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Houghton LC, Adkins-Jackson PB. Mixed-Method, Multilevel Clustered-Randomized Control Trial for Menstrual Health Disparities. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024:10.1007/s11121-024-01646-1. [PMID: 38358576 DOI: 10.1007/s11121-024-01646-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/16/2024]
Abstract
Menstrual cycle characteristics are largely considered unmodifiable reproductive factors, a framing that prevents exploration of the ways structural factors interfere with menstrual health. Given the role of structural factors like healthy food and healthcare access on reproductive health and the grave need for structural interventions to known reproductive health disparities that disproportionately target cisgender women racialized as Black, it is imperative that science begin to examine how structural factors influence menstrual health. To explore such research, we employ critical race theory and intersectionality to illustrate what a structural intervention to improve menstrual cycle health could look like. Centering those with the greatest need, persons racialized as Black and/or LatinX living in food and healthcare deserts in Northern Manhattan, our illustrative sample includes four groups of persons who menstruate (e.g., cisgender girls and women) that are pre-menarche, pre-parous, postpartum, or perimenopausal. We describe a hypothetical, multilevel clustered-randomized control trial (cRCT) that provides psychoeducation on racism-related trauma and free delivered groceries to both treatment and control groups, while randomizing 30 clusters of housing associations to receive either sexual health clinics at their housing association or free vouchers for healthcare. We embed mixed methods (diaries, interviews, surveys, mobile apps, observation) into the design to evaluate the effectiveness of the 1-year intervention, in addition to determining the impact on participants through their perspectives. Through this illustration, we provide a novel example of how structural interventions can apply mixed methods to evaluate effectiveness while delivering services to populations impacted by multiple structural factors. We demonstrate how qualitative and quantitative approaches can be paired in clustered RCTs and how a living logic model can empirically incorporate the population perspective into more effective interventions. Lastly, we reveal how sensitive menstrual health is to structural factors and how upstream improvements will trickle down to potentially reduce health disparities in reproductive health.
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Affiliation(s)
- Lauren C Houghton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA.
| | - Paris B Adkins-Jackson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA
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Liu F, Chang H, Liu X. Adherence Behaviors and Related Factors Among Elderly Hypertensive Patients in China: Evidence from the China Health and Retirement Longitudinal Study. Patient Prefer Adherence 2023; 17:3539-3553. [PMID: 38152445 PMCID: PMC10752232 DOI: 10.2147/ppa.s445789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023] Open
Abstract
Background Non-adherence or partial adherence is the main reason for poor therapeutic effect of hypertension. This paper aims to assess adherence behaviors and related factors among elderly hypertensive patients in China. Methods Participants aged ≥60 years, with hypertension, and with complete data in 2018 interviews of the China Health and Retirement Longitudinal Study (CHARLS) were included. The adherence behaviors included medication, blood pressure monitoring and the combined adherence behaviors. Referring to the social-ecological theory, correlates of adherence behaviors were divided into three layers, namely demographic characteristics, health behaviors, living environment and retirement. Univariate and multivariable logistic regression models were performed to identify factors of adherence behaviors. Results The prevalence of medication adherence (76.58%) was higher than that of blood pressure monitoring adherence (20.08%), and the full adherence rate was 18.53%. Self-rated health status, smoking status, living area, and health education status were detected to be associated with medication adherence and blood pressure monitoring adherence (all p < 0.05). Gender, sleep duration, health examination, and physical exercise were also detected to be associated with blood pressure monitoring adherence (all p < 0.05). Self-rated health status and health education status were detected to be associated with partially and fully adherence, while age, living area, and life satisfaction were detected to be associated with partially adherence, smoking status, sleep duration, health examination, and pension reliance were detected to be associated with fully adherence (all p < 0.05). Conclusion Our study reveals the poor adherence behaviors of elderly hypertensive patients in China. This is most evident among those who were male, 60-69 years old, living in rural areas, self-reported being healthier, those without health examination and health education. Targeting these vulnerable populations, we suggest to strengthen health education, increase the publicity of basic public health services and enhance the self-management ability of hypertensive patients.
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Affiliation(s)
- Fengyu Liu
- School of Public Health, Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
- School of Public Health, National Key Laboratory of Health Technology Assessment (National Health Commission of the People’s Republic of China), Global Health Institute, Fudan University, Shanghai, People’s Republic of China
| | - Huajing Chang
- School of Public Health, Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
| | - Xiaojun Liu
- School of Public Health, Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
- School of Health Management, Provincial Research Center for Healthcare Reform and Development of Fujian, Health Research Institute, Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
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Petrik AF, Johnson ES, Mummadi R, Slaughter M, Coronado GD, Lin SC, Savitz L, Wallace N. The use of individual and multilevel data in the development of a risk prediction model to predict patients' likelihood of completing colorectal cancer screening. Prev Med Rep 2023; 36:102366. [PMID: 37732019 PMCID: PMC10507149 DOI: 10.1016/j.pmedr.2023.102366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/22/2023] Open
Abstract
Promotion of colorectal cancer (CRC) screening can be expensive and unnecessary for many patients. The use of predictive analytics promises to help health systems target the right services to the right patients at the right time while improving population health. Multilevel data at the interpersonal, organizational, community, and policy levels, is rarely considered in clinical decision making but may be used to improve CRC screening risk prediction. We compared the effectiveness of a CRC screening risk prediction model that uses multilevel data with a more conventional model that uses only individual patient data. We used a retrospective cohort to ascertain the one-year occurrence of CRC screening. The cohort was determined from a Health Maintenance Organization, in Oregon. Eligible patients were 50-75 years old, health plan members for at least one year before their birthday in 2018 and were due for screening. We created a risk model using logistic regression first with data available in the electronic health record (EHR), and then added multilevel data. In a cohort of 59,249 patients, 36.1% completed CRC screening. The individual level model included 14 demographic, clinical and encounter based characteristics, had a bootstrap-corrected C-statistic of 0.722 and sufficient calibration. The multilevel model added 9 variables from clinical setting and community characteristics, and the bootstrap-corrected C-statistic remained the same with continued sufficient calibration. The predictive power of the CRC screening model did not improve after adding multilevel data. Our findings suggest that multilevel data added no improvement to the prediction of the likelihood of CRC screening.
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Affiliation(s)
- Amanda F. Petrik
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- Northwest Permanente, Portland, OR, USA
| | - Eric S. Johnson
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- Northwest Permanente, Portland, OR, USA
| | - Rajasekhara Mummadi
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- Northwest Permanente, Portland, OR, USA
| | | | | | - Sunny C. Lin
- Oregon Health & Science University/Portland State University School of Public Health, Portland, OR, USA
- Washington University, St. Louis, MO, USA
| | - Lucy Savitz
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Neal Wallace
- Oregon Health & Science University/Portland State University School of Public Health, Portland, OR, USA
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Mthiyane N, Rapulana AM, Harling G, Copas A, Shahmanesh M. Effect of multi-level interventions on mental health outcomes among adolescents in sub-Saharan Africa: a systematic review. BMJ Open 2023; 13:e066586. [PMID: 37788931 PMCID: PMC10551963 DOI: 10.1136/bmjopen-2022-066586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/09/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVE In sub-Saharan Africa (SSA), multiple factors contribute to the considerable burden of mental health disorders among adolescents, highlighting the need for interventions that address underlying risks at multiple levels. We reviewed evidence of the effectiveness of community or family-level interventions, with and without individual level interventions, on mental health disorders among adolescents in SSA. DESIGN Systematic review using the Grades of Recommendation, Assessment, Development and Evaluation approach. DATA SOURCES A systematic search was conducted on Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science up to 31 March 2021. ELIGIBILITY CRITERIA Studies were eligible for inclusion in the review if they were randomised controlled trials (RCTs) or controlled quasi-experimental studies conducted in sub-Saharan African countries and measured the effect of an intervention on common mental disorders in adolescents aged 10-24 years. DATA EXTRACTION AND SYNTHESIS We included studies that assessed the effect of interventions on depression, anxiety, post-traumatic stress disorder and substance abuse. Substance abuse was only considered if it was measured alongside mental health disorders. The findings were summarised using synthesis without meta-analysis, where studies were grouped according to the type of intervention (multi-level, community-level) and participants. RESULTS Of 1197 studies that were identified, 30 studies (17 RCTs and 3 quasi-experimental studies) were included in the review of which 10 delivered multi-level interventions and 20 delivered community-level interventions. Synthesised findings suggest that multi-level interventions comprise economic empowerment, peer-support, cognitive behavioural therapy were effective in improving mental health among vulnerable adolescents. Majority of studies that delivered interventions to community groups reported significant positive changes in mental health outcomes. CONCLUSIONS The evidence from this review suggests that multi-level interventions can reduce mental health disorders in adolescents. Further research is needed to understand the reliability and sustainability of these promising interventions in different African contexts. PROSPERO REGISTRATION NUMBER CRD42021258826.
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Affiliation(s)
- Nondumiso Mthiyane
- Africa Health Research Institute, Durban, South Africa
- Institute for Global Health, University College London, London, UK
| | - Antony M Rapulana
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Science, University of KwaZulu-Natal, Durban, South Africa
| | - Guy Harling
- Africa Health Research Institute, Durban, South Africa
- Institute for Global Health, University College London, London, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology & Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, South Africa
- Institute for Global Health, University College London, London, UK
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Mills SD, Golden SD, O'Leary MC, Logan P, Hassmiller Lich K. Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking. Tob Control 2023; 32:287-295. [PMID: 34535509 PMCID: PMC9466654 DOI: 10.1136/tobaccocontrol-2021-056695] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/11/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Develop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies. METHODS We developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies. RESULTS The CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking. CONCLUSIONS The CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.
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Affiliation(s)
- Sarah D Mills
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shelley D Golden
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Meghan C O'Leary
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paige Logan
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Havrda M, Klocek A. Well-being impact assessment of artificial intelligence - A search for causality and proposal for an open platform for well-being impact assessment of AI systems. EVALUATION AND PROGRAM PLANNING 2023; 99:102294. [PMID: 37209640 DOI: 10.1016/j.evalprogplan.2023.102294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 03/26/2023] [Accepted: 04/24/2023] [Indexed: 05/22/2023]
Abstract
In recent years, the well-being impact assessment approach has been applied in the area of Artificial Intelligence (AI). Existing well-being frameworks and tools provide a relevant starting point. Taking into account its multidimensional nature, well-being assessment is well suited to assess both the expected positive effects of the technology as well as unintended negative consequences. To-date the establishment of causal links mostly stems from intuitive causal models. Such approaches neglect the fact that to prove causal links between the operation of an AI system and observed effects is difficult due to the immense complexity of the socio-technical context. This article aims at providing a framework for ascertaining the attribution of effects of observed impact of AI on well-being. An elaborated approach to impact assessment potentially enabling causal inferences is demonstrated. Furthermore, a new Open Platform for Well-Being Impact Assessment of AI systems (OPIA) is introduced, which is based on a distributed community to build reproducible evidence through effective identification, refinement, iterative testing, and cross-validation of expected causal structures.
