Implementation research and practice最新文献

Introduction: The ongoing opioid epidemic and rising number of patients with chronic pain highlight the need for alternative and integrative pain management approaches as a strategy to reduce opioid use and misuse. Evidence-based nonpharmacologic pain management strategies are available; however, they remain underutilized due to barriers including time limitations, cost, and lack of training. To address these barriers, we implemented a pain coach educator pilot program and nonpharmacologic patient toolkit in the emergency department of a large safety-net hospital. This paper describes the implementation process and preliminary evaluation of the first year of the program.

Method: We implemented a multimodal pain coach educator program that included education on pain neuroscience and over-the-counter analgesic options, demonstration of integrative techniques, and dissemination of nonpharmacologic toolkits for home use in January 2021. Implementation strategies included changing the electronic health record infrastructure, developing stakeholder interrelationships, and ongoing education and training. We used the RE-AIM framework to guide evaluation of the first year of program implementation using data from the electronic health record, program records, and patient-reported outcomes.

Results: In the first year of program implementation, 550 pain coach educator sessions were conducted. Upon session completion, 61% of patients felt the program was helpful, 39% were unsure at the time, and none reported session was not helpful. Clinician feedback was overwhelmingly positive. Program cost per patient was $344.35. Adaptations to intervention and implementation strategies included modifications of session delivery timing to accommodate clinical workflows, additions to program content to align with patient characteristics, and changes to patient identification strategies in response to the COVID-19 pandemic.

Conclusions: Our pain coach educator program provides a model for implementing nonpharmacologic pain management opioid alternatives which can be scaled and adapted for other settings. This work demonstrates the importance of intervention and implementation strategy adaptations to enhance program reach and effectiveness.

Background: School-based universal prevention programs, like the Michigan Model for Health™ (MMH), hold promise for enhancing youth behavioral health but often face implementation challenges due to insufficiently addressing priority student issues. Previous research identified trauma-sensitive content as a student need in the MMH. Enhanced Replicating Effective Programs (REP), a multicomponent implementation strategy, is well suited to support program providers in addressing priority health issues among youth.

Method: This pilot cluster-randomized controlled trial compared Enhanced REP (tailored curriculum, training, and implementation facilitation with trauma-sensitive content) to standard REP (standard curriculum, initial training, as-needed technical assistance) across eight high schools serving low-income students. Through semistructured interviews at three time points, we assessed teacher perceptions of feasibility, acceptability, and appropriateness related to REP core and enhanced components.

Results: Teachers generally found Enhanced REP to deliver MMH satisfactory and suitable. However, the school environment, notably administrative support, influenced feasibility compared to standard REP. Enhanced REP teachers reported benefits in meeting student needs that were not seen in the standard REP group. The standard REP data helped to understand the comparative value of the enhanced strategy during a time of notable upheaval and mental health challenges due to the COVID-19 pandemic.

Conclusions: While some schools may succeed with less intensive strategies (REP), many may require more intensive approaches for effective implementation. Enhanced REP shows promise in tailoring curriculum delivery and providing additional support to meet student needs, but its success may hinge on organizational support, especially from leadership. Future research should investigate the addition of organizational-level strategies, such as leadership training, to optimize implementation and explore the comparative effectiveness of Enhanced versus standard REP.

Background: The perinatal period is a high-risk time for body dissatisfaction and disordered eating. Evidence-based interventions for disordered eating have not been adapted to address the needs of this population. We describe the process of adapting the Body Project, an evidence-based eating disorder (ED) prevention program, for pregnant individuals with histories of disordered eating behaviors.

Method: Our approach is informed by ADAPT, a framework offering guidance for adapting interventions to new contexts, to modify the Body Project for pregnant individuals. Following initial adaptations informed by a needs assessment and stakeholder input, we conducted a pilot trial with individuals who have lived experience relative to our target population (i.e., previously pregnant individuals with ED history, n = 10). Participants provided feedback on the intervention through surveys and a focus group assessing perceptions of the intervention and barriers and facilitators to its implementation as guided by the Consolidated Framework for Implementation Research (CFIR).

