Implementation science communications最新文献

Background: Many implementation determinants of school nutritional interventions have been identified, but a deeper understanding of their interplay within a system is needed. The present study aimed to investigate how the Norwegian School Fruit Programme, particularly the No Parental Payment Programme (NPPP), is being implemented in schools and how it interacts with the school system structure and dynamics as perceived by school personnel and pupils. Moreover, it aimed to understand the dynamic interplay between the determinants of the Consolidated Framework for Implementation Research (CFIR) in the NPPP's context.

Method: The overarching methodology was qualitative system dynamics modelling, with data collected through a series of group model building (GMB) workshops at four schools offering the NPPP. Using GMB scripts, facilitated discussions between school personnel and pupils were held for a better understanding of the NPPP's implementation dynamics and to create diagrams illustrating how implementation determinants interact with each other and each school's unique context. The individual school diagrams were compiled into a single diagram. The CFIR was subsequently mapped on to this diagram.

Results: Lack of communication with pupils, the food stores outside schools, and the NPPP's design weakened the reinforcing mechanism that fostered pupils' eating of fruit. Not eating enough of the fruit increased implementation costs because schools had to deal with leftover fruit and littering issues. Implementation costs caused schools to adopt implementation processes, like reflecting, engaging, and adapting to reduce the costs, although some of these did not work or counterintuitively decreased pupils' eating of fruit. The success of these processes was contested by the design of the NPPP and mechanisms that were shaped by the goals and priorities of the schools.

Conclusions: This research employed qualitative system dynamics to investigate NPPP implementation dynamics. Recommendations for improving implementation include aligning NPPP's design with pupils' preferences, monitoring eating of fruit, and involving internal stakeholders (pupils and school personnel) for gathering feedback, and external stakeholders (municipalities) for monitoring.

Background: The full-scale Russian invasion of Ukraine in February 2022 dramatically increased mental health needs while simultaneously disrupting service delivery systems. This study examines bridging factors-elements that connect the outer system and inner organizational context-within Ukraine's evolving mental health system during an emergency context.

Methods: We conducted semi-structured interviews with 18 mental health stakeholders from diverse professional backgrounds and organizational types across Ukraine between March and October 2023. Using deductive and inductive qualitative analysis approaches, we identified and categorized bridging factors according to established typology.

Results: Using previously described categories of bridging factors, we identified and classified bridging factors described by stakeholders: coordination structures, regulatory and guidance and funding frameworks (formal arrangements), information exchange and synthesis, referral networks, knowledge transfer (process-oriented bridging factors), and collaborations, recruitment, and individual boundary spanners (relational ties). The interviewees perceived these factors as functioning with varying degrees of formalization, effectiveness, and sustainability in facilitating resource flow, knowledge exchange, and mental health service delivery. Although some bridging factors were deliberately planned (e.g., coordination mechanisms), others remained underdeveloped (e.g., referral systems). Notably, individuals who crossed the institutional boundaries played a critical bridging role by leveraging multiple affiliations to connect actors within mental health system.

Conclusions: In the described conflict-affected setting, bridging factors served as essential adaptation mechanisms, creating connections between fragmented system components while simultaneously supporting emergency response functions and transformation toward an evidence-based community-oriented mental health system. The strategic development of these bridging mechanisms, particularly through formalizing effective relational networks, strengthening local coordination capacity, and optimizing resource pathways, can enhance system integration when structural reform resources are constrained.

Background: Integration of comprehensive oncology financial and legal navigation (OFLN) programs within health systems are needed to address cancer-related financial toxicity, however, implementation challenges exist.

Objectives: The aim of this study was to assess contextual factors that may influence implementation of a virtual OFLN intervention within a pediatric and adolescent and young adult oncology clinic and to inform necessary modifications to the proposed implementation strategies, pathways, and workflows.

Methods: We conducted 18 key informant interviews with healthcare team members, patients and caregivers. Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR) to provide a structured evaluation and framework to tailor the implementation of the proposed virtual OFLN intervention. Interviews were recorded, transcribed, and analyzed by two independent coders and organized as facilitators and barriers to implementation within each CFIR domain.

Results: We identified ten potential implementation facilitators related to high demand and need for OFLN services, adaptability of virtual resources, and nurse-led navigation. Six potential implementation barriers related to limited confidence among nurses in facilitating cost of care conversations and conflicts between existing workflows and the intervention were identified.