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Affiliation(s)
| | - Adam Klocek
- SCHOLA EMPIRICA, z.s., Blanická 25, Prague, Czech Republic; Institute of Psychology, The Czech Academy of Sciences, Hybernská 1000/8, 110 00, Czech Republic
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Lion KC, Zhou C, Fishman P, Senturia K, Cole A, Sherr K, Opel DJ, Stout J, Hazim CE, Warren L, Rains BH, Lewis CC. A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol. Implement Sci 2023; 18:8. [PMID: 36915138 PMCID: PMC10012737 DOI: 10.1186/s13012-023-01263-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/12/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices. METHODS We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data. DISCUSSION Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities. TRIAL REGISTRATION NCT05591586.
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Affiliation(s)
- K Casey Lion
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, 98145-5005, USA.
| | - Chuan Zhou
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, 98145-5005, USA
| | - Paul Fishman
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Kirsten Senturia
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Allison Cole
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - James Stout
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Carmen E Hazim
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
| | - Louise Warren
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Bonnie H Rains
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Cara C Lewis
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Ewald DR, Orsini MM, Strack RW. The path to good health: Shifting the dialogue and promoting social ecological thinking. SSM Popul Health 2023; 22:101378. [PMID: 36992717 PMCID: PMC10041553 DOI: 10.1016/j.ssmph.2023.101378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
The purpose of our research was to assess whether an intervention could produce changes in critical consciousness (CC) relative to participants' understanding of social influences on health and individual health behaviors. The intervention was a 4-min animation, entitled The Path to Good Health , that described how factors in our social environment influence individuals in a variety of ways and thereby our health. We used the same sampling and intervention strategies with two discrete cohorts of participants (Initial study: June 2018, n = 249; Retest study: October 2019, n = 315), who were recruited and incentivized through Amazon's Mechanical Turk platform. We measured direction and extent of change from pre-to post-intervention in four key constructs of CC (Passive Adaptation, Emotional Engagement, Cognitive Awakening, and Intentions to Act) using the 4-Factor Critical Consciousness Scale (4-FCCS), and we investigated differential effects of the intervention related to demographics of participants, including political typology. We also assessed concurrent and predictive validity of the (4-FCCS). Changes of CC subscale scores from pretest to posttest moved in the expected direction in both the Initial and Retest studies; Cohen's d effect sizes were medium to very large in both studies. Overall, findings suggest the video intervention was effective at improving CC among participants drawn from the general population. We demonstrated that it is possible to influence people's cognitive-emotional interpretations in as little as 4 min, regardless of one's political ideology, and that the (4-FCCS) is sufficiently sensitive to measure changes in CC. This study provides preliminary evidence that a brief intervention can broaden cognitive-emotional interpretations from an over-emphasis on personal responsibility for individual health to an appreciation of the impact of social ecological factors on population health.
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McHugh SM, Riordan F, Kerins C, Curran G, Lewis CC, Presseau J, Wolfenden L, Powell BJ. Understanding tailoring to support the implementation of evidence-based interventions in healthcare: The CUSTOMISE research programme protocol. HRB Open Res 2023; 6:7. [PMID: 37361339 PMCID: PMC10285335 DOI: 10.12688/hrbopenres.13675.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 09/22/2023] Open
Abstract
Although there are effective evidence-based interventions (EBIs) to prevent, treat and coordinate care for chronic conditions they may not be adopted widely and when adopted, implementation challenges can limit their impact. Implementation strategies are "methods or techniques used to enhance the adoption, implementation, and sustainment of a clinical program or practice". There is some evidence to suggest that to be more effective, strategies should be tailored; that is, selected and designed to address specific determinants which may influence implementation in a given context. Despite the growing popularity of tailoring the concept is ill-defined, and the way in which tailoring is applied can vary across studies or lack detail when reported. There has been less focus on the part of tailoring where stakeholders prioritise determinants and select strategies, and the way in which theory, evidence and stakeholders' perspectives should be combined to make decisions during the process. Typically, tailoring is evaluated based on the effectiveness of the tailored strategy, we do not have a clear sense of the mechanisms through which tailoring works, or how to measure the "success" of the tailoring process. We lack an understanding of how stakeholders can be involved effectively in tailoring and the influence of different approaches on the outcome of tailoring. Our research programme, CUSTOMISE (Comparing and Understanding Tailoring Methods for Implementation Strategies in healthcare) will address some of these outstanding questions and generate evidence on the feasibility, acceptability, and efficiency of different tailoring approaches, and build capacity in implementation science in Ireland, developing and delivering training and supports for, and network of, researchers and implementation practitioners. The evidence generated across the studies conducted as part of CUSTOMISE will bring greater clarity, consistency, coherence, and transparency to tailoring, a key process in implementation science.
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Affiliation(s)
- Sheena M McHugh
- School of Public Health, University College Cork, Cork, Ireland
| | - Fiona Riordan
- School of Public Health, University College Cork, Cork, Ireland
| | - Claire Kerins
- School of Public Health, University College Cork, Cork, Ireland
| | - Geoff Curran
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Cara C Lewis
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, Washington, USA
| | - Justin Presseau
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Luke Wolfenden
- College of Medicine, Health and Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Byron J Powell
- Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine,, Washington University in St. Louis, St. Louis, Missouri, USA
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
- Center for Dissemination & Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA
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Oh AY, Rising CJ, Gaysynsky A, Tsakraklides S, Huang GC, Chou WYS, Blake KD, Vanderpool RC. Advancing multi-level health communication research: A Delphi study on barriers and opportunities. Transl Behav Med 2022; 12:1133-1145. [PMID: 36378100 PMCID: PMC9802573 DOI: 10.1093/tbm/ibac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Adopting a multi-level perspective that considers the many interrelated contexts influencing health could make health communication interventions more effective and equitable. However, despite increasing interest in the use of multi-level approaches, multi-level health communication (MLHC) interventions are infrequently utilized. We therefore sought to conduct a modified Delphi study to better understand how researchers conceptualize MLHC interventions and identify opportunities for advancing MLHC work. Communication and health behavior experts were invited to complete two rounds of surveys about the characteristics, benefits, pitfalls, best practices, barriers, and facilitators of MLHC interventions; the role of technology in facilitating MLHC interventions; and ways to advance MLHC intervention research (46 experts completed the first survey, 44 completed both surveys). Survey data were analyzed using a mixed-methods approach. Panelists reached consensus on two components of the proposed definition of MLHC interventions and also put forward a set of best practices for these interventions. Panelists felt that most health intervention research could benefit from a multi-level approach, and generally agreed that MLHC approaches offered certain advantages over single-level approaches. However, they also expressed concern related to the time, cost, and complexity of MLHC interventions. Although panelists felt that technology could potentially support MLHC interventions, they also recognized the potential for technology to exacerbate disparities. Finally, panelists prioritized a set of methodological advances and practical supports that would be needed to facilitate future MLHC intervention research. The results of this study point to several future directions for the field, including advancing how interactions between levels are assessed, increasing the empirical evidence base demonstrating the advantages of MLHC interventions, and identifying best practices for the use of technology. The findings also suggest that researchers may need additional support to overcome the perceived practical challenges of conducting MLHC interventions.
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Affiliation(s)
- April Y Oh
- Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Camella J Rising
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Anna Gaysynsky
- Health Communication and Informatics Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
- ICF Next, ICF, Rockville, MD, USA
| | | | - Grace C Huang
- Public Health and Epidemiology, Westat, Rockville, MD, USA
| | - Wen-Ying Sylvia Chou
- Health Communication and Informatics Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Kelly D Blake
- Health Communication and Informatics Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Robin C Vanderpool
- Health Communication and Informatics Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
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Beresford SA, Ornelas IJ, Bauer MC, Garrity GA, Bishop SK, Francis B, Rillamas-Sun E, Garcia LV, Vecenti FS, Lombard KA. Group Randomized Trial of Healthy Eating and Gardening Intervention in Navajo Elementary Schools (Yéego!). AJPM FOCUS 2022; 1:100033. [PMID: 37791240 PMCID: PMC10546586 DOI: 10.1016/j.focus.2022.100033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Few healthy eating, school-based interventions have been rigorously evaluated in American Indian communities. Gardening and healthy eating are priorities in the Navajo Nation. Collaborations between researchers and local partners supported the design and implementation of this project. Design The Yéego! Healthy Eating and Gardening Study was a group-randomized controlled trial to evaluate a school-based healthy eating and gardening intervention in 6 schools in the Navajo Nation. Schools were randomized 1:2 to intervention or comparison. Setting/participants The Shiprock and Tsaile/Chinle areas in the Navajo Nation were selected. Elementary schools were screened for eligibility. All students in third and fourth grades were invited to participate in the assessments. Intervention Delivered during 1 school year in the intervention schools, the intervention included a culturally relevant nutrition and gardening curriculum and a school garden. Main outcome measures Student self-efficacy for eating fruits and vegetables, student self-efficacy for gardening, and student healthy foods score from a modified Alternative Healthy Eating Index were assessed in third and fourth graders at the beginning and end of a school year affected by the COVID-19 pandemic. Primary analyses used repeated measures linear mixed models accounting for students nested within schools to estimate the intervention effect and 95% CIs. Results Students in the intervention schools had self-efficacy scores for eating fruits and vegetables that were 0.22 points greater (95% CI=0.04, 0.41) than those in the comparison schools, although the student healthy foods score increased in the intervention schools by 2.0 (95% CI=0.4, 3.6); the differential change was modest at 1.7 (95% CI=-0.3, 3.7). The self-efficacy to grow fruits and vegetables in the school garden increased among those in the intervention schools (OR=1.92; 95% CI=1.02, 3.63) but not significantly more than it increased in the comparison schools (OR=1.29; 95% CI=0.60, 2.81). Conclusions The intervention was efficacious in improving self-efficacy for eating fruits and vegetables among third- and fourth-grade students over a school year. The findings warrant further evaluation of the intervention in larger-group randomized trials with schools in Navajo communities. Trial registration This study is registered at clinicaltrials.gov NCT03778021.