Results: Eighty percent of enrolled participants attended five or more sessions (out of six). Across sessions, average satisfaction ratings were 9.28 (1 = poor to 10 = excellent). Most participants (89%) reported improvements in body satisfaction. Approximately 33% reported reductions in disordered eating with the remainder reporting no change due to healthy eating behaviors at baseline. Themes from the focus group are reported aligning with CFIR domains and all final modifications are summarized and reported aligning with the Framework for Reporting Adaptation and Modifications-Enhanced.

Conclusions: Applying implementation science frameworks to structure our process for making and summarizing planned adaptations, we adapted an empirically supported ED prevention program for pregnant individuals with histories of an ED. We made adaptation decisions based on participant feedback while weighing intervention fidelity and scalability. We will formally test the adapted intervention in a subsequent pilot randomized controlled trial versus a time- and dose-matched educational control.

Background: Youth in contact with the juvenile legal system experience disproportionate rates of homelessness. While system contact is a critical intervening point, juvenile courts do not typically offer housing services. One solution is to refer youth to evidence-based, community-based services to meet housing-related needs, but a myriad of individual and organizational factors often impede court staff from making such referrals. Housing Stability for Youth in Courts (HSYNC) is a novel, cross-system service linkage model for court-involved youth facing housing instability. HSYNC was developed using codesign as a strategy to improve usability and incorporated evidence on juvenile court linkage strategies effective at increasing service referrals and improving outcomes.

Method: The current study utilized a multimethod approach to evaluate the usability of HSYNC from the perspective of juvenile probation counselors (JPCs) as one group of end-users. As part of the pilot implementation study, survey (N = 15) and semi-structured interview (N = 20) data were obtained from JPCs from four juvenile courts in one northwestern state.

Results: Survey results indicated good usability for HSYNC (mean implementation strategy usability scale score of 80). Themes from the interviews complemented survey findings, pointing to HSYNC as a value-added program that integrated well with existing probation practices. The housing navigator's approach was highlighted as a strong facilitator of program usability. Themes also provided greater insight into implementation barriers (i.e., individual and contextual factors) and areas for improvement (e.g., eligibility screening process).

Conclusions: Drivers of program usability and implications for program improvement to address identified implementation challenges to ensure the HSYNC model is effective and sustainable long-term are discussed.

Background: Few evidence-based interventions have been successfully scaled up and sustained long-term. Within an implementation trial testing strategies for scale-up of the Systems Navigation and Psychosocial Counseling (SNaP) intervention for people who inject drugs (PWID) with HIV across HIV testing clinics in Vietnam, we sought to assess if the implementation of SNaP was sustained after study support ended and to identify factors, including adaptations, that affected SNaP sustainment.

Method: Across all 42 SNaP clinics, we surveyed clinic staff at 6-10 months post-study completion to assess SNaP sustainment. We purposively selected six high and six low-sustaining clinics and conducted 31 in-depth interviews with clinic staff (n = 23) and clinic directors (n = 8). Interviews were coded and analyzed using thematic analysis informed by the Integrated Sustainability Framework. Matrices were used to compare themes across high and low-sustaining clinics.

Results: 1/12 clinics sustained all of SNaP's core components, 2/12 would continue to sustain SNaP if they had new PWID patients, and the remainder did not fully sustain SNaP but continued conducting a modified version, including shorter or fewer SNaP sessions, tailoring SNaP to participants' specific needs, and conducting SNaP-style counseling for all clients. Facilitators of sustainment included leadership directives to clinic staff around SNaP sustainment, clinicians' belief in SNaP's effectiveness, and SNaP's perceived fit with clinic activities and mission. Major barriers to SNaP sustainment included lack of funding for PWID outreach activities, time, staff, training continuity, and systemic challenges with getting PWID into care, such as poverty and lack of transportation.

Conclusions: We identified the challenge of sustaining the SNaP intervention long-term, the ubiquity of intervention adaptations, and multi-level barriers and facilitators to intervention sustainment. These findings demonstrate the need for sustainment strategies and could inform trials of strategies to improve the longevity of effective HIV interventions for populations that are disproportionately affected by this epidemic.

