Implementation science communications最新文献

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.

Background: Implementation fidelity-the degree to which an intervention is executed as intended-is critical for evaluating healthcare interventions' success. Contextual determinants such as organizational culture, communication, and leadership influence how interventions unfold at the site level. The Veterans Health Administration (VA) developed the Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook to improve standardization of patient safety reporting across VA-delivered and VA-purchased care. While the Guidebook aims to enhance reporting fidelity, little is known about which local contextual factors influence its implementation success across diverse VA sites. This study examined the contextual determinants associated with site-level variation in Guidebook implementation fidelity.

Methods: We conducted a cross-sectional, mixed-methods evaluation of 18 geographically diverse VA Medical Centers. Data were collected from 32 interviews with 45 key personnel involved in Guidebook implementation. Using the 2009 Consolidated Framework for Implementation Research (CFIR), 12 constructs were rated at each site. Fidelity was assessed across three safety processes (reporting, investigation, and improvement) on a three-point scale. We used Coincidence Analysis, a configurational comparative method, to identify combinations of CFIR constructs (difference-makers) that consistently distinguished higher- from lower-fidelity sites.

Results: Guidebook fidelity varied across sites (range = 0.23 to 1.59). We identified three key CFIR constructs associated with higher fidelity: Networks & Communications, Relative Priority, and Leadership Engagement. Of these, Networks & Communications was both a necessary and sufficient condition for higher fidelity, serving as a precondition for high levels of Leadership Engagement. Sites that rated highly in Relative Priority were more likely to fully implement Guidebook processes. These constructs fostered strong collaboration, timely information exchange, and internal alignment on the importance of patient safety reporting.

Conclusions: Effective communication networks and perceived priority of the intervention were central to high-fidelity implementation of the VA's safety reporting Guidebook. These findings highlight critical levers for improving implementation fidelity in complex healthcare systems. Targeted strategies that strengthen communication and emphasize the value of safety interventions may enhance implementation success, offering valuable insights for patient safety efforts both within and beyond the VA.

Background: Given the substantial public funding of health-related research, tangible benefits of this support must be demonstrated. Implementation science provides actionable methods to enhance population health, reduce health inequities, and guide effective public health and clinical practices and policies. We must elevate the notion of impact (the "so-what gap") and the role of implementation science, particularly in university settings.

Main text: We distinguish between scientific output and impacts. Impacts in implementation science are commonly defined as improvements in health outcomes, quality of life, quality of services, or policy change. In contrast, traditional academic outputs, such as citation counts and grant awards, hold minimal, direct societal relevance. Principles of audience segmentation (partitioning the target audience for dissemination and implementation into smaller groups by meaningful distinctions), which are increasingly applied in implementation science, can enhance impact. We highlight trade-offs in enhancing the focus on impact across multiple categories (e.g., accountability, evaluation). We describe four essential domains of implementation impact: speed of research translation, sustainability, de-implementation, and equity. Multiple examples, across diverse topics, illustrate these domains (e.g., HIV treatment, use of community health workers). To boost impact via more active dissemination and implementation of research findings, we provide ideas within five categories: (1) co-production of knowledge, (2) tailored dissemination, (3) organizational support, (4) capacity building, and (5) implementation metrics.

Conclusions: Generating new research knowledge does not guarantee societal impact. For implementation science to become more relevant to societal needs, enhancing and evaluating its impacts matter; otherwise, systemic changes required in institutions will continue to evolve slowly. We argue that impactful implementation science involves developing new skill sets and uncovering meaningful work that changes the field while adopting a collaborative working approach with individual researchers, their organizations, funders, and the communities they aim to benefit. Navigating the hurdles and translating research into practice and policy can amplify societal impact, making implementation science more applicable, accessible, and equitable for all.