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Affiliation(s)
- Shirley A.A. Beresford
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
- Cancer Prevention Program, Fred Hutchinson Cancer Center, Seattle, Washington
| | - India J. Ornelas
- Cancer Prevention Program, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington
| | | | | | - Sonia K. Bishop
- Cancer Prevention Program, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, Washington
| | - Brandon Francis
- Agricultural Science Center at Farmington, College of Agricultural, Consumer, and Environmental Sciences, New Mexico State University, Farmington, New Mexico
| | - Eileen Rillamas-Sun
- Cancer Prevention Program, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | | | - Kevin A. Lombard
- Agricultural Science Center at Farmington, College of Agricultural, Consumer, and Environmental Sciences, New Mexico State University, Farmington, New Mexico
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McHugh SM, Riordan F, Curran GM, Lewis CC, Wolfenden L, Presseau J, Lengnick-Hall R, Powell BJ. Conceptual tensions and practical trade-offs in tailoring implementation interventions. FRONTIERS IN HEALTH SERVICES 2022; 2:974095. [PMID: 36925816 PMCID: PMC10012756 DOI: 10.3389/frhs.2022.974095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/31/2022] [Indexed: 11/19/2022]
Abstract
Tailored interventions have been shown to be effective and tailoring is a popular process with intuitive appeal for researchers and practitioners. However, the concept and process are ill-defined in implementation science. Descriptions of how tailoring has been applied in practice are often absent or insufficient in detail. This lack of transparency makes it difficult to synthesize and replicate efforts. It also hides the trade-offs for researchers and practitioners that are inherent in the process. In this article we juxtapose the growing prominence of tailoring with four key questions surrounding the process. Specifically, we ask: (1) what constitutes tailoring and when does it begin and end?; (2) how is it expected to work?; (3) who and what does the tailoring process involve?; and (4) how should tailoring be evaluated? We discuss these questions as a call to action for better reporting and further research to bring clarity, consistency, and coherence to tailoring, a key process in implementation science.
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Affiliation(s)
| | - Fiona Riordan
- School of Public Health, University College Cork, Cork, Ireland
| | - Geoff M. Curran
- Department of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Cara C. Lewis
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Luke Wolfenden
- College of Medicine, Health and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Justin Presseau
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Rebecca Lengnick-Hall
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Byron J. Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, United States
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO, United States
- Division of Infectious Diseases, John T. Milliken Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
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13
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Reese TJ, Liu S, Steitz B, McCoy A, Russo E, Koh B, Ancker J, Wright A. Conceptualizing clinical decision support as complex interventions: a meta-analysis of comparative effectiveness trials. J Am Med Inform Assoc 2022; 29:1744-1756. [PMID: 35652167 PMCID: PMC9471719 DOI: 10.1093/jamia/ocac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/26/2022] [Accepted: 05/23/2022] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Complex interventions with multiple components and behavior change strategies are increasingly implemented as a form of clinical decision support (CDS) using native electronic health record functionality. Objectives of this study were, therefore, to (1) identify the proportion of randomized controlled trials with CDS interventions that were complex, (2) describe common gaps in the reporting of complexity in CDS research, and (3) determine the impact of increased complexity on CDS effectiveness. MATERIALS AND METHODS To assess CDS complexity and identify reporting gaps for characterizing CDS interventions, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting tool for complex interventions. We evaluated the effect of increased complexity using random-effects meta-analysis. RESULTS Most included studies evaluated a complex CDS intervention (76%). No studies described use of analytical frameworks or causal pathways. Two studies discussed use of theory but only one fully described the rationale and put it in context of a behavior change. A small but positive effect (standardized mean difference, 0.147; 95% CI, 0.039-0.255; P < .01) in favor of increasing intervention complexity was observed. DISCUSSION While most CDS studies should classify interventions as complex, opportunities persist for documenting and providing resources in a manner that would enable CDS interventions to be replicated and adapted. Unless reporting of the design, implementation, and evaluation of CDS interventions improves, only slight benefits can be expected. CONCLUSION Conceptualizing CDS as complex interventions may help convey the careful attention that is needed to ensure these interventions are contextually and theoretically informed.
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Affiliation(s)
- Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Siru Liu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Steitz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Allison McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elise Russo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian Koh
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jessica Ancker
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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Wurz A, Bean C, Shaikh M, Culos-Reed SN, Jung ME. From laboratory to community: Three examples of moving evidence-based physical activity into practice in Canada. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e1690-e1700. [PMID: 34623004 DOI: 10.1111/hsc.13596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/12/2021] [Accepted: 09/20/2021] [Indexed: 06/13/2023]
Abstract
Physical activity (PA) is important for enhancing and sustaining people's health and well-being. Although a number of efficacious PA interventions have been developed, few have been translated from research into practice. Consequently, the knowledge-to-practice gap continues to grow, leaving many individuals unable to access evidence-based PA opportunities. This gap may be particularly relevant for those who grapple with poor health due to intrapersonal, interpersonal, cultural and system-level barriers that limit their access to evidence-based PA opportunities. Implementation efforts designed to bring research into real-world settings may bridge the knowledge-to-practice gap. Yet, cultivating quality partnerships and ensuring effectiveness, methodological rigour and scalability in real-world settings can be difficult. Furthermore, researchers seldom publish examples of how they addressed these challenges and translated their evidence-based PA opportunities into practice. Herein, we describe three cases of successful PA implementation among diverse populations: (a) individuals affected by cancer, (b) adults living with prediabetes, and (c) children from under-resourced communities. Commonalities across cases include guiding theories and frameworks, the strategies to facilitate and maintain partnerships, and scalability and sustainability plans. Practical tips and recommendations are provided to spur research and translation efforts that consider implementation from the outset, ultimately ensuring that people receive the benefits PA can confer.
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Affiliation(s)
- Amanda Wurz
- Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | - Corliss Bean
- Department of Recreation & Leisure Studies, Brock University, St. Catharines, Canada
| | - Majidullah Shaikh
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - S Nicole Culos-Reed
- Faculty of Kinesiology, University of Calgary, Calgary, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Psychosocial Resources, Tom Baker Cancer Centre, Calgary, Canada
| | - Mary E Jung
- School of Health and Exercise Sciences, The University of British Columbia, Kelowna, Canada
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15
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Czosnek L, Zopf EM, Cormie P, Rosenbaum S, Richards J, Rankin NM. Developing an implementation research logic model: using a multiple case study design to establish a worked exemplar. Implement Sci Commun 2022; 3:90. [PMID: 35974402 PMCID: PMC9382723 DOI: 10.1186/s43058-022-00337-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 08/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Implementation science frameworks explore, interpret, and evaluate different components of the implementation process. By using a program logic approach, implementation frameworks with different purposes can be combined to detail complex interactions. The Implementation Research Logic Model (IRLM) facilitates the development of causal pathways and mechanisms that enable implementation. Critical elements of the IRLM vary across different study designs, and its applicability to synthesizing findings across settings is also under-explored. The dual purpose of this study is to develop an IRLM from an implementation research study that used case study methodology and to demonstrate the utility of the IRLM to synthesize findings across case sites. Method The method used in the exemplar project and the alignment of the IRLM to case study methodology are described. Cases were purposely selected using replication logic and represent organizations that have embedded exercise in routine care for people with cancer or mental illness. Four data sources were selected: semi-structured interviews with purposely selected staff, organizational document review, observations, and a survey using the Program Sustainability Assessment Tool (PSAT). Framework analysis was used, and an IRLM was produced at each case site. Similar elements within the individual IRLM were identified, extracted, and re-produced to synthesize findings across sites and represent the generalized, cross-case findings. Results The IRLM was embedded within multiple stages of the study, including data collection, analysis, and reporting transparency. Between 33-44 determinants and 36-44 implementation strategies were identified at sites that informed individual IRLMs. An example of generalized findings describing “intervention adaptability” demonstrated similarities in determinant detail and mechanisms of implementation strategies across sites. However, different strategies were applied to address similar determinants. Dependent and bi-directional relationships operated along the causal pathway that influenced implementation outcomes. Conclusions Case study methods help address implementation research priorities, including developing causal pathways and mechanisms. Embedding the IRLM within the case study approach provided structure and added to the transparency and replicability of the study. Identifying the similar elements across sites helped synthesize findings and give a general explanation of the implementation process. Detailing the methods provides an example for replication that can build generalizable knowledge in implementation research. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00337-8.
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16
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Gormley L, Belton CA, Lunn PD, Robertson DA. Interventions to increase physical activity: An analysis of candidate behavioural mechanisms. Prev Med Rep 2022; 28:101880. [PMID: 35813395 PMCID: PMC9260609 DOI: 10.1016/j.pmedr.2022.101880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/24/2022] Open
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17
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Andersen ER, Hofmann BM, Kjelle E. Reducing low-value radiological services in Norway -a qualitative multi-professional study on measures and facilitators for change. BMC Health Serv Res 2022; 22:678. [PMID: 35596215 PMCID: PMC9122550 DOI: 10.1186/s12913-022-08077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/11/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Overuse, underuse, and significant variation in the utilisation of radiological services are well documented in the literature. Several radiological examinations are identified as low-value examinations as they do not lead to a change in diagnosis or course of treatment. Even so, such examinations are frequently performed. Many measures for reducing low-value imaging have been carried out with variable outcomes. While there is little evidence as to why some measures work and others do not, adjusting to the context seems important for success. The objective of this study was to investigate which measures stakeholders consider appropriate for reducing the use of low-value imaging and what it takes to make them work. METHODS Semi-structured interviews were conducted among radiographers, radiologists, radiological department managers, hospital clinicians, general practitioners, and health government/authorities' representatives. The interview guide covered two broad areas: Experience with low-value services, and possible future measures deemed appropriate for reducing low-value services. Data were analysed in line with a qualitative framework analysis. RESULTS The analysis included information from 27 participants. All participants acknowledged that low-value imaging was a problem, but few had very specific suggestions on reducing this in practice. Suggested measures were to stop referrals from being sent, provide support in assessing referrals, or change the healthcare system. Identified facilitators were categorised as management and resources, evidence, and experienced value. In general, appropriate measures should be practical, well-founded, and valuable. CONCLUSIONS This study provides insight into various stakeholders' perceptions of suitable interventions to reduce low-value imaging. While many measures for reducing low-value imaging are available, contextual sensitivity is crucial to make them work.