Background: De-implementing non-effective or even harmful practices in healthcare is sometimes necessary, as has been the case with opioid prescribing in dentistry over the past decade. One approach to practice transformation is to deploy clinical decision support (CDS) tools. This qualitative study examined barriers to CDS use as part of a cluster randomized trial that aimed to decrease opioid prescribing for pain management following tooth extractions across a large dental practice.

Method: Twenty dental providers who took part in the larger randomized trial were purposively selected to complete a semi-structured qualitative interview. Participants represented a broad range in terms of years of practice, dental specialization, and CDS use patterns. Interviews were conducted via Zoom, audio recorded, transcribed, and analyzed using a content analysis approach in ATLAS.ti following participation in the cluster randomized trial.

Results: Reasons for not using the CDS fell generally into two broad categories: unintentional (i.e., forgetting to use the CDS) and intentional. Providers who forgot to use the CDS after training and implementation either were not sure where to look for the alert on the screen or did not remember to look for it because its use was never incorporated into their workflow. Reasons for deciding not to use the CDS included feeling that it slowed down their workflow, thinking that the information it provided would not be useful, and not trusting the functionality of the system.

Conclusions: There were numerous, interdependent human, organizational, and technological factors that influenced the intentionally and unintentionally low CDS use rates observed in the study. Findings highlight issues to be aware of and address in future implementation efforts that utilize CDS.

Trial registration: Clinicaltrials.gov NCT03584789.

Background: Implementation of evidence-based practices (EBPs) in schools is fraught with challenges. Even when EBPs are initiated, deterioration of implementation efforts often hinders their long-term success. School leadership behaviors can influence teachers' EBP implementation. Our study tested an implementation strategy called Helping Educational Leaders Mobilize Evidence (HELM), adapted from the Leadership and Organizational Change for Implementation strategy, to enhance EBP implementation through improvements in school leadership teams' implementation leadership and climate to buffer against the deterioration of implementation efforts. This study explores the impact of HELM on theorized mechanisms of change (i.e., implementation leadership, climate), educator-level factors (i.e., implementation citizenship), and implementation outcomes (i.e., fidelity, initiative stability).

Method: One school district and 10 schools in Washington participated. Five of the schools were randomized to receive the HELM strategy and the remaining five schools received an alternative leadership training as an implementation attention control. Teachers at every school (n = 341) received training for an EBP called Positive Greetings at the Door that has been previously demonstrated to reduce student behavior problems. Principals and Assistant Principals (n = 18) received the HELM strategy or alternative leadership training. Three district Administrators also participated in HELM as part of the Organizational Strategy Development meetings.

Results: HELM significantly slowed the average decline of implementation leadership (perseverant leadership and communication), three dimensions of implementation climate (recognition, rewards, and existing supports) and total implementation climate, and one dimension of implementation citizenship (keeping informed). No significant effects were found with regard to implementation outcomes (i.e., fidelity, initiative stability).

Conclusions: HELM shows promise in buffering the deterioration of EBP implementation efforts in schools. HELM positively influenced implementation leadership and climate, which are the hypothesized mechanisms for promoting successful long-term implementation efforts. An appropriately powered trial is needed to determine the efficacy of HELM in the future.Name of the registry: clinicaltrials.govTrial registration number: NCT06340074Date of registration: March 29, 2024. Retrospectively registeredURL of trial registry record: https://clinicaltrials.gov/study/NCT06340074?intr=helm&rank=.

Background: Dissemination initiatives have the potential to increase consumer knowledge of and engagement with evidence-based treatments (e.g., cognitive behavioral therapy [CBT]). Opinion leaders (OLs) have been used in public health campaigns, but have not been examined for the dissemination of mental health treatments. This study uses the Theory of Planned Behavior to test the dissemination strategy of involving an OL in an educational presentation to increase caregiver demand for CBT for youth anxiety.