Background: Climate-sensitive hazards such as extreme heat are increasing in frequency and severity. Protecting population health requires hazard-specific risk assessment, selection of potential interventions, and support for intervention implementation. This process typically takes several years, constraining health adaptation to climate-sensitive hazards. The investigators have developed an online decision support platform, CHaRT, that links evidence-based, location-specific heat-health risk assessment with transparent analyses of risk drivers and evidence-based risk reduction guidance for use in local health departments (LHDs). CHaRT's effectiveness in supporting delivery of effective health interventions has not been evaluated.  METHODS: LHDs are the organizational unit being studied. In this pilot randomized controlled trial, LHDs from the conterminous US will be recruited in coordination with the National Association of City and County Health Officials (NACCHO). Thirty LHDs will be selected at random from interested participants. Fifteen will be randomized to receive the intervention, a facilitated engagement with CHaRT, and 15 will receive the control, a package with information on heat vulnerability assessment and potential interventions. Intervention and control packages will be delivered simultaneously. Facilitated engagement will include an introduction to the tool, user exploration of the tool, elective inclusion of site-specific data into the tool, follow-up sessions to address additional questions, and discussion with investigators regarding planning and implementation needs. Pre- and post-study surveys will be used to assess CHaRT's effectiveness using the RE-AIM (Reach, Effectiveness, Acceptability, Implementation, Maintenance) framework and by comparing each site's intentions to implement specific interventions. After the trial, barriers and facilitators of the CHaRT platform's implementation will be assessed through key informant interviews with the intervention group and analyzed using the Consolidated Framework for Implementation Research (CFIR).

Discussion: This study will allow investigators to evaluate the public health impact of a decision support platform and to identify barriers and facilitators of its implementation. The results will guide future research into strategies for increasing public health adaptation to climate change at the speed and breadth required.

Trial registration: NCT06971978, https://clinicaltrials.gov/study/NCT06971978 , 5/14/25.

Background: Mental health services play a key role in caring for autistic youth given the common and often unmet mental health needs in this population. There is a pressing need to enhance the uptake and use of evidence-based interventions (EBIs) that improve mental health services for autism and optimize outcomes. EBIs targeting transdiagnostic or key factors relevant across autism and mental health conditions exist and have the potential to enhance mental health services for autism. Yet, these interventions have not been widely tested. Similarly, autism EBI training is an implementation strategy with the potential to enhance mental health service quality broadly given specific components and strategies incorporated into the EBI to enhance its impact and fit. This protocol paper describes a multisite study that examines the clinical and implementation effectiveness of a transdiagnostic EBI developed for autistic children compared to a non-autism transdiagnostic EBI in children's mental health settings (Aim 1), confirms engaged clinical and implementation mechanisms (Aim 2), and examines the generalized and expanded effects of EBI training beyond autism (Aim 3).

Methods: This study will employ a hybrid type 2 effectiveness-implementation design to test Unstuck and On Target, an executive functioning EBI adapted for mental health services (autism EBI) and Unified Protocol for Children (non-autism EBI). Twenty-eight mental health programs will be randomized to an EBI condition and 224 therapists across these programs will be recruited and receive EBI training. Additionally, 224 autistic children and 224 non-autistic children, yoked to participating therapists, will be recruited as EBI recipients. This study will measure clinical (mental health symptom change) and implementation outcomes (EBI fidelity, training engagement, psychotherapy quality, reach) and clinical (executive functioning skills, emotion regulation skills) and implementation (autism self-efficacy and knowledge, perception of fit) mechanisms.

Discussion: This study will confirm the effectiveness of a promising executive functioning EBI in mental health settings as well as generate clinical knowledge about the potential of transdiagnostic interventions improve mental health outcomes for autistic children. Findings also have immense potential to demonstrate the ability of autism EBIs to enhance mental health services for autistic and non-autistic children more broadly.

Trial registration: This study is registered with Clinicaltrials.gov (NCT06651086). Registered on October 18, 2024.