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Affiliation(s)
- Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway.
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway.,Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway
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18
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Schilling S, Bigal L, Powell BJ. Developing and applying synergistic multilevel implementation strategies to promote reach of an evidence-based parenting intervention in primary care. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221091219. [PMID: 37091079 PMCID: PMC9924241 DOI: 10.1177/26334895221091219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed. Plain Language Summary There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.
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Affiliation(s)
- Samantha Schilling
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Luisa Bigal
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Byron J. Powell
- Center for Mental Health Services Research, Brown School and School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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19
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Abstract
Since its introduction, photovoice has been implemented in numerous fields with a wide array of outcomes of interest, but has the method been implemented in a way that is consistent with its initial aims in mind? From Caroline Wang and Mary Ann Burris's initial 1994 project, photovoice has demonstrated power to harness visual imagery and stories within a participatory empowerment process and established a new tool for the profession for understanding community members' lived experience and needs, raising the critical consciousness of communities, and advocating for actions leading to social change. Based in Freirean philosophy, feminist theory, and documentary photography, photovoice engages community members to identify, represent, and change their community by means of photography, dialogue, and action. Public health can benefit when researchers and practitioners more carefully conceptualize the intended aims of each photovoice effort. The purpose of this article is to consider the varied applications of photovoice and propose a classification system that encapsulates its wide-ranging aims. Close examination of foundational literature and previous applications of photovoice suggest the following categories for framing the application of the method; specifically, photovoice for (a) photovention, (b) community assessment, (c) community capacity building, and (d) advocacy for change. Full implementations of photovoice have the capacity to illuminate complex real-world issues leading to advocacy for policy, systems, and environmental change. It is our hope that the proposed framing clarifies the language used to discuss photovoice and its outcomes, distinguishes its various uses and stated aims, and maximizes its impact in future applications.
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Affiliation(s)
- Robert W Strack
- University of North Carolina Greensboro, Greensboro, NC, USA
| | | | - D Rose Ewald
- University of North Carolina Greensboro, Greensboro, NC, USA
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20
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Kolko DJ, McGuier EA, Turchi R, Thompson E, Iyengar S, Smith SN, Hoagwood K, Liebrecht C, Bennett IM, Powell BJ, Kelleher K, Silva M, Kilbourne AM. Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial. Implement Sci 2022; 17:20. [PMID: 35193619 PMCID: PMC8862323 DOI: 10.1186/s13012-022-01195-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms. METHODS We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life. DISCUSSION This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home. TRIAL REGISTRATION ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.
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Affiliation(s)
- David J Kolko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Elizabeth A McGuier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Renee Turchi
- Department of Pediatrics, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Eileen Thompson
- PA Medical Home Program, PA Chapter, American Academy of Pediatrics, Media, PA, USA
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shawna N Smith
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kimberly Hoagwood
- Department of Child and Adolescent Psychiatry, New York University Langone Health, New York, NY, USA
| | - Celeste Liebrecht
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ian M Bennett
- Departments of Family Medicine and Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kelly Kelleher
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Nationwide Children's Hospital Research Institute, Columbus, OH, USA
| | - Maria Silva
- Allegheny Family Network, Pittsburgh, PA, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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21
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Leeman J, Boisson A, Go V. Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels. Annu Rev Public Health 2021; 43:155-171. [PMID: 34724390 DOI: 10.1146/annurev-publhealth-052020-113438] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Jennifer Leeman
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina, USA;
| | - Alix Boisson
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA;
| | - Vivian Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA;
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22
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Makarov DV, Ciprut S, Kelly M, Walter D, Shedlin MG, Braithwaite RS, Tenner CT, Gold HT, Zeliadt S, Sherman SE. Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging. Trials 2021; 22:711. [PMID: 34663435 PMCID: PMC8522153 DOI: 10.1186/s13063-021-05645-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/19/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that (1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment and (2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer. METHODS We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: (1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers' and to published guidelines, (2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and (3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically distributed study sites. DISCUSSION This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed. TRIAL REGISTRATION CliniclTrials.gov NCT03445559. Prospectively registered on February 26, 2018.
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Affiliation(s)
- Danil V Makarov
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
- Robert F. Wagner Graduate School of Public Service, New York University, New York, USA
- Perlmutter Cancer Center, New York University School of Medicine, New York, USA
| | - Shannon Ciprut
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
| | - Matthew Kelly
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA.
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA.
- VA New York Harbor Healthcare System, New York, USA.
| | - Dawn Walter
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
| | | | - Ronald Scott Braithwaite
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
| | - Craig T Tenner
- VA New York Harbor Healthcare System, New York, USA
- Department of Medicine - General Internal Medicine, New York University, New York, NY, USA
| | - Heather T Gold
- Department of Population Health, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
- Robert F. Wagner Graduate School of Public Service, New York University, New York, USA
| | - Steven Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Scott E Sherman
- Department of Urology, New York University School of Medicine, 227 E 30th St, 617 L, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, New York, USA
- Perlmutter Cancer Center, New York University School of Medicine, New York, USA
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Lewis CC, Powell BJ, Brewer SK, Nguyen AM, Schriger SH, Vejnoska SF, Walsh-Bailey C, Aarons GA, Beidas RS, Lyon AR, Weiner B, Williams N, Mittman B. Advancing mechanisms of implementation to accelerate sustainable evidence-based practice integration: protocol for generating a research agenda. BMJ Open 2021; 11:e053474. [PMID: 34663668 PMCID: PMC8524292 DOI: 10.1136/bmjopen-2021-053474] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/04/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Mechanisms explain how implementation strategies work. Implementation research requires careful operationalisation and empirical study of the causal pathway(s) by which strategies effect change, and factors that may amplify or weaken their effects. Understanding mechanisms is critically important to replicate findings, learn from negative studies or adapt an implementation strategy developed in one setting to another. Without understanding implementation mechanisms, it is difficult to design strategies to produce expected effects across contexts, which may have disproportionate effects on settings in which priority populations receive care. This manuscript outlines the protocol for an Agency for Healthcare Research and Quality-funded initiative to: (1) establish priorities for an agenda to guide research on implementation mechanisms in health and public health, and (2) disseminate the agenda to research, policy and practice audiences. METHODS AND ANALYSIS A network of scientific experts will convene in 'Deep Dive' meetings across 3 years. A research agenda will be generated through analysis and synthesis of information from six sources: (1) systematic reviews, (2) network members' approaches to studying mechanisms, (3) new proposals presented in implementation proposal feedback sessions, (4) working group sessions conducted in a leading implementation research training institute, (5) breakout sessions at the Society for Implementation Research Collaboration's (SIRC) 2019 conference and (6) SIRC conference abstracts. Two members will extract mechanism-relevant text segments from each data source and a third member will generate statements as an input for concept mapping. Concept mapping will generate unique clusters of challenges, and the network will engage in a nominal group process to identify priorities for the research agenda. ETHICS AND DISSEMINATION This initiative will yield an actionable research agenda to guide research to identify and test mechanisms of change for implementation strategies. The agenda will be disseminated via multiple channels to solicit feedback and promote rigorous research on implementation mechanisms.
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Affiliation(s)
- Cara C Lewis
- MacColl Center, Kaiser Permanente, Seattle, Washington, USA
| | - Byron J Powell
- Brown School, Washington University in St Louis, St. Louis, Missouri, USA
| | - Stephanie K Brewer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ann M Nguyen
- Center for State Health Policy, Rutgers, New Brunswick, New Jersey, USA
| | - Simone H Schriger
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah F Vejnoska
- Department of Psychiatry and Behavioral Sciences, UC Davis MIND Institute, Sacramento, California, USA
| | | | - Gregory A Aarons
- Department of Psychiatry and Dissemination and Implementation Science Center, University of California San Diego, La Jolla, California, USA
| | - Rinad S Beidas
- Departments of Psychiatry, Medical Ethics and Health Policy, and Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center at the Leonard Davis Institute (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aaron R Lyon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Bryan Weiner
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Brian Mittman
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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24
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Graboyes EM, Sterba KR, Li H, Warren GW, Alberg AJ, Calhoun EA, Nussenbaum B, McCay J, Marsh CH, Osazuwa-Peters N, Neskey DM, Kaczmar JM, Sharma AK, Harper J, Day TA, Hughes-Halbert C. Development and Evaluation of a Navigation-Based, Multilevel Intervention to Improve the Delivery of Timely, Guideline-Adherent Adjuvant Therapy for Patients With Head and Neck Cancer. JCO Oncol Pract 2021; 17:e1512-e1523. [PMID: 33689399 PMCID: PMC8791819 DOI: 10.1200/op.20.00943] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE More than half of patients with head and neck squamous cell carcinoma (HNSCC) experience a delay initiating guideline-adherent postoperative radiation therapy (PORT), contributing to excess mortality and racial disparities in survival. However, interventions to improve the delivery of timely, equitable PORT among patients with HNSCC are lacking. This study (1) describes the development of NDURE (Navigation for Disparities and Untimely Radiation thErapy), a navigation-based multilevel intervention (MLI) to improve guideline-adherent PORT and (2) evaluates its feasibility, acceptability, and preliminary efficacy. METHODS NDURE was developed using the six steps of intervention mapping (IM). Subsequently, NDURE was evaluated by enrolling consecutive patients with locally advanced HNSCC undergoing surgery and PORT (n = 15) into a single-arm clinical trial with a mixed-methods approach to process evaluation. RESULTS NDURE is a navigation-based MLI targeting barriers to timely, guideline-adherent PORT at the patient, healthcare team, and organizational levels. NDURE is delivered via three in-person navigation sessions anchored to case identification and surgical care transitions. Intervention components include the following: (1) patient education, (2) travel support, (3) a standardized process for initiating the discussion of expectations for PORT, (4) PORT care plans, (5) referral tracking and follow-up, and (6) organizational restructuring. NDURE was feasible, as judged by accrual (88% of eligible patients [100% Blacks] enrolled) and dropout (n = 0). One hundred percent of patients reported moderate or strong agreement that NDURE helped solve challenges starting PORT; 86% were highly likely to recommend NDURE. The rate of timely, guideline-adherent PORT was 86% overall and 100% for Black patients. CONCLUSION NDURE is a navigation-based MLI that is feasible, is acceptable, and has the potential to improve the timely, equitable, guideline-adherent PORT.
