversity in ORC conceptualization and measurement supports previous calls for clearer conceptual definitions of ORC. Future efforts should integrate team-level perspectives, recognizing ORC as both an individual and team attribute. Prioritizing the use of rigorous, repeated ORC measures in longitudinal implementation research is essential for advancing the collective ORC knowledge base.

Background: Implementing evidence-based interventions (EBIs) in practice requires balancing fidelity and adaptation to suit new contexts. Careful considerations are needed to maintain the core elements for effectiveness while ensuring fit with new contexts. The Adaptation and Fidelity Tool (A-FiT) intervention addresses this challenge by providing support for professionals using EBIs in the sustainment phase of implementation. This study evaluates the A-FiT intervention and examines how professionals delivering an EBI manage fidelity and adaptation during the sustainment phase of implementation, before and after the intervention. Method Short, structured interviews were repeatedly conducted with 14 professionals delivering an EBI (n = 127). Data was analyzed using deductive content analysis focusing on adaptation types, planning, intentionality, and fidelity consistency. The adaptations were counted and compared before versus after the A-FiT intervention using a chi²-test.

Results: The professionals made about the same number of adaptations before and after the A-FiT intervention. However, after the intervention, significant changes in the type and intentionality of the adaptations were observed. Changes in type consisted of fewer "removing," "substituting," and "integrating another framework" adaptations and more "loosening structure" and "departing from the intervention" adaptations. Regarding intentionality, fewer planned adaptations with the intention of improving the EBI effects were made, while adaptations made for practical reasons, both planned and unplanned, increased after the A-FiT intervention. No statistical change was found regarding fidelity consistency.

Conclusions: The findings indicate increased awareness about fidelity and adaptation among the group leaders, resulting in fewer planned adaptations to enhance program effects and more practical adaptations to address context challenges. The A-FiT intervention appears to help professionals in their management of fidelity and adaptations when delivering EBIs. The study underscores the importance of understanding adaptations in their context, purpose, and impact (intended and unintended) on the outcome/value.