Implementation science communications最新文献

Background: The University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) is a complex, multilevel evidence-based intervention (EBI) aimed at enhancing access to high-quality cancer services for under-served patients. MCCAN is promising but has not been scaled beyond its original context. We aimed to adapt MCCAN, originally developed in Kentucky, to address systematic differences that threatened its implementation and effectiveness in a new context, Iowa, yielding the Iowa Cancer Affiliate Network (I-CAN).

Methods: We report our adaptation of MCCAN using the Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI) approach: (1) identify key information about MCCAN, learning about Kentucky and Iowa contexts and users; (2) adapt MCCAN's forms while leaving its core functions intact to produce I-CAN; and (3) evaluate I-CAN. Specifically, we conducted studies to identify MCCAN's forms and core functions, gathered extensive knowledge of the original and new contexts, and identified systematic differences between the two. We created a matrix to map MCCAN's core functions to its original forms, contextual differences between Kentucky and Iowa, and proposed adapted forms to produce I-CAN. We interviewed I-CAN affiliates to assess perceptions of acceptability, feasibility, and efficacy.

Results: MCCAN forms were mapped to eight intervention and 10 implementation core functions. Adaptation was required for 11 core functions, as contextual differences impacted the ability of the original forms of those core functions to be carried out in the new context. Contextual differences reflected existing relationships and referral patterns, as well as available resources (e.g., personnel and infrastructure). Lack of familiarity with the intervention process and outcomes limited the ability of I-CAN affiliates to evaluate potential adapted forms. Forms evolved as I-CAN affiliates gained practical experience in applying them and/or experienced changes in organizational structure, personnel, etc. CONCLUSIONS: We successfully adapted MCCAN, a complex, multilevel EBI designed to support community hospitals and enhance access to high-quality cancer services and programs in Kentucky to improve care for patients in Iowa affected by cancer-nearly half of whom reside in rural areas. Our application of MODIFI suggests several opportunities for refinement to advance successful EBI adaptation.

Trial registration: ClinicalTrials.gov, NCT05645328. Registered 01 December 2022, https://clinicaltrials.gov/study/NCT05645328.

Introduction: We define clinical practice guideline (CPGs) implementability as the characteristics of the guideline that reflect the extent to which it is likely to be adopted in clinical practice. Our objectives were to create a comprehensive and evidence-informed framework of guideline implementability (CFGI).

Methods: A mixed-methods approach was used. Based on a systematic literature review of six databases as the foundation, the initial version of the CFGI was created, followed by external consultations to gather feedback and natural language processing tool-assisted classification to refine the framework. To get external validation of the CFGI from expert feedback at an international conference.

Results: Fifteen studies related to guideline implementability were identified from the systematic Literature review. The first version of CFGI was compiled, including 6 domains. Feedback on the first version was received from 16 stakeholders, including clinicians, nurses, medical managers, and guideline methodologists, combined with natural language processing tool-assisted classification. The final version of the CFGI is comprised of 6 core domains, containing 21 constructs: (1) Scope and purpose; (2) Clarity and consistency of recommendations; (3) Development and evidence base; (4) Structure and Contents; (5) Development team and transparency; and (6) Implementation environment and tools. Twenty-nine experts participated in the external validation, and the results showed that CFGI had good rationality, importance, clarity, feasibility, and necessity.

Conclusions: The development of the CFGI provides a systematic theoretical basis for the development and implementation of future CPGs, which will help to enhance the implementability of guidelines and facilitate their promotion and application in different medical settings. Future research can further validate and apply the CFGI, explore its effectiveness and feasibility in actual operation.

Background: Social prescribing connects healthcare with community-based services to address social determinants of health, such as loneliness, social isolation, and low health-related quality of life. Although widely implemented in countries such as the United Kingdom and Australia, social prescribing remains underdeveloped in Denmark. The Social Prescribing Vesterbro-Sydhavnen project is the first attempt to systematically implement a general practice-embedded model of social prescribing within a tax-funded healthcare system. It aims to reduce loneliness and promote well-being among socially vulnerable adults by integrating link workers into the patient pathway, in close collaboration with general practitioners, local authorities, and voluntary organizations.

Methods: This research programme uses a Hybrid Type II effectiveness-implementation design to evaluate both clinical and implementation outcomes. The programme comprises nine interrelated work packages using mixed methods. Quantitative components include a quasi-experimental study assessing healthcare service use and patient-reported outcomes (loneliness and quality of life) among 350 referred individuals. Qualitative components include ethnographic fieldwork, semi-structured interviews, and realist evaluation to explore implementation strategies, mechanisms of change, and contextual determinants. Two programme theories guide data collection and analysis and are refined iteratively throughout the studies.

Discussion: This study addresses a gap in implementation research by investigating how a complex, socially embedded intervention can be effectively integrated into routine primary care. The use of a Hybrid Type II design enables simultaneous learning about what works and how implementation strategies interact with local contexts. Particular focus is placed on the roles of link workers, intersectoral collaboration, organizational readiness, and the fit between patient needs and community services. The research contributes to the understanding of strategy selection, adaptation, and sustainment across clinical, organizational, and community settings. Findings will inform the scale-up of social prescribing in Denmark and offer transferable insights on implementing person-centred, equity-oriented interventions in other healthcare systems.