Background: Modifications and adaptations to evidence-based interventions are common, and of special relevance to complex interventions in healthcare. Although they play an important role in scale-up and sustainment, the potential exists for negatively affecting the core functions of an intervention. This study explores modifications to rapid response systems (RRSs), using the established Framework for Reporting Adaptations and Modifications - Expanded (FRAME). RRSs are patient safety interventions developed to identify and respond to hospital patients in clinical deterioration. Despite widespread use, little evidence-based guidance exists for necessary adaptations to local context. Applying adaptation frameworks is a novel perspective to improve RRS intervention design and implementation guidance. We aimed to explore which modifications and adaptations to RRSs that have taken place in Norwegian hospital units, how they occurred, and what the underlying reasons were by using FRAME.

Methods: Nine hospital units across six hospitals, which had initiated the implementation of RRSs 4 to 12 years previously, were included. Data was collected through focus group and individual interviews with clinicians and leaders. Analysis involved two steps: a conventional, inductive content analysis to identify and categorize modifications, followed by further characterization of these modifications through deductive analysis employing FRAME.

Results: Inductive analysis identified 5 categories and 24 subcategories of modifications to the RRS intervention. Application of FRAME revealed modifications to be mainly reactive and occurring in the maintenance/sustainment phase, decided at the unit level and with varying fidelity consistency. Both structured and informal processes were identified. The goals of modifications were improvement of feasibility, effectiveness and fit, and reasons were related to available resources, service structure, clinical judgment and patient factors. Minor adaptations to FRAME were necessary to fit the RRS intervention and the methods of data collection.

Conclusions: Studying real-life implementations of RRSs provides insight in modification processes, highlights which intervention elements are modified for better fit and feasibility, and which modifications are prone to fidelity inconsistency. Our findings underline the ubiquity of modifications to RRSs, and the need to systematically anticipate them throughout all implementation stages. Further exploration of RRS core functions and application of FRAME within collectively implemented patient safety interventions could advance the field.

Background: Health equity intervention implementation (which promotes positive health outcomes for populations experiencing disproportionately worse health) is often impeded by health-equity-specific barriers like provider bias; few studies demonstrate how to overcome these barriers through implementation strategies. An urgent health equity problem in the U.S. is the mental health of transgender youth. To address this, we developed Gender-Affirming Psychotherapy (GAP), a health equity intervention comprising best-practice mental health care for transgender youth. This paper details the identification of implementation determinants and the development of targeted strategies to promote provider adoption of GAP.

Methods: This study represents part of a larger study of mental health provider adoption of GAP. Here we describe the first 2 stages of the 3-stage community-engaged and human-centered design process - Discover, Design/Build, and Test - to identify implementation determinants of adoption and develop implementation strategies with transgender youth, their parents, and mental health providers. This process involved collecting data via focus groups, design meetings, usability testing, and champion meetings. Data were analyzed using rapid and conventional content analysis. Qualitative coding of implementation determinants was guided by the Health Equity Implementation Framework, and implementation strategy coding was facilitated by the ERIC Implementation Strategy Compilation.

Results: We identified 15 determinants of GAP adoption, and all were specific to the transgender population (e.g., inclusive record system, anti-transgender attitudes). Seventeen implementation strategies were recommended and 12 were developed, collectively addressing all identified determinants. Most strategies were packaged into an online self-paced mental health provider training (implementation intervention) with 6 training tools. Additional inner-setting strategies were designed to support training uptake (e.g., mandate training) and GAP adoption (e.g., change record system).

Conclusions: Community-engaged and human-centered design methods can identify health equity intervention implementation determinants and develop targeted strategies. We highlight five generalizable takeaways for health equity implementation scientists: (1) implementer bias may be a key barrier, (2) experience with the health equity population may be an important facilitator, (3) stakeholder stories may be an effective training tool, (4) inner-setting-level implementation strategies may be necessary, and (5) teaching implementers how to build implementation strategies can overcome resource-constraints.

Trial registration: November 11, 2022; NCT05626231.