Conclusions: Guided by CFIR, we were able to identify contextual factors that may influence the implementation of the proposed virtual OFLN intervention. These findings will be used to further adapt our proposed OFLN intervention and implementation processes to facilitate seamless integration into health systems.

Background: Community-based organizations (CBOs) are well-positioned to deliver evidence-based interventions (EBIs) to communities facing health inequities. However, CBO practitioners do not typically have the opportunity to build the necessary skills for EBI delivery. Few validated measures assess EBI skill levels among CBO practitioners, limiting the development and evaluation of capacity-building interventions. Additionally, capacity-building models typically represent academics' views of the subject, with little incorporation of practitioner voices. Thus, we sought to develop a new measure of EBI skills among CBO practitioners.

Methods: Drawing on existing measures, qualitative research, and group concept mapping processes that privileged practitioner and academic expertise, we developed a 54-item instrument covering 10 core EBI skill domains (assessing needs, collaborating with partners, identifying evidence-based programs, adapting for context, implementing; evaluating and iterating; community engagement; planning for sustainability; managing; and funding). After conducting cognitive testing (n = 12), the instrument was administered online to CBO practitioners with at least 3 years of practice experience who served populations experiencing health inequities. Complete case factor analysis and reliability testing were conducted using R.

Results: Participants included 314 respondents, 96% of whom (n = 304) were included in this analysis. They predominantly identified as Black or African American (31%) and White (30%), female (76%), social workers (45%), having 3-5 years of work experience, and were predominantly from the Northeast region of the United States. All work with populations experiencing health inequities. Exploratory factor analysis confirmed measure reliability of a 24-item version with Cronbach's alpha of 0.93. Factor loadings indicated three underlying domains: 1) community needs and partnerships to support implementation, 2) community engagement to support implementation, and 3) evaluation and adaptation of EBIs.

Conclusions: This study is the first step towards a validated, practitioner-informed measure of EBI skills tailored to the unique contexts of CBOs addressing inequities, contributing to the growing literature on capacity-building for EBI implementation in community settings. By centering practitioner perspectives and aligning with long-term health promotion goals, this measure offers a practical tool for strengthening the foundational skills necessary to address health inequities. Future research should explore its application in diverse CBO contexts and assess its impact on EBI implementation and health equity outcomes.

Background: Low back pain (LBP) is the primary contributor to disability worldwide, leading to a significant healthcare burden. Implementing evidence-based practice (EBP) can reduce this burden, as healthcare professionals (HCPs) working evidence-based reduce the number of treatments, the use of imaging and medication compared to HCPs not working evidence-based. Clinical practice guidelines have been published to help HCPs implement research evidence into practice. Unfortunately, studies have consistently shown a lack of adherence to guidelines in LBP care. This study aimed to investigate the implementation outcomes of a tailored programme for implementing key recommendations from LBP guidelines among Danish physiotherapists and chiropractors working in primary care.

Methods: This study was conducted as a 'pre-post' implementation study among 80 physiotherapists and chiropractors from 15 primary care clinics. The implementation object was the two key guideline recommendations: 1) screening of psychosocial risk factors and 2) patient education, including reassuring information. The programme comprised multipronged strategies and was designed as a step-by-step implementation process comprising 16 hours of activities distributed over 16 weeks. Adoption was measured as changes in self-reported behaviour and perceptions of the professional role and culture from baseline to follow-up at 16 weeks. Acceptability and appropriateness of the programme were measured weekly using a four-point Likert scale. Feasibility was measured at 16-week follow-up using a five-point Likert scale. Fidelity was measured as the number of strategies and implementation support delivered as planned and registered by the research team.

Results: An increase in the adoption of screening of psychosocial factors and offering patient education, including reassuring information, was seen in 38% and 33% of participants, respectively. Most participants reported that the programme was partly or overall acceptable and appropriate. The feasibility of the implementation programme was assessed as moderate to high, and the fidelity of the implementation programme was determined as high.

Conclusion: The tailored implementation programme enhanced the adoption of the guidelines and changed the participants' professional identity and culture. Most participants found the programme partly or overall acceptable and appropriate. The programme was feasible, but the perspective requires refinements, as most participants rated it moderately feasible.

Trial registration: Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19.

Background: Implementation science has made significant advances in our understanding of organizational factors that impact the implementation process. Critical to those advances has been the development of measures of key implementation-focused organizational constructs, such as implementation leadership. The Implementation Leadership Scale (ILS) was developed to capture leadership behavior identified as critical to implementation effectiveness. Recent research in education has identified additional dimensions of implementation leadership that extend our understanding of how leaders contribute to the successful implementation and sustainment of new practices. The goal of this paper is to validate the extended version of the Implementation Leadership Scale, or the ILS-X, in behavioral health settings.