Method: Participants (N = 262; 92% female; 69% White, 82% non-Hispanic) were caregivers who registered for a virtual presentation on youth anxiety treatment through their child's school. Schools within 1.5-hr drive of Philadelphia, PA were cluster-randomized (k = 25; two-arm prospective randomization) to the OL condition (presented by a clinical researcher and local caregiver OL; n = 119 participants) or the researcher-only condition (n = 143 participants). Presentations occurred from May 2021 to May 2022. Measures were completed pre- and post-presentation and at 3-month follow-up.

Results: Relative to the researcher co-presenter, participants rated the OL as significantly more relatable, familiar, similar, and understanding of their community, but less credible than the researcher co-presenter. In both conditions, there was a significant pre-post increase in participants' knowledge of, attitudes about, subjective norms related to, and intention of seeking CBT for youth anxiety, but not stigma. Presentation conditions did not differ in change on these measures, or on rates of seeking youth anxiety CBT at follow-up.

Conclusions: Although involvement of a caregiver OL did not increase caregiver demand for evidence-based treatment for youth anxiety, the outreach presentation was associated with increases in knowledge of, attitudes about, subjective norms related to, and intention to seek CBT for youth anxiety. Involving OLs in researcher-delivered dissemination efforts may not be necessary for all consumer audiences, but may be beneficial for engendering a sense of relatability, similarity, and connection with disseminators.

Background: Community access to evidence-based information is critical, especially during a pandemic, as it can impact knowledge and adoption of health behaviors that affect health disparities. The field of dissemination and implementation (D&I) science is ideally positioned to address this need through its focus on reducing the research-to-practice gap through improved distribution of information. The purpose of this paper is to describe the creation of a weekly webinar series about COVID-19 directed toward community members, and the extent to which webinars were found useful and increased awareness of evidence-based information and services. Lessons learned about this dissemination strategy as well as the selection and involvement of trusted credible messengers (TCMs) to share information are discussed.

Method: Data were derived from Zoom attendance reports, YouTube views, and survey responses collected about the weekly webinar series over 133 weeks from March 20, 2020 through September 30, 2022.

Results: The webinar reached a minimum of 877 unique within-webinar participants, representing more than 9,190 in-webinar participant hours and an additional 17,303 YouTube views. A consistent base of weekly attendees (e.g., service providers, community members) reported increasing levels of satisfaction and utility over time.

Conclusions: This study supports the use of a community webinar series to disseminate evidence-based, locally relevant information through TCMs to improve community access to knowledge of health information and resource utility.

Background: In Ontario, Canada, province-wide initiatives supporting safer opioid prescribing in primary care include voluntary audit and feedback reports and academic detailing. In this process evaluation, we aimed to determine the fidelity of delivery and receipt of the interventions, the observed change strategies used by physicians, potential mechanisms of action, and how complementary the initiatives can be to each other.

Method: Semi-structured interviews were conducted with academic detailers and with physicians who received both interventions. Academic detailer interviews were coded using the Behavior Change Technique Taxonomy; physician interviews were coded to the Theoretical Domain Framework. Change strategies were summarized based on academic detailer intentions and physician-reported practice changes. Potential mechanisms of action were identified using the Theories and Techniques Tool and the literature. Patient partners informed the interpretation of results through ongoing group discussions of preliminary findings.

Results: Interviews were conducted with eight academic detailers and 12 physicians. Change strategies described by academic detailers to support physicians' opioid prescribing included problem solving, instructions on how to perform the behavior, adding objects to the environment, credible source, shaping knowledge, and social support. Physicians mentioned that academic detailing validated current opioid practices or increased their belief about capabilities and their intentions, mediated by increased skills and the impact of environmental context and resources. Potential mechanisms of action included behavioral regulation, behavioral cueing, and general attitudes/beliefs. On its own, receiving the audit and feedback report did not lead to changes in beliefs about prescribing practices; however, for some physicians, it provided validation and reassurance. Physicians saw unrealized potential for complementarity.

Conclusions: New interventions are often implemented in a complex ecosystem with other competing interventions. In this study, we show how examining the fidelity of the intervention from initial design through to delivery can identify opportunities for potential optimization.