Implementation science communications最新文献

Background: Provision of government subsidized school meals at no charge to all students in income-eligible schools (Universal School Meals) is a critical policy approach to address food insecurity and risk for obesity in school-aged children. However, despite documented benefits, implementation challenges remain, which limit the uptake and associated impact of this provision. To ensure the longevity of this policy approach, equity-focused solutions that center the needs of those tasked with implementation and the most vulnerable Universal School Meals recipients are necessary. The aims of this study are to develop equity-focused implementation strategies and test them through a hybrid type III cluster-randomized trial to examine potential effectiveness on improving student uptake and implementation across the school system.

Methods: Aim 1 will comprise the first tasks of Implementation Mapping to co-develop implementation strategies in partnership with school implementers and recipients to ensure contextual fit within their school system. Aim 2 will comprise the final step of implementation mapping with a hybrid type III implementation-effectiveness trial to examine primary implementation and effectiveness outcomes of the applied strategies. Reach and penetration will be the primary implementation outcomes in addition to acceptability, feasibility, cost, and sustainability. Health outcomes comprise family food security, student dietary behaviors, and body mass index. Baseline, 6-month, and 12-month assessments will be recorded. A convergent (Quantitative-Qualitative) mixed methods design will be employed for analysis; exploratory hierarchical multiple regression models will be run for each behavioral outcome using students as the unit of observation and schools as the unit of analysis. Survey and interview data for implementation outcomes will be analyzed deductively according to the Exploration, Preparation, Implementation, and Sustainment and Getting to Equity frameworks then inductively to generate overarching themes across the trial period.

Discussion: This implementation mapping process will yield equity-driven strategies, which can be successfully implemented in school settings to improve uptake of USM and reduce food insecurity and obesity-related disparities in high-risk youth. This study presents a rigorous and equity-driven implementation research agenda with the potential to advance school-based obesity prevention efforts by identifying, developing, and evaluating context-specific strategies that meet the needs of vulnerable student populations.

Trial registration: ClinicalTrials.gov, NCT06579079, Registered on 11-5-2024.

Background: LGBTQ + youth are at elevated risk for numerous negative health and behavioral health outcomes, which largely stem from minority stress and maladaptive coping. Schools are an important environment where these youth may be exposed to both stressors, like experiences of stigma, bias, discrimination, and violence, and health promotive factors that moderate the impact of minority stress. Collaboration between schools and the broader community plays a crucial role in initiatives designed to improve school climate and culture. The purpose of this study was to validate the use of an adapted "Collaborating with Community Scale" in the context of a cluster randomized controlled trial implementing LGBTQ + supportive practices in high schools.

Methods: We conducted annual surveys over five years with an administrator and an implementation leader in each of the 42 high schools randomly assigned to either an implementation condition or a delayed implementation condition. The survey included questions on organizational leadership, implementation climate, and the CCS-LGBTQ + . We analyzed inter-rater reliability between respondent types, internal consistency, and change over time in scale items and means.

Results: Scale scores between administrators and implementation leaders were strongly correlated. However, administrators rated items higher than implementation leaders. The scale demonstrated a high level of internal consistency, with Cronbach's alphas ranging from .777 to .930 and was sensitive to changes in the implementation of scale items, indicated by increases in the scale means of implementation condition schools from 1.59 in year 1 to 2.08 in year 4 (p < .035).

Conclusions: Testing of the CCS-LGBTQ + resulted in a scale with high internal consistency to measure the extent to which schools collaborate with community resources to support and enhance school environments for LGBTQ + students. When used in the context of the parent trial, findings from the CCS-LGBTQ + show that schools' collaboration with community resources increased over time. However, the impact of the COVID-19 pandemic likely reversed some of the gains made within the first years of implementation. The CCS-LGBTQ + is a reliable and useful tool for assessing school-community collaboration for supporting LGBTQ + populations.

Background: Digital health interventions are increasingly promoted in healthcare and prevention practices due to their potential for reaching key populations in a cost-efficient manner. Yet there has been limited research on how to effectively implement them with pragmatic approaches that can facilitate scale-up. Keep It Up! (KIU!) 3.0 was a hybrid type 3 implementation-effectiveness trial comparing two delivery strategies (i.e. trial arms) of an HIV prevention intervention for cisgender, young men who have sex with men. We aimed to determine the level of pragmatism of our two-armed trial before and after changes to the county-randomized design.