Method: This paper utilized baseline data from two large implementation trials conducted in behavioral health settings that collected survey data on the ILS-X measure from 389 providers across 68 behavioral health clinics. The ILS-X is a pragmatic measure with 21 items assessing seven dimensions of implementation leadership (proactive, knowledgeable, supportive, perseverant, communication, vision/mission, and available). Analyses assessed internal consistency reliability, interrater reliability and agreement, factor structure, and construct validity evidence for scores on the measure.

Results: The ILS-X performed well across all criteria. A second-order confirmatory factor model fit the data well and had high factor loadings across all dimensions. Correlations with other clinic-level measures (e.g., transformational leadership, organizational climate, aggregate job satisfaction, clinic characteristics) were consistent with theory-guided expectations. Internal consistency reliability and aggregation indices supported future use of the measure.

Conclusion: The ILS-X allows implementation researchers and practitioners to reliably assess a more comprehensive array of implementation leadership behaviors that builds on the original ILS measure. The ILS-X will be valuable for targeting an expanded range of behaviors for identifying areas of leadership strength and improvement during implementation efforts.

Background: Pregnancy is a crucial period to improve cardiovascular health (CVH) for mothers and their families. The current study emphasizes framework-guided factors that influence the adaptation of an evidence-based intervention (Parents as Teachers and Healthy Eating Active Living Taught at Home [PAT + HEALTH]) to support healthy gestational weight gain and postpartum weight management among pregnant women with obesity and their infants in Nigeria.

Methods: From May to June 2023, 43 in-depth interviews were conducted with 11 parents, 15 community health extension workers (CHEWs)/health educators, and 17 policymakers/ healthcare supervisors in the Federal Capital Territory, Nigeria. Additionally, nine focus groups were conducted with 75 participants. Interviews were recorded, de-identified, and transcribed. The updated Consolidated Framework for Implementation Research (CFIR 2.0) informed the development of the interview guides and the thematic analysis. Transcripts were double-coded using Dedoose.

Results: We identified assessing context, tailoring strategies, local attitudes, and sustainability as constructs to consider when adapting and implementing the PAT + HEALTH intervention successfully within the Nigerian primary care context. For example, policymakers and healthcare supervisors emphasized the feasibility of the intervention, including raising community awareness, planning for hard-to-reach areas, and ensuring supportive supervision of CHEWs delivering the intervention. Additional factors included customizing educational content and delivery methods to fit the cultural, socioeconomic, and environmental contexts of Nigerian families. CHEWs highlighted the importance of public education on locally available foods for better nutrition. Potential barriers to the PAT + HEALTH intervention included local attitudes influenced by sociocultural factors, such as food taboos, and structural factors, including limited financial support for the long-term sustainability of some components of the home visiting program.

Conclusions: Building on these formative activities, the ENHANCE CVH trial will advance dissemination and implementation science by adapting, testing, and evaluating the effectiveness and implementation of the PAT + HEALTH intervention among pregnant women with obesity and their infants in Nigeria in a cluster randomized trial.

Trial registration: ClinicalTrials.gov/NCT06773299, Registration Date: January 14, 2025.

Background: There are many approaches in implementation science research and practice to prospectively and pragmatically measure the amount of effort required to implement a particular evidence-based practice (EBP). We sought to 1) demonstrate how to prospectively and pragmatically document implementation activities in a real-world implementation trial; 2) quantify implementation dose (frequency and time spent) across the implementation of four EBPs; and 3) explore potential drivers of variation in implementation dose across EBP, sites, implementation progress, and wave.

Methods: We built on the existing literature to develop a prospective and pragmatic way to track implementation activities during a type III hybrid effectiveness-implementation stepped wedge trial. We then quantified both total implementation dose (defined as total time spent by the implementer team) and how much of this dose was synchronous (defined as time spent working directly with local implementers at the sites receiving the intervention). We used multiple linear regression to understand what factors may influence differences in total implementation dose delivered (such as which evidence-based practice was being implemented, in which wave of the stepped wedge, at which medical centers), as well as how dose was related to implementation progress, categorized by 1) decision to participate, 2) training, 3) implementation with support, and 4) independent implementation.