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Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC,Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC,Evan M. Graboyes, MD, MPH, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Ave, MSC 550, Charleston, SC 29425; e-mail:
| | - Katherine R. Sterba
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Hong Li
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Graham W. Warren
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC,Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston, SC
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | | | - Brian Nussenbaum
- American Board of Otolaryngology - Head and Neck Surgery, Houston, TX
| | - Jessica McCay
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Courtney H. Marsh
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, NC,Department of Population Health Sciences, Duke University, Durham, NC
| | - David M. Neskey
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC,Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - John M. Kaczmar
- Department of Medicine, Division of Medical Oncology, Medical University of South Carolina, Charleston, SC
| | - Anand K. Sharma
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC
| | - Jennifer Harper
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC
| | - Terry A. Day
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Chanita Hughes-Halbert
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC,Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC
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25
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, Alberta T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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26
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Klein AB, Kline AC, Bowling AR, Feeny NC. Bridging the science-practice gap in treatment for posttraumatic stress disorder: Testing strategies to enhance beliefs toward exposure therapy. J Clin Psychol 2021; 77:2765-2780. [PMID: 34273910 DOI: 10.1002/jclp.23221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Exposure therapies (e.g., prolonged exposure [PE]), are first-line interventions for posttraumatic stress disorder but remain underutilized, partially due to providers' negative beliefs about these interventions. We examined two experimental strategies aimed at enhancing beliefs towards PE and subsequent utilization. METHOD Clinicians (N = 155) were randomized to one of three conditions presenting a PE rationale: basic, empirically-based, or emotionally-based description. Participants were rerandomized to write or not write arguments for utilizing PE. Before and after PE rationales and 1-month later, participants completed questions about PE beliefs and utilization. RESULTS Participants reported small yet durable belief change across all rationale conditions, with greatest change following the empirically-based description. Across conditions, belief change was not impacted by writing condition or associated with utilization. CONCLUSION Addressing negative beliefs with empirical information may be a brief, cost-effective strategy to improve clinicians' beliefs toward PE. Complementary strategies that leverage belief modification to increase utilization are needed.
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Affiliation(s)
- Alexandra B Klein
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alexander C Kline
- Clinical Psychology, VA San Diego Healthcare System, San Diego, California, USA
| | - Alexandra R Bowling
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Norah C Feeny
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
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27
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Lucas T, Thompson HS, Blessman J, Dawadi A, Drolet CE, Hirko KA, Penner LA. Effects of culturally targeted message framing on colorectal cancer screening among African Americans. Health Psychol 2021; 40:305-315. [PMID: 34152784 PMCID: PMC8330134 DOI: 10.1037/hea0001073] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This study examined how standard and culturally targeted versions of gain and loss-framed messaging affect African Americans' colorectal cancer (CRC) screening receptivity and behavior, as well as their anticipation of experiencing racism in undertaking CRC screening. METHOD Screening-deficient African Americans (N = 457) viewed an informational video about CRC risks, prevention, and screening and were randomized to receive a gain or loss-framed message about screening. Half of participants viewed an additional culturally targeted message about overcoming racial disparities in CRC by obtaining screening. Using the Theory of Planned Behavior, we measured general receptivity to CRC screening. We also measured arousal of anticipatory racism in response to messaging. Finally, we offered participants a no-cost fecal immunochemical testing kit (FIT Kit) and measured uptake and use. RESULTS Message framing interacted with culturally targeted messaging to affect CRC screening receptivity and behavior. Participants were no more receptive to CRC screening when standard loss-framing was used, but were more favorable if loss-framing was culturally targeted. Targeted loss-framing also reduced anticipatory racism, which partially mediated effects on screening receptivity. Finally, although participants least often accepted a FIT Kit with standard loss-framing, effects of messaging on FIT Kit uptake and use were not significant. CONCLUSION This study adds to growing recognition of important cultural nuance in effective use of message framing. Current finding also suggest that targeted and framed messaging could synergistically impact the extent to which African Americans engage in CRC screening, although specific impacts on FIT Kit screening are less certain. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Todd Lucas
- Division of Public Health, College of Human Medicine, Michigan State University
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University
| | - Hayley S. Thompson
- Department of Community Outreach and Engagement, Karmanos Cancer Institute, Wayne State University School of Medicine
| | - James Blessman
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine
| | - Anurag Dawadi
- Division of Public Health, College of Human Medicine, Michigan State University
| | - Caroline E. Drolet
- Division of Public Health, College of Human Medicine, Michigan State University
| | - Kelly A. Hirko
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University
| | - Louis A. Penner
- Department of Oncology, Wayne State University School of Medicine, Karmanos Cancer Institute
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28
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Luecking CT, Vaughn AE, Burney R, Hennink-Kaminski H, Hales D, Ward DS. Fidelity and factors influencing implementation of Healthy Me, Healthy: process evaluation of a social marketing campaign for diet and physical activity behaviors of children in childcare. Transl Behav Med 2021; 11:733-744. [PMID: 33538306 PMCID: PMC8034246 DOI: 10.1093/tbm/ibab001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The effectiveness of interventions targeting children's eating and physical activity behaviors through childcare settings is inconsistent. To enhance public health impact, it is imperative to evaluate fidelity of implementing complex interventions in real-world settings. This study evaluated fidelity and contextual factors influencing implementation of Healthy Me, Healthy We (HMHW). HMHW was an 8-month social marketing campaign delivered through childcare to support children's healthy eating and physical activity. HMHW required two levels of implementation support (research team and childcare providers) and two levels of campaign delivery (childcare providers and parents). Process evaluation was conducted among childcare centers in the intervention group (n=48) of the cluster-randomized control trial. Measures included attendance logs, self-report surveys, observation checklists, field notes, and semi-structured interviews. A 35-item fidelity index was created to assess fidelity of implementation support and campaign delivery. The fidelity with which HMHW was implemented by childcare providers and parents was low (mean 17.4 out of 35) and decreased between childcare providers and parents. Childcare providers had high acceptability of the program and individual components (80 - 93%). Only half of parents felt intervention components were acceptable. Frequently cited barriers to implementation by childcare providers included time constraints, parent engagement, staff turnover, and restrictive policies. The lack of observable effect of HMHW on children's dietary or physical activity behaviors may be due to inadequate implementation at multiple levels. Different or additional strategies are necessary to support implementation of multilevel interventions, particularly when individuals are expected to deliver intervention components and support others in doing so.
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Affiliation(s)
- Courtney T Luecking
- Department of Dietetics and Human Nutrition, College of Agriculture, Food and Environment, University of Kentucky, Lexington, KY, USA
| | - Amber E Vaughn
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Regan Burney
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Heidi Hennink-Kaminski
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Derek Hales
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dianne S Ward
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Shea CM. A conceptual model to guide research on the activities and effects of innovation champions. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2. [PMID: 34541541 PMCID: PMC8445003 DOI: 10.1177/2633489521990443] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The importance of having a champion to promote implementation efforts has been discussed in the literature for more than five decades. However, the empirical literature on champions remains underdeveloped. As a result, health organizations commonly use champions in their implementation efforts without the benefit of evidence to guide decisions about how to identify, prepare, and evaluate their champions. The goal of this article is to present a model of champion impact that draws upon previous literature and is intended to inform future research on champions and serve as a guide for practitioners serving in a champion role. Methods The proposed model is informed by existing literature, both conceptual and empirical. Prior studies and reviews of the literature have faced challenges in terms of operationalizing and reporting on champion characteristics, activities, and impacts. The proposed model addresses this challenge by delineating these constructs, which allows for consolidation of factors previously discussed about champions as well as new hypothesized relationships between constructs. Results The model proposes that a combination of champion commitment and champion experience and self-efficacy influence champion performance, which influences peer engagement with the champion, which ultimately influences the champion's impact. Two additional constructs have indirect effects on champion impact. Champion beliefs about the innovation and organizational support for the champion affect champion commitment. Conclusion The proposed model is intended to support prospective studies of champions by hypothesizing relationships between constructs identified in the champion literature, specifically relationships between modifiable factors that influence a champion's potential impact. Over time, the model should be modified, as appropriate, based on new findings from champion-related research.
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Affiliation(s)
- Christopher M Shea
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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30
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Jaarsma T, Strömberg A, Dunbar SB, Fitzsimons D, Lee C, Middleton S, Vellone E, Freedland KE, Riegel B. Self-care research: How to grow the evidence base? (reprint). Int J Nurs Stud 2021; 116:103903. [PMID: 33637295 DOI: 10.1016/j.ijnurstu.2021.103903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field. METHOD During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research. RESULTS In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components. CONCLUSION Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.
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Affiliation(s)
- T Jaarsma
- Department of Health, Medicine and Caring Sciences, Linkoping University, 58381 Linköping, Sweden; Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia; Julius Center, University Medical Center Utrecht, the Netherlands.
| | - A Strömberg
- Department of Health, Medicine and Caring Sciences, Linkoping University, 58381 Linköping, Sweden; Department of Cardiology, Linkoping University, Sweden
| | - S B Dunbar
- Nell Hodgson Woodruff School of Nursing, Emory University, USA
| | - D Fitzsimons
- School of Nursing & Midwifery, Queen's University Belfast, UK
| | - C Lee
- William F. Connell, School of Nursing, Boston College, USA
| | - S Middleton
- Nursing Research Institute, St Vincent's Health Australia & Australian Catholic University, Australia
| | - E Vellone
- University of Rome "Tor Vergata", Italy
| | - K E Freedland
- Department of Psychiatry, Washington University School of Medicine, USA
| | - B Riegel
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia; School of Nursing, University of Pennsylvania, USA
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31
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Understanding the link between health systems and cancer survival: A novel methodological approach using a system-level conceptual model. J Cancer Policy 2020. [DOI: 10.1016/j.jcpo.2020.100233] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Hasson H, Leviton L, von Thiele Schwarz U. A typology of useful evidence: approaches to increase the practical value of intervention research. BMC Med Res Methodol 2020; 20:133. [PMID: 32460833 PMCID: PMC7254642 DOI: 10.1186/s12874-020-00992-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 04/26/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Too often, studies of evidence-based interventions (EBIs) in preventive, community, and health care are not sufficiently useful to end users (typically practitioners, patients, policymakers, or other researchers). The ways in which intervention studies are conventionally conducted and reported mean that there is often a shortage of information when an EBI is used in practice. The paper aims to invite the research community to consider ways to optimize not only the trustworthiness but also the research's usefulness in intervention studies. This is done by proposing a typology that provides some approaches to useful EBIs for intervention researchers. The approaches originate from different research fields and are summarized to highlight their potential benefits from a usefulness perspective. MAIN MESSAGE The typology consists of research approaches to increase the usefulness of EBIs by improving the reporting of four features in intervention studies: (1) the interventions themselves, including core components and appropriate adaptations; (2) strategies to support-high-quality implementation of the interventions; (3) generalizations about the evidence in a variety of contexts; and (4) outcomes based on end users' preferences and knowledge. The research approaches fall into three levels: Description, Analysis, and Design. The first level, Description, outlines what types of information about the intervention and its implementation, context, and outcomes can be helpful for end users. Research approaches under analysis offers alternative ways of analyzing data, increasing the precision of information provided to end users. Approaches summarized under design involve more radical changes and far-reaching implications for how research can provide more useful information. These approaches partly flip the order of efficacy and effectiveness, focusing not on whether an intervention works in highly controlled and optimal circumstances, but first and foremost whether an intervention can be implemented and lead to anticipated outcomes in everyday practice. CONCLUSIONS The research community, as well as the end users of research, are invited to consider ways to optimize research's usefulness as well as its trustworthiness. Many of the research approaches in the typology are not new, and their contributions to quality have been described for generations - but their contributions to useful knowledge need more attention.