Methods: We applied different versions of the PRagmatic Explanatory Continuum Indicator Summary (PRECIS) tool to the two trial arms: delivery of KIU! by community-based organizations (CBO) versus centralized, direct-to-consumer (DTC) delivery. We scored PRECIS-2 for the original study design and the modified design in which the DTC strategy expanded nationally. We applied PRECIS-2-PS to the modified study design. Nine coders in three groups independently scored the tools. Scores were iteratively discussed to arrive at one consensus score per domain, tool, design stage, and arm. We plotted results using the PRECIS-2 and PRECIS-2-PS wheels and averaged domains scores to describe overall score along the Pragmatic-Explanatory Continuum.

Results: Using PRECIS-2, the trial was on the pragmatic side of the spectrum for both arms and design stages, with average ratings ranging from 3.89-4.33. Both arms were highly pragmatic in the original and modified design in the Setting and Primary Analysis domains and least pragmatic in the Follow-up domain. In the modified trial design, the CBO and DTC arms again scored rather pragmatic using the PRECIS-2-PS tool, but CBO arm scored higher in the eligibility, recruitment, and organization domains compared to PRECIS-2 (5 vs. 4, respectively).

Conclusions: Application of both the PRECIS-2 and PRECIS-2-PS tools validated the pragmatic design of KIU! 3.0 as originally designed and after modifications during trial implementation. Our findings highlight instances where one tool may be more suitable than the other to assess the pragmatic-explanatory continuum for emerging digital health interventions delivered in diverse settings and with different implementation strategies.

Background: The demand for homecare is increasing, and reducing low-value care is essential for achieving sustainable healthcare. Low-value care refers to practices that are ineffective, inefficient, unwanted, or potentially harmful to the client. This study aimed to evaluate the effects of a tailored, multifaceted de-implementation strategy in reducing low-value home-based nursing care.

Methods: A prospective, multicenter, convergent parallel mixed method design was employed, including a before-and-after study, using the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework. The effect of reducing low-value home-based nursing care was assessed from client records, focusing on the number of clients receiving care, minutes of care per week, frequency of visits per week, and clients no longer requiring care. The de-implementation process was evaluated qualitatively through individual interviews with de-implementation ambassadors, registered nurses, and nurse assistants, using Directed Qualitative Content Analysis. This approach served to interpret the effects of the deployment of de-implementation ambassadors and the strategies they implemented.

Results: We observed a reduction in low-value home-based nursing care, with a decrease of 130 h per week in daily showering, bathing and/or dressing; 54 h per week in the assistance with compression stockings; and 8 h per week in changing bandages enabling clients to regain their independence. Important de-implementation strategies included involving clients and relatives in decision making, organizing informational meetings for homecare professionals, and fostering collaboration with other healthcare professionals. Factors that influenced adoption included providing reassurance and using a stepwise approach with clients and relatives. Homecare professionals noted that the de-implementation ambassadors were highly committed to reducing care. De-implementation ambassadors found their role to be intense, challenging, and exciting.

Conclusions: This evaluation found that the deployment of de-implementation ambassadors, paired with additional de-implementation strategies, enhanced the reduction of low-value home-based nursing care. Providing reassurance and involving clients and their relatives were identified as beneficial for the de-implementation process.

Background: Tuberculosis (TB) poses a considerable challenge for people with HIV (PWH), especially in low- and middle-income countries. Even with the availability of effective preventive strategies such as tuberculosis preventive therapy (TPT), the implementation of these measures continues to fall short. Our study explores the perceptions of healthcare workers (HCWs) regarding the barriers and facilitators to TPT implementation in the Philippines and Indonesia.

Methods: We performed 10 focus group discussions and four in-depth interviews with HCWs from June to December 2023. Each discussion and interview lasted between 45 and 120 min. Discussions explored HCWs' perspectives on the policies, logistics, and prescribing practices related to TPT, as well as their personal experiences, concerns, and suggested improvements. Data were coded using MAXQDA24 qualitative software informed by the tenets of constructivist grounded theory. We organized themes using the Consolidated Framework for Implementation Research (CFIR), while contextualizing implementation determinants most pertinent to the local contexts.