Trial registration: The effectiveness assessment is registered prospectively at ClinicalTrials.gov (NCT07029334).

Background: Contingency management (CM) is the most effective treatment for stimulant use, but is underutilized due to implementation challenges. Digital CM platforms have shown promise in addressing barriers to implementation, but there is limited understanding of factors impacting delivery of a digital CM platform over time. The goal of this longitudinal study was to measure change in implementation determinants affecting uptake of a digital CM platform in opioid treatment programs (OTPs) for individuals who are stimulant users. The study used a novel assessment tool called the Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS) to compare implementation determinants across OTPs and measure changes in determinants over a 6-month implementation period.

Methods: Five OTPs in Rhode Island completed the IFASIS prior to and 6 months into implementation of a digital CM platform. OTP staff completed the IFASIS as a team. Twenty-seven items measuring external context, internal context, intervention factors, and recipient factors were each rated on the impact of the factor on implementation (scores 1-2 = barrier, 3 = neutral, 4-5 = facilitator) and the importance of the factor (1 = not important to 3 = very important). Teams also verbalized the rationale for their ratings. Interviews were recorded and transcribed for rapid qualitative analysis. Quantitative ratings were recorded and median scores for each item were calculated.

Results: Internal organizational factors such as leadership commitment to implementation and organizational policies were perceived as becoming greater barriers to implementation over time. Staff capacity was perceived as a stable facilitator across sites despite sites experiencing turnover and new hires from baseline to follow-up. Despite initial perceptions of recipient and intervention factors as facilitators, these factors were generally viewed as neutral or as barriers at follow-up. Staff comments revealed unanticipated challenges in referring and engaging patients that contributed to the shift in their ratings.

Discussion: Findings underscore the complex and dynamic nature of implementation determinants and highlight the importance of monitoring recipient and intervention factors when implementing digital CM platforms. Results of this study suggest the need to help OTP staff set realistic expectations about the implementation process, particularly with regard to the ease of identifying and engaging patients.

Background: Forensic mental health (FMH) serves as a critical juncture between the mental health and criminal justice systems. Factors on multiple levels - including sociopolitical, organizational, and individual- pose challenges to conducting implementation research in these settings. This hinders the uptake of evidence-based interventions and improvements to patient outcomes. This study examined implementation research conducted in FMH settings to understand its current state and inform future implementation research and practice.

Methods: We conducted a scoping review following the Joanna Briggs Institute methodology. A comprehensive literature search was performed across seven databases from their inception through April 2024, supplemented by searches in Google Scholar and six review studies, to identify relevant research. We analyzed included studies descriptively to explore determinants, strategies, and outcomes associated with the implementation of evidence-, or policy-based interventions in FMH.

Results: Of the 1327 records retrieved, 41 implementation studies were included. All studies were conducted in high-income countries and focused on interventions such as risk assessment, rehabilitation, patient support, and technology interventions, primarily using qualitative approaches. Key determinants for implementing interventions in FMH included individual characteristics (e.g., motivation, capacity) and inner setting factors (e.g., intervention compatibility with existing practices, access to knowledge and information). Various strategies, such as using evaluative and iterative strategies, training and educating stakeholders, changing infrastructure, and engaging consumers have been used to facilitate intervention uptake in FMH. Implementation outcomes primarily focused on uptake, fidelity, and acceptability.

Conclusions: There is a clear need for more implementation research using rigorous study designs in FMH. Multilevel implementation strategies should be employed to address barriers from both the inner settings and individual characteristics, thereby promoting the successful implementation of interventions in FMH. Future implementation research should incorporate a health equity lens throughout the research process to enhance inclusivity and improve reporting on implementation strategies to support replications of interventions in FMH.

Background: Financial incentives are increasingly used to achieve UNAIDS' 95-95-95 goals for ending HIV by 2030. While evidence supports their effectiveness, scaling these interventions remains challenging. This study examines the implementation successes and challenges of a financial incentive intervention in Tanzania, delivered via an mHealth application that provides automated mobile money disbursements, biometric identification, and SMS reminders.

Methods: Conducted alongside a Hybrid Type 1 Effectiveness-Implementation trial, the study evaluated financial incentives given to adults starting ART at 32 clinics. We used the Structured Assessment of Feasibility, Compatibility Beliefs in Technology (CBIT) scales, and the Program Sustainability Assessment Tool. Perspectives from 657 participants living with HIV and 90 clinic staff were collected using Proctor's implementation science framework.

Results: Clinic staff rated the mHealth system highly on CBIT subscales for perceived usefulness, ease of use, and compatibility, each scoring over 6 out of 7. Integration and applicability of the financial incentive within the mHealth system were well received, with 93.0% of staff agreeing it improved job performance. Among participants, 86.4% found SMS reminders helpful for attending appointments, and 76.7% felt the cash delivery met their expectations. Challenges included unreliable fingerprint identification and undelivered SMS reminders.

Conclusions: Despite issues with fingerprint identification and SMS delivery, the financial incentive intervention via mHealth was found to be acceptable, feasible, and potentially sustainable in resource-limited settings, with support from host governments. Future research should enhance the intervention's effectiveness and optimize biometric identification methods.

Trial registration: ClinicalTrials.gov NCT04201353. Registered 17 December 2019, https://clinicaltrials.gov/study/NCT04201353.

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.