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Affiliation(s)
- Henna Hasson
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
- Unit for Implementation and Evaluation, Centre for Epidemiology and Community Medicine (CES), Stockholm County Council, SE 171 29, Stockholm, Sweden.
| | | | - Ulrica von Thiele Schwarz
- Procome research group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Mälardalen, Sweden
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Riordan F, Racine E, Phillip ET, Bradley C, Lorencatto F, Murphy M, Murphy A, Browne J, Smith SM, Kearney PM, McHugh SM. Development of an intervention to facilitate implementation and uptake of diabetic retinopathy screening. Implement Sci 2020; 15:34. [PMID: 32429983 PMCID: PMC7236930 DOI: 10.1186/s13012-020-00982-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND 'Implementation interventions' refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence. METHODS First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention 'fit' with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness. RESULTS We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients. CONCLUSIONS Using the example of an intervention to improve DRS uptake, this study illustrates an approach to integrate theory with user involvement. This process highlighted tensions between theory-informed and stakeholder suggestions, and the need to apply the Theoretical Domains Framework (TDF)/BCT structure flexibly. The final intervention draws on the trusted professional-patient relationship, leveraging existing services to enhance implementation of the DRS programme. Intervention feasibility in primary care will be evaluated in a randomised cluster pilot trial.
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Affiliation(s)
- Fiona Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland.
| | - Emmy Racine
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Eunice T Phillip
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Colin Bradley
- Department of General Practice, University College Cork, Cork, Ireland
| | | | - Mark Murphy
- Department of General Practice, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Aileen Murphy
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Susan M Smith
- Department of General Practice, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Patricia M Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Sheena M McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
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Riordan F, Racine E, Smith SM, Murphy A, Browne J, Kearney PM, Bradley C, James M, Murphy M, McHugh SM. Feasibility of an implementation intervention to increase attendance at diabetic retinopathy screening: protocol for a cluster randomised pilot trial. Pilot Feasibility Stud 2020; 6:64. [PMID: 32426158 PMCID: PMC7216495 DOI: 10.1186/s40814-020-00608-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/23/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diabetic retinopathy screening (DRS) leads to the earlier detection of retinopathy and treatment that can prevent or delay the development of diabetes-related blindness. However, uptake continues to be sub-optimal in many countries, including Ireland. Routine management of type 2 diabetes largely takes place in primary care. As such, there may be an opportunity in primary care to introduce interventions to improve DRS uptake. However, few studies test the feasibility of interventions to enhance DRS uptake in this context. Our aim is to investigate the feasibility of an implementation intervention (IDEAs (Improving Diabetes Eye screening Attendance)) delivered in general practice to improve the uptake of the national DRS programme, RetinaScreen. METHODS The IDEAs study is a cluster randomised pilot trial with an embedded process evaluation and economic evaluation. Following stratification by practice size, eight general practices (clusters) will be randomly allocated to intervention (n = 4) or wait-list control groups (n = 4). The intervention will be delivered for 6 months, after which, it will be administered to wait-list control practices. The intervention is multi-faceted and comprises provider-level components (training, audit and feedback, health care professional prompt, reimbursement) and patient-level components (GP-endorsed reminder with information leaflet delivered opportunistically face-to-face, and systematically by phone and letter). Patient inclusion criteria are type 1 or type 2 diabetes and DRS programme non-attendance. A multi-method approach will be used to determine screening uptake, evaluate the trial and study procedures and examine the acceptability and feasibility of the intervention from staff and patient perspectives. Quantitative and qualitative data will be collected on intervention uptake and delivery, research processes and outcomes. Data will be collected at the practice, health professional and patient level. A partial economic evaluation will be conducted to estimate the cost of delivering the implementation intervention in general practice. Formal continuation criteria will be used to determine whether IDEAs should progress to a definitive trial. DISCUSSION Findings will determine whether IDEAsis feasible and acceptable and will be used to refine the intervention and study procedures. A definitive trial will determine whether IDEAs is a cost-effective intervention to improve DRS uptake and reduce diabetes-related blindness. TRIAL REGISTRATION ClinicalTrials.gov NCT03901898. Registered 3rd April 2019.
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Affiliation(s)
- Fiona Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Emmy Racine
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Susan M. Smith
- Department of General Practice, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Aileen Murphy
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Patricia M. Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - Colin Bradley
- Department of General Practice, University College Cork, Cork, Ireland
| | - Mark James
- Medical Education Unit, University College Cork, Cork, Ireland
| | - Mark Murphy
- Department of General Practice, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Sheena M. McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
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Strategy Configurations Directly Linked to Higher Hepatitis C Virus Treatment Starts: An Applied Use of Configurational Comparative Methods. Med Care 2020; 58:e31-e38. [PMID: 32187105 DOI: 10.1097/mlr.0000000000001319] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus (HCV) than any other US health care system. We tracked the implementation strategies that VA sites used to implement highly effective new treatments for HCV with the aim of uncovering how combinations of implementation strategies influenced the uptake of the HCV treatment innovation. We applied Configurational Comparative Methods (CCMs) to uncover causal dependencies and identify difference-making strategy configurations, and to distinguish higher from lower HCV treating sites. METHODS We surveyed providers to assess VA sites' use of 73 implementation strategies to promote HCV treatment in the fiscal year 2015. CCMs were used to identify strategy configurations that uniquely distinguished higher HCV from lower HCV treating sites. RESULTS From the 73 possible implementation strategies, CCMs identified 5 distinct strategy configurations, or "solution paths." These were comprised of 10 individual strategies that collectively explained 80% of the sites with higher HCV treatment starts with 100% consistency. Using any one of the following 5 solution paths was sufficient to produce higher treatment starts: (1) technical assistance; (2) engaging in a learning collaborative AND designating leaders; (3) site visits AND outreach to patients to promote uptake and adherence; (4) developing resource sharing agreements AND an implementation blueprint; OR (5) creating new clinical teams AND sharing quality improvement knowledge with other sites AND engaging patients. There was equifinality in that the presence of any one of the 5 solution paths was sufficient for higher treatment starts. CONCLUSIONS Five strategy configurations distinguished higher HCV from lower HCV treating sites with 100% consistency. CCMs represent a methodological advancement that can help inform high-yield implementation strategy selection and increase the efficiency and effectiveness of future implementation efforts.
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Self-care research: How to grow the evidence base? Int J Nurs Stud 2020; 105:103555. [DOI: 10.1016/j.ijnurstu.2020.103555] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
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A systematic review of empirical studies examining mechanisms of implementation in health. Implement Sci 2020. [PMID: 32299461 DOI: 10.1186/s13012‐020‐00983‐3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding the mechanisms of implementation strategies (i.e., the processes by which strategies produce desired effects) is important for research to understand why a strategy did or did not achieve its intended effect, and it is important for practice to ensure strategies are designed and selected to directly target determinants or barriers. This study is a systematic review to characterize how mechanisms are conceptualized and measured, how they are studied and evaluated, and how much evidence exists for specific mechanisms. METHODS We systematically searched PubMed and CINAHL Plus for implementation studies published between January 1990 and August 2018 that included the terms "mechanism," "mediator," or "moderator." Two authors independently reviewed title and abstracts and then full texts for fit with our inclusion criteria of empirical studies of implementation in health care contexts. Authors extracted data regarding general study information, methods, results, and study design and mechanisms-specific information. Authors used the Mixed Methods Appraisal Tool to assess study quality. RESULTS Search strategies produced 2277 articles, of which 183 were included for full text review. From these we included for data extraction 39 articles plus an additional seven articles were hand-entered from only other review of implementation mechanisms (total = 46 included articles). Most included studies employed quantitative methods (73.9%), while 10.9% were qualitative and 15.2% were mixed methods. Nine unique versions of models testing mechanisms emerged. Fifty-three percent of the studies met half or fewer of the quality indicators. The majority of studies (84.8%) only met three or fewer of the seven criteria stipulated for establishing mechanisms. CONCLUSIONS Researchers have undertaken a multitude of approaches to pursue mechanistic implementation research, but our review revealed substantive conceptual, methodological, and measurement issues that must be addressed in order to advance this critical research agenda. To move the field forward, there is need for greater precision to achieve conceptual clarity, attempts to generate testable hypotheses about how and why variables are related, and use of concrete behavioral indicators of proximal outcomes in the case of quantitative research and more directed inquiry in the case of qualitative research.