Results: From 2022 to 2023, we prospectively captured implementation dose across 25 implementation instances related to four EBPs that were implemented at seven VA medical centers. We implemented Surgical Pause seven times, TAP six times, CAPABLE six times, and EMPOWER six times. We captured and categorized 1,271 h of implementation activities. Asynchronous administrative activities were most common across implementation phases. Other common synchronous activities include engaging collaborators, problem solving, providing updates, and ongoing action/implementation planning. The EBP was the largest driver of variation in implementation dose overall. Site, implementation progress, and wave did not independently explain variations in implementation dose.

Conclusions: The EBP being implemented was a much stronger predictor of the implementation dose required than were other factors, such as experience implementing the EBP or characteristics of the medical center where the intervention was being implemented.

Background: Task shifting and task sharing (TSS) are widely used implementation strategies to expand HIV service delivery in low-resource settings. Informal lay health workers, such as traditional healers (THs), have been proposed as critical partners in bridging service delivery gaps. However, the mechanisms that support their successful integration into formal health systems remain underexplored. This qualitative sub-study aimed characterizes a novel proximal implementation outcome - empowerment - based on lived experiences of THs participating in a TSS intervention in rural Uganda.

Methods: Between July and August 2023, we conducted 22 in-depth interviews with THs in rural Uganda who completed a three day training to become lay HIV supporters. The curriculum included HIV transmission, ART adherence, stigma reduction, and HIV self-testing. Interviews were conducted in the local language, transcribed, translated into English, and analyzed using a thematic approach. Our analysis was guided by Lee and Koh's empowerment framework, which links role transformation to domains of empowerment.

Results: THs reported experiencing empowerment across four domains: meaningfulness, competence, self-determination, and impact. Participants described strong alignment between their traditional caregiving roles and new responsibilities in HIV support. They reported increased HIV-related knowledge, confidence in client care, autonomy in decision-making, and a sense of contributing meaningfully to improved health outcomes. Notably, we identified a fifth domain - external validation - defined as recognition and legitimacy conferred by representatives of the biomedical health system. This domain was central to participants' perceived integration, motivation, and potential sustainability of their involvement in these types of programs.

Conclusions: We propose empowerment as a novel proximal implementation outcome that reflects the internal and external transformations necessary for successful implementation with informal providers. Our findings support expanding Lee and Koh's empowerment framework to include external validation, particularly for cadres operating outside the formal system. Positioning empowerment as a proximal outcome offers a valuable lens for evaluating early success of broad implementation strategies that involve role transformation, such as training trainers, or engaging community champions.

Trial registration: ClinicalTrials.gov, NCT05943548. Registered 2023-07-13, https://clinicaltrials.gov/study/NCT05943548 .

Background: Autism has significantly increased in the United States with 1 in 31 children affected and increasingly included in general education settings as mandated by the Individuals with Disabilities Education Act. While several evidence-based practices (EBPs) effectively support autistic students, organizational-level factors hinder successful implementation in school settings. Implementation climate-implementers' collective perceptions that their organization prioritizes, rewards, and supports EBP implementation-strongly predicts EBP use. However, little is known about implementation climate within general education settings in public schools.

Methods: A sequential explanatory mixed-methods approach was applied. Participants included 361 general education teachers (n = 161), special education teachers (n = 138), and paraeducators (n = 62) across 60 elementary schools. All participants served at least one autistic student included in a general education classroom, with the total number of autistic students served ranging from 1 to 30 (M = 3.75). Participants completed the School Implementation Climate Scale (SICS) and aggregate mean scores for each subscale (i.e., focus on EBP, education support, recognition for EBPs, rewards for EBPs, use of data to support EBPs, existing support to deliver EBPs, integration of EBPs) were calculated. To better understand EBP use, participants were randomly selected (n = 82: 24 general education teachers, 49 special education teachers, 9 paraeducators) to complete 30-40 min semi-structured interviews, with equal distributions of non, low, and high EBP users. Data were collected between 2021-2024.

Results: Quantitative analysis via aggregate mean scores on the SICS (Total M = 1.8) subscales revealed that educators rated implementation constructs relatively low. Qualitative findings provide additional insights into implementation challenges such as limited educational and professional development opportunities, insufficient EBP preparation time, lack of resources for autistic children, and minimal recognition and reward for EBP implementation.

Conclusions: Findings reveal a suboptimal implementation climate within general education settings in public schools for supporting autistic students. These insights suggest the need to improve the implementation climate to facilitate successful EBP implementation. Recommendations and key areas for future research are discussed. Limitations, including the need to examine the impact of outer contextual factors are described.