Background: Interprofessional collaboration (IPC) among health and social care providers is crucial to effectively implement community-based fall prevention. Several factors hinder successful and sustainable IPC, highlighting the need to both design and evaluate context-specific implementation strategies. However, there remains a fundamental gap in the detailed description and evaluation of such strategies. Therefore, this study aims to (1) monitor the implementation process over time and (2) evaluate the impact of a multifaceted implementation strategy aimed at improving interprofessional collaboration among health and social care professionals in community-based fall prevention.

Methods: This study was conducted in two districts and one municipality in the Netherlands. We conducted a longitudinal mixed-methods study with a convergent design, emphasizing qualitative methodology. Over 24 months, qualitative (focus groups and regular meetings) and quantitative (questionnaires) data were collected semi-annually from three working groups of health and social care professionals (HSCPs). Qualitative and quantitative data were initially analyzed separately, followed by an integrated analysis for comprehensive insights on themes influencing the implementation process and the impact of the strategy on IPC and implementation outcomes.

Results: In total, 32 HSCPs originating from three communities participated in this study. Monitoring and evaluation of the multifaceted implementation strategy revealed four overarching themes: (1) "Network building", including aspects and activities that contribute to network building; (2) "Team dynamics", referring to interactions within the working groups; (3) "Coordination", addressing the coordination of implementation and establishment of protocols and work flows; and (4) "Implementation dynamics" highlighting aspects that influence the implementation process and outcomes.

Conclusions: This study identified four key themes influencing the implementation process and impact of a multifaceted implementation strategy aimed at improving IPC among HSCPs in community-based fall prevention: network building, team dynamics, coordination and implementation dynamics. Monitoring and evaluation are crucial for identifying the specific activities needed to effectively implement interventions in real-world settings. Given the complexity of implementation processes and ongoing contextual changes, continuous adjustments are necessary. An iterative monitoring and evaluation approach, as used in this study, enables these adaptations and maximizes real-world impact.

Background: Although the management of psychosocial risks in the work environment represents an evidence-based approach to the prevention of mental health problems, its implementation is limited, including in schools, and knowledge on how to support better implementation is scarce. This study compares the effectiveness of a multifaceted vs. a discrete implementation strategy on fidelity to an occupational guideline for the prevention of mental health problems. Dual perspectives were used to assess fidelity, an important aspect of the measurement agenda.

Methods:  A cluster-randomized controlled trial was conducted among 55 schools in Sweden. A multifaceted strategy (educational meeting, implementation teams, ongoing training, Plan-Do-Study-Act cycles, and facilitation) was compared with a discrete strategy (teams participating in the educational meeting). Fidelity to the guideline's recommendations from the recipients' perspective was measured by questionnaire (Baseline n = 2276; 12 months n = 1891). Fidelity from the implementers' perspective (n = 54) was assessed via a checklist at 12 months. Linear mixed modeling was used. A qualitative approach was applied to analyze the open-ended responses to the checklist.

Results:  Absolute changes in recipient fidelity were observed in all three indicators of the guideline's recommendation 1 (Multifaceted: 13.2 to 19.5%, Discrete: 10.4 to 13.2%). A statistically significant effect was found favoring the multifaceted strategy (d = 0.16). The indicator of recommendation 2 also supported the effect of the multifaceted strategy (Multifaceted: 9.2%, Discrete: 5.0%; d = 0.16). The largest difference between the strategies was observed for recommendation 3, for six indicators (Multifaceted: 0.7 to 13.9%, Discrete:-3.2 to 0.0%; d = 0.19 to 0.41). Convergence was observed between the two perspectives in support of the multifaceted strategy's favorable effect on guideline fidelity compared to the discrete strategy. The findings complemented each other, with implementers describing the activities that were enacted and recipients quantifying the change in fidelity over time.

Conclusions: The multifaceted strategy was more effective than the discrete strategy in fidelity attainment after 12 months. Assessing fidelity from the implementer and recipient perspectives provided an understanding of the contextual functioning of the strategies, highlighting the variation in fidelity and the importance of examining the need for adaptations of strategies during the implementation process.

Trial registration: The trial was registered the 9th of August 2021 at Clinicaltrials.gov with Trial registration number: NCT05019937 .