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Lewis CC, Boyd MR, Walsh-Bailey C, Lyon AR, Beidas R, Mittman B, Aarons GA, Weiner BJ, Chambers DA. A systematic review of empirical studies examining mechanisms of implementation in health. Implement Sci 2020; 15:21. [PMID: 32299461 PMCID: PMC7164241 DOI: 10.1186/s13012-020-00983-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/12/2020] [Indexed: 11/15/2022] Open
Abstract
Background Understanding the mechanisms of implementation strategies (i.e., the processes by which strategies produce desired effects) is important for research to understand why a strategy did or did not achieve its intended effect, and it is important for practice to ensure strategies are designed and selected to directly target determinants or barriers. This study is a systematic review to characterize how mechanisms are conceptualized and measured, how they are studied and evaluated, and how much evidence exists for specific mechanisms. Methods We systematically searched PubMed and CINAHL Plus for implementation studies published between January 1990 and August 2018 that included the terms “mechanism,” “mediator,” or “moderator.” Two authors independently reviewed title and abstracts and then full texts for fit with our inclusion criteria of empirical studies of implementation in health care contexts. Authors extracted data regarding general study information, methods, results, and study design and mechanisms-specific information. Authors used the Mixed Methods Appraisal Tool to assess study quality. Results Search strategies produced 2277 articles, of which 183 were included for full text review. From these we included for data extraction 39 articles plus an additional seven articles were hand-entered from only other review of implementation mechanisms (total = 46 included articles). Most included studies employed quantitative methods (73.9%), while 10.9% were qualitative and 15.2% were mixed methods. Nine unique versions of models testing mechanisms emerged. Fifty-three percent of the studies met half or fewer of the quality indicators. The majority of studies (84.8%) only met three or fewer of the seven criteria stipulated for establishing mechanisms. Conclusions Researchers have undertaken a multitude of approaches to pursue mechanistic implementation research, but our review revealed substantive conceptual, methodological, and measurement issues that must be addressed in order to advance this critical research agenda. To move the field forward, there is need for greater precision to achieve conceptual clarity, attempts to generate testable hypotheses about how and why variables are related, and use of concrete behavioral indicators of proximal outcomes in the case of quantitative research and more directed inquiry in the case of qualitative research.
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Affiliation(s)
- Cara C Lewis
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA. .,Department of Psychological and Brain Sciences, Indiana University, 1101 E 10th Street, Bloomington, IN, 47405, USA. .,Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, 1959 NE Pacific Avenue, Seattle, WA, 98195, USA.
| | - Meredith R Boyd
- Department of Psychology, University of California Los Angeles, 1177 Franz Hall, 502 Portola Plaza, Los Angeles, CA, 90095, USA
| | - Callie Walsh-Bailey
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.,Brown School, Washington University in St. Louis, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Aaron R Lyon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, 1959 NE Pacific Avenue, Seattle, WA, 98195, USA
| | - Rinad Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - Brian Mittman
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles Avenue, Pasadena, CA, 91101, USA
| | - Gregory A Aarons
- Department of Psychiatry, School of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Bryan J Weiner
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - David A Chambers
- Division of Cancer Control and Population Science, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
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Harrison MI, Shortell SM. Multi-level analysis of the learning health system: Integrating contributions from research on organizations and implementation. Learn Health Syst 2020; 5:e10226. [PMID: 33889735 PMCID: PMC8051352 DOI: 10.1002/lrh2.10226] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/11/2020] [Accepted: 03/08/2020] [Indexed: 11/08/2022] Open
Abstract
Introduction Organizations and systems that deliver health care may better adapt to rapid change in their environments by acting as learning organizations and learning health systems (LHSs). Despite widespread recognition that multilevel forces shape capacity for learning within care delivery organizations, there is no agreed-on, comprehensive, multilevel framework to inform LHS research and practice. Methods We develop such a framework, which can enhance both research on LHSs and practical steps toward their development. We draw on existing frameworks and research within organization and implementation science and synthesize contributions from three influential frameworks: the Consolidated Framework for Implementation Research, the social-ecological framework, and the organizational change framework. These frameworks come, respectively, from the fields of implementation science, public health, and organization science. Results Our proposed integrative framework includes both intraorganizational levels (individual, team, mid-management, organization) and the operating and general environments in which delivery organizations operate. We stress the importance of examining interactions among influential factors both within and across system levels and focus on the effects of leadership, incentives, and culture. Additionally, we indicate that organizational learning depends substantially on internal and cross-level alignment of these factors. We illustrate the contribution of our multilevel perspective by applying it to the analysis of three diverse implementation initiatives that aimed at specific care improvements and enduring system learning. Conclusions The framework and perspective developed here can help investigators and practitioners broadly scan and then investigate forces influencing improvement and learning and may point to otherwise unnoticed interactions among influential factors. The framework can also be used as a planning tool by managers and practitioners.
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Affiliation(s)
- Michael I Harrison
- Senior Social Scientist Agency for Healthcare Research and Quality Rockville Maryland USA
| | - Stephen M Shortell
- Professor of the Graduate School, Blue Cross of California Distinguished Professor of Health Policy and Management, Emeritus; Professor of Organization Behavior, Emeritus School of Public Health and Haas School of Business, University of California - Berkeley Berkeley California USA
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Carandang RR, Shibanuma A, Kiriya J, Vardeleon KR, Asis E, Murayama H, Jimba M. Effectiveness of peer counseling, social engagement, and combination interventions in improving depressive symptoms of community-dwelling Filipino senior citizens. PLoS One 2020; 15:e0230770. [PMID: 32236104 PMCID: PMC7112231 DOI: 10.1371/journal.pone.0230770] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 03/06/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Little is known about community-based interventions for geriatric depression in low-resource settings. This study assessed the effectiveness of 3-month-duration interventions with peer counseling, social engagement, and combination vs. control in improving depressive symptoms of community-dwelling Filipino senior citizens. METHODS We conducted an open (non-blinded), non-randomized trial of senior citizens at risk for depression. Three different 3-month interventions included peer counseling (n = 65), social engagement (n = 66), and combination (n = 65) were compared with the control group (n = 68). We assessed geriatric depression, psychological resilience, perceived social support, loneliness, and working alliance scores at baseline and three months after the intervention. This trial was registered with ClinicalTrials.gov, identifier: NCT03989284. RESULTS Geriatric depression score over three months significantly improved in all intervention groups (control as reference). Significant improvements were also seen in psychological resilience and social support. Not all interventions, however, significantly improved the loneliness score. The combination group showed the largest effect of improving depressive symptoms (d = -1.33) whereas the social engagement group showed the largest effect of improving psychological resilience (d = 1.40), perceived social support (d = 1.07), and loneliness (d = -0.36) among senior citizens. CONCLUSION At the community level, peer counseling, social engagement, and combination interventions were effective in improving depressive symptoms, psychological resilience, and social support among Filipino senior citizens. This study shows that it is feasible to identify senior citizens at risk for depression in the community and intervene effectively to improve their mental health. Further studies are required to target loneliness and investigate the long-term benefits of the interventions. CLINICAL TRIAL ClinicalTrials.gov: NCT03989284.
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Affiliation(s)
- Rogie Royce Carandang
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Institute of Gerontology, The University of Tokyo, Tokyo, Japan
| | - Akira Shibanuma
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Kiriya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Edward Asis
- Department of Global Studies, Faculty of Liberal Arts, Sophia University, Tokyo, Japan
| | | | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Powell BJ, Haley AD, Patel SV, Amaya-Jackson L, Glienke B, Blythe M, Lengnick-Hall R, McCrary S, Beidas RS, Lewis CC, Aarons GA, Wells KB, Saldana L, McKay MM, Weinberger M. Improving the implementation and sustainment of evidence-based practices in community mental health organizations: a study protocol for a matched-pair cluster randomized pilot study of the Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS). Implement Sci Commun 2020; 1. [PMID: 32391524 PMCID: PMC7207049 DOI: 10.1186/s43058-020-00009-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Implementing and sustaining evidence-based programs with fidelity may require multiple implementation strategies tailored to address multi-level, context-specific barriers and facilitators. Ideally, selecting and tailoring implementation strategies should be guided by theory, evidence, and input from relevant stakeholders; however, methods to guide the selection and tailoring of strategies are not well-developed. There is a need for more rigorous methods for assessing and prioritizing implementation determinants (barriers and facilitators) and linking implementation strategies to determinants. The Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS) is an intervention designed to increase the effectiveness of evidence-based practice implementation and sustainment. COAST-IS will enable organizational leaders and clinicians to use Intervention Mapping to select and tailor implementation strategies to address their site-specific needs. Intervention Mapping is a multi-step process that incorporates theory, evidence, and stakeholder perspectives to ensure that implementation strategies effectively address key determinants of change. Methods COAST-IS will be piloted with community mental health organizations that are working to address the needs of children and youth who experience trauma-related emotional or behavioral difficulties by engaging in a learning collaborative to implement an evidence-based psychosocial intervention (trauma-focused cognitive behavioral therapy). Organizations will be matched and then randomized to participate in the learning collaborative only (control) or to receive additional support through COAST-IS. The primary aims of this study are to (1) assess the acceptability, appropriateness, feasibility, and perceived utility of COAST-IS; (2) evaluate the organizational stakeholders' fidelity to the core elements of COAST-IS; and (3) demonstrate the feasibility of testing COAST-IS in a larger effectiveness trial. Discussion COAST-IS is a systematic method that integrates theory, evidence, and stakeholder perspectives to improve the effectiveness and precision of implementation strategies. If effective, COAST-IS has the potential to improve the implementation and sustainment of a wide range of evidence-based practices in mental health and other sectors. Trial registration This study was registered in ClinicalTrials.gov (NCT03799432) on January 10, 2019 (last updated August 5, 2019).