Results: Our findings revealed nuanced barriers and facilitators-marked by paradoxes-organized across three CFIR domains: the outer, inner, and individual domains of HIV-TB care. In the outer setting, barriers include limited patient knowledge and drug shortages, while facilitators involved national policies and external pressures from mass media and peer imitation. The inner setting was shaped by structural gaps-such as poor documentation, staff turnover, and procedural challenges in ruling out active TB-that affected patient trust, whereas open communication and role clarity supported TPT implementation. At the individual level, HCWs expressed high motivation but cited limited capacity due to lack of training and information to deliver effective TPT care.

Conclusions: Our findings highlight implementation determinants to TPT implementation across outer, inner, and individual domains of HIV-TB care. Understanding how structural gaps, provider capacity, and patient trust intersect with supportive policies, and peer and mass media influences offer insights into the complex dynamics shaping TPT uptake and integration. Our study insights may inform policy adjustments and guide strategies to better integrate TPT into national health frameworks.

Background: Evidence based practices such as cognitive behavioral therapy (CBT) are often underutilized in community mental health settings. Implementation efforts can be effective in increasing CBT use among clinicians, but not all therapists successfully reach CBT competence at the end of training. Past studies have focused on how clinicians overall acquire CBT skills, rather than examining different learning trajectories that clinicians may follow and predictors of those trajectories; however, understanding of learning trajectories may suggest targets for implementation strategies.

Methods: We used growth mixture models to identity trajectories in CBT skill acquisition among clinicians (n = 812) participating in a large scale CBT training and implementation program, and examined predictors (attitudes towards EBPs, clinician burnout, professional field, educational degree level) of trajectory membership. We assessed model fit using BIC, Vuong likelihood tests, and entropy. We hypothesized that there would be at least two trajectories- one where clinicians increased in skills over time and reach CBT competence, and one with minimal increases in CBT skills that did not result in competence. We hypothesized that presence of a graduate degree, more positive attitudes towards EBPs, and lower burnout would predict more positive trajectories in CBT skill acquisition. We did not have a specific prediction for field of study and CBT skill acquisition.

Results: Clinicians followed either a progressive trajectory with steady increases in CBT skills over time, or a stagnant trajectory with minimal increases in CBT skills. Clinicians with more positive attitudes towards EBPs were 3.51 times more likely to follow a progressive trajectory, while clinicians who were in an 'Other' professional field were 0.46 times less likely to follow a progressive trajectory. Contrary to our hypotheses, educational degree and clinician burnout did not predict CBT trajectories.

Conclusion: Our results indicate that attitudes towards EBPs can be an important intervention point to improve CBT skill acquisition for therapists in training and implementation efforts. More structured support for clinicians who did not receive training in mental health focused fields may also help improve CBT learning.

Background: The overlapping epidemics of opioid use disorder (OUD) and HIV present a critical public health challenge. Although people with OUD frequently engage with healthcare settings, uptake of HIV prevention services such as pre-exposure prophylaxis (PrEP) remains low. Integrating HIV prevention into routine OUD care could reduce new infections, but scalable, evidence-based strategies are lacking. Rhode Island offers a unique opportunity to design and evaluate such strategies using its robust data infrastructure and high OUD burden.

Methods: We will conduct a three-phase, sequential implementation study. In Aim 1, we will use the Rhode Island All-Payer Claims Database and State Emergency Department Database data to identify healthcare engagement patterns and gaps in HIV prevention service delivery among people with OUD, including rates of HIV screening, PrEP use, and medications for OUD uptake, across settings from 2012 to 2022. In Aim 2, we will convene a series of five stakeholder-engaged evidence-based quality improvement panels-including with providers, policymakers, and people with lived experience-to co-develop implementation strategies tailored to each care setting (i.e., primary care, mental health clinics, emergency department, and opioid use treatment centers). Finally, in Aim 3, we will develop an agent-based model (ABM) to simulate the population-level effect of implementation strategies developed for each care setting (as identified in Aim 2). The ABM will project outcomes such as HIV incidence, cases averted, and number needed to treat (NNT) over 5- and 10-year horizons under various scenarios. Model parameters will be based on literature and findings from Aim 1. Outputs from the ABM will be used to prioritize feasible, high-impact strategies for future real-world implementation.

Discussion: This study addresses critical gaps in HIV prevention for people with OUD by combining claims-based analysis, evidence-based quality improvement, and agent-based modeling. By leveraging real-world data and engaging diverse stakeholders, the study aims to generate actionable strategies tailored to clinical settings. Findings will inform future implementation efforts in Rhode Island and other jurisdictions facing overlapping HIV and opioid epidemics.

Trial registration: This study does not meet the World Health Organization's definition of a clinical trial and, therefore, was not registered.

Background: Adverse Childhood Experiences (ACEs) screenings are increasingly being used in primary care clinics to identify toxic stress and potential trauma in children. ACEs are negative life events (e.g., violence exposure) occurring before age 18, that can increase health risks when unaddressed. However, we lack evidence on the impact of ACEs screenings and how they can be feasibly implemented in community-based clinics. We partnered with federally qualified health clinics to test the impact of a multifaceted implementation strategy on ACEs screening reach and mental health referrals for children ages 0-5.

Methods: We conducted a Hybrid Type 2 pilot trial using a stepped-wedge design (2021-2024). Reach data was measured as the proportion of eligible children screened for ACEs, with data collected from Electronic Health Records. We also assessed the percentage of mental health service referrals among all eligible children. Study clinics (n = 3) switched from no ACEs screenings (control) to implementing ACEs screenings supported by the multi-faceted ACE implementation strategy (intervention). The tested strategy comprised personnel training (e.g., trauma-informed care), integrated technology, team-based screening workflows, and ongoing care team implementation support. Additional clinics (n = 2) implemented ACEs screenings as usual without the strategy and served as additional comparison sites for exploratory analyses. Log-binomial and robust Poisson regression models examined differences in screening reach and referrals and were adjusted for site and patient race.

Results: Screening reach rates increased in the intervention period, from 0.0% of patients screened during control to 11.2% screened during intervention. Mental health service referrals increased from 0.4% at control to 7.2% during the intervention, resulting in a risk difference (95% confidence interval) of 6.9% (6.0%, 7.7%). For both the reach and referral outcomes, risk differences were significantly greater for 18-to-60-month-old patients than for patients under 18-months-old.

Discussion: Healthcare policy efforts promoting ACEs screenings in primary care are commendable. We found that a multi-faceted implementation strategy informed by partners and designed to support ACEs screenings in community-based clinics was feasible. However, its impact was attenuated by policy requirements, clinics' capacity to add ACEs screenings to strained workflows, and multiple impactful outer-context events related and unrelated to the COVID-19 pandemic.

Trial registration: Trial # NCT04916587 registered at clinicaltrials.gov on June 4, 2021, https://clinicaltrials.gov/study/NCT04916587.

Background: Despite high post-implementation adherence, clinicians may have unresolved questions or concerns regarding use of a protocol to standardize routine daily coordination of the spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) on ventilated patients. Unresolved questions or concerns may unwittingly curtail practice normalization, impacting practice sustainment when implementation support is withdrawn. The objective of this study was to identify unresolved questions or concerns that may persist following successful implementation of a coordinated SAT/SBT (C-SAT/SBT) protocol.

Methods: We used an attributed, cross-sectional survey of physicians, advanced practice providers, nurses and respiratory therapists likely to have participated in a C-SAT/SBT in 12 hospitals (15 intensive care units) in Utah and Idaho. We evaluated clinician perceptions of acceptability, including ease of use, usefulness and confidence, along with perceived practice normalization, six months post implementation of a protocol to routinize C-SAT/SBT use.

Results: C-SAT/SBT adherence was 83.1% at the 6th month post implementation. 606 clinicians completed the survey (response rate: 50.0%). Perceived individual usefulness, ease of use, and confidence using the C-SAT/SBT protocol were high [range: 72.1%-88.1% agree/strongly agree], though individuals not performing an SAT or SBT in more than six months and respiratory therapists scored lower. Perceived practice normalization was similar with 82.0% aggregate agreement [agree/strongly agree]. However, when stratifying respondents into four categories based upon respondent percentage agreement with all statements, 71% did not agree with at least one practice normalization statement and 27% agreed with less than 80% of statements, varying by role and site. Sets of observable characteristics or phenotypes regarding the degree of practice normalization begin to emerge by subgroup.

Conclusions: Unresolved questions or concerns may persist regarding implementation of a C-SAT/SBT protocol among certain population subgroups despite current high practice adherence and high levels of perceived acceptability, including ease of use, usefulness and confidence. It is not clear what impact these unresolved questions or concerns may have on practice normalization and multi-year practice sustainment systemwide, including whether targeted late post-implementation strategies are needed to mitigate concerns and promote sustainment when implementation support is withdrawn.