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Affiliation(s)
- Byron J Powell
- Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130, USA.,Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amber D Haley
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sheila V Patel
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lisa Amaya-Jackson
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.,National Center for Child Traumatic Stress, Durham, NC, USA.,North Carolina Child Treatment Program, Center for Child and Family Health, Durham, NC, USA
| | - Beverly Glienke
- North Carolina Child Treatment Program, Center for Child and Family Health, Durham, NC, USA
| | - Mellicent Blythe
- North Carolina Child Treatment Program, Center for Child and Family Health, Durham, NC, USA.,School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca Lengnick-Hall
- Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130, USA
| | - Stacey McCrary
- Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130, USA
| | - Rinad S Beidas
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA
| | - Cara C Lewis
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Gregory A Aarons
- Department of Psychiatry, Child and Adolescent Services Research Center, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Kenneth B Wells
- Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.,The Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Mary M McKay
- Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Yang Y. A narrative review of the use of agent-based modeling in health behavior and behavior intervention. Transl Behav Med 2019; 9:1065-1075. [PMID: 30649559 DOI: 10.1093/tbm/iby132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Studies of health behaviors and behavior intervention have begun to explore the potential of agent-based modeling (ABM). A review of how ABMs have been used in health behavior, behavior intervention, and corresponding insights is warranted. The goal of this study was to provide a narrative review of the applications of ABMs in health behavior change and intervention. I will focus on two perspectives: (a) the mechanism of behavior and behavior change and (b) ABMs' use for behavior intervention. I identified and reviewed 17 ABMs applied to behaviors including physical activity, diet, alcoholic drinking, smoking, and drug use. Among these ABMs, I grouped their mechanisms of behavior change into four categories and evaluated the advantages and disadvantages of each mechanism. For behavior intervention, I evaluated the use of ABMs on levels of individual, interpersonal, and neighborhood environment. Various behavior change mechanisms and simplifications existed because of our limited knowledge of behaviors at the individual level. Utility maximization was the most frequently used mechanism. ABMs offered insights for behavior intervention including the benefits of upstream interventions and multilevel intervention, as well as balances among various factors, outcomes, and populations. ABMs have been used to model a diversity of behaviors, populations, and interventions. The use of ABMs in health behavior is at an early stage, and a major challenge is our limited knowledge of behaviors at the individual level.
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Affiliation(s)
- Yong Yang
- Division of Social and Behavioral Sciences, School of Public Health, University of Memphis, Memphis, TN, USA
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Risk J, Mohammadi L, Rhee J, Walters L, Ward PR. Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis. BMJ Open 2019; 9:e030275. [PMID: 31537570 PMCID: PMC6756326 DOI: 10.1136/bmjopen-2019-030275] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice? DESIGN A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting. SETTING Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews. RESULTS The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging. CONCLUSION Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice. PROSPERO REGISTRATION NUMBER CRD42018088838.
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Affiliation(s)
- Jo Risk
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Leila Mohammadi
- Library, Flinders University, Adelaide, South Australia, Australia
| | - Joel Rhee
- General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Lucie Walters
- Rural Health, Flinders University, Adelaide, South Australia, Australia
| | - Paul R Ward
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Waltz TJ, Powell BJ, Fernández ME, Abadie B, Damschroder LJ. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci 2019. [PMID: 31036028 DOI: 10.1186/s13012‐019‐0892‐4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers. METHODS Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices. RESULTS Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD = 4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants. CONCLUSIONS The wide heterogeneity of endorsements obtained in this study's task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study's results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.
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Affiliation(s)
- Thomas J Waltz
- Eastern Michigan University, Ypsilanti, USA.,Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA
| | - Byron J Powell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - María E Fernández
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, USA
| | | | - Laura J Damschroder
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA.
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45
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Waltz TJ, Powell BJ, Fernández ME, Abadie B, Damschroder LJ. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci 2019; 14:42. [PMID: 31036028 PMCID: PMC6489173 DOI: 10.1186/s13012-019-0892-4] [Citation(s) in RCA: 365] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/12/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers. METHODS Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices. RESULTS Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD = 4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants. CONCLUSIONS The wide heterogeneity of endorsements obtained in this study's task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study's results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.
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Affiliation(s)
- Thomas J Waltz
- Eastern Michigan University, Ypsilanti, USA
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA
| | - Byron J Powell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - María E Fernández
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, USA
| | | | - Laura J Damschroder
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA.
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46
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Leppin AL, Boehmer KR, Branda ME, Shah ND, Hargraves I, Dick S, Elwyn G, Ting HH, Ye S, Gilles R, Abbas M, Alexander A, Montori VM. Developing a toolkit to implement the Statin Choice Conversation Aid at scale: application of a work reduction model. BMC Health Serv Res 2019; 19:249. [PMID: 31018840 PMCID: PMC6480421 DOI: 10.1186/s12913-019-4055-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/31/2019] [Indexed: 11/26/2022] Open
Abstract
Background Guidelines recommend shared decision making (SDM) for determining whether to use statins to prevent cardiovascular events in at-risk patients. We sought to develop a toolkit to facilitate the cross-organizational spread and scale of a SDM intervention called the Statin Choice Conversation Aid (SCCA) by (i) assessing the work stakeholders must do to implement the tool; and (ii) orienting the resulting toolkit’s components to communicate and mitigate this work. Methods We conducted multi-level and mixed methods (survey, interview, observation, focus group) characterizations of the contexts of 3 health systems (n = 86, 84, and 26 primary care clinicians) as they pertained to the impending implementation of the SCCA. We merged the data within implementation outcome domains of feasibility, appropriateness, and acceptability. Using Normalization Process Theory, we then characterized and categorized the work stakeholders did to implement the tool. We used clinician surveys and IP address-based tracking to calculate SCCA usage over time and judged how stakeholder effort was allocated to influence outcomes at 6 and 18 months. After assessing the types and impact of the work, we developed a multi-component toolkit. Results At baseline, the three contexts differed regarding feasibility, acceptability, and appropriateness of implementation. The work of adopting the tool was allocated across many strategies in complex and interdependent ways to optimize these domains. The two systems that allocated the work strategically had higher uptake (5.2 and 2.9 vs. 1.1 uses per clinician per month at 6 months; 3.8 and 2.1 vs. 0.4 at 18 months, respectively) than the system that did not. The resulting toolkit included context self-assessments intended to guide stakeholders in considering the early work of SCCA implementation; and webinars, EMR integration guides, video demonstrations, and an implementation team manual aimed at supporting this work. Conclusions We developed a multi-component toolkit for facilitating the scale-up and spread of a tool to promote SDM across clinical settings. The theory-based approach we employed aimed to distinguish systems primed for adoption and support the work they must do to achieve implementation. Our approach may have value in orienting the development of multi-component toolkits and other strategies aimed at facilitating the efficient scale up of interventions. Trial registration ClinicalTrials.govNCT02375815. Electronic supplementary material The online version of this article (10.1186/s12913-019-4055-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aaron L Leppin
- Division of Health Care Policy and Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Megan E Branda
- Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ian Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sara Dick
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Level 5, Williamson Translational Research Building, 1 Medical Center Drive, Labanon, NH, 03756, USA
| | - Henry H Ting
- Department of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - Siqin Ye
- Department of Medicine, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10033, USA
| | - Ryan Gilles
- Department of Family Medicine, Kootenai Health, 2003 Kootenai Health Way, Coeur d'Alene, ID, 83814, USA
| | - Marghoob Abbas
- Mosaic Life Care, 5325 Faraon Street, St. Joseph, MO, 64506, USA
| | - Alex Alexander
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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47
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Hall KL, Oh A, Perez LG, Rice EL, Patel M, Czajkowski S, Klesges L. The ecology of multilevel intervention research. Transl Behav Med 2019; 8:968-978. [PMID: 30428073 DOI: 10.1093/tbm/iby102] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Behavior change research to promote health and prevent disease increasingly relies on a complex set of interacting characteristics across levels of influence such as biological, psychological, behavioral, interpersonal, and environmental. How to best develop health-related interventions that incorporate the individual, the macro-environment, and their interactions remains a challenge. This article considers a set of key dimensions that constitute what we refer to as the ecology of research across a broad context of multilevel research (MLR), spanning fundamental multilevel research (FMLR), multilevel intervention research (MLIR), and multilevel implementation science (MIS). With the goal of promoting improvements in MLIR, we describe the inherent interdependencies among aspects of research and consider how the growth and development of evidence and resources influence the cross-talk among researchers from different perspectives (e.g., disciplines and domains). We propose a framework that highlights opportunities to reduce barriers and address gaps in areas critical to generating an evidence base through MLR, MLIR, and MIS. Overall, we aim to support strategic decisions that can accelerate our understanding of ML health outcomes and interactions among factors within and across levels, with the goal of strengthening the effectiveness of ML interventions across health-related outcomes.
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Affiliation(s)
- Kara L Hall
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - April Oh
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Lilian G Perez
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Elise L Rice
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Minal Patel
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Susan Czajkowski
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Lisa Klesges
- Division of Epidemiology, Biostatistics and Environmental Health, University of Memphis, Memphis, TN, USA
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48
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Data-Powered Participatory Decision Making: Leveraging Systems Thinking and Simulation to Guide Selection and Implementation of Evidence-Based Colorectal Cancer Screening Interventions. ACTA ACUST UNITED AC 2019; 24:136-143. [PMID: 29794539 DOI: 10.1097/ppo.0000000000000317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
A robust evidence base supports the effectiveness of timely colorectal cancer (CRC) screening, follow-up of abnormal results, and referral to care in reducing CRC morbidity and mortality. However, only two-thirds of the US population is current with recommended screening, and rates are much lower for those who are vulnerable because of their race/ethnicity, insurance status, or rural location. Multiple, multilevel factors contribute to observed disparities, and these factors vary across different populations and contexts. As highlighted by the Cancer Moonshot Blue Ribbon Panel working groups focused on Prevention and Early Detection and Implementation Science inadequate CRC screening and follow-up represent an enormous missed opportunity in cancer prevention and control. To measurably reduce CRC morbidity and mortality, the evidence base must be strengthened to guide the identification of (1) multilevel factors that influence screening across different populations and contexts, (2) multilevel interventions and implementation strategies that will be most effective at targeting those factors, and (3) combinations of strategies that interact synergistically to improve outcomes. Systems thinking and simulation modeling (systems science) provide a set of approaches and techniques to aid decision makers in using the best available data and research evidence to guide implementation planning in the context of such complexity. This commentary summarizes current challenges in CRC prevention and control, discusses the status of the evidence base to guide the selection and implementation of multilevel CRC screening interventions, and describes a multi-institution project to showcase how systems science can be leveraged to optimize selection and implementation of CRC screening interventions in diverse populations and contexts.
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Ma J, Lewis MA, Smyth JM. Translational behavioral medicine for population and individual health: gaps, opportunities, and vision for practice-based translational behavior change research. Transl Behav Med 2019; 8:753-760. [PMID: 29669065 DOI: 10.1093/tbm/ibx032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In this commentary, we propose a vision for "practice-based translational behavior change research," which we define as clinical and public health practice-embedded research on the implementation, optimization, and fundamental mechanisms of behavioral interventions. This vision intends to be inclusive of important research elements for behavioral intervention development, testing, and implementation. We discuss important research gaps and conceptual and methodological advances in three key areas along the discovery (development) to delivery (implementation) continuum of evidence-based interventions to improve behavior and health that could help achieve our vision of practice-based translational behavior change research. We expect our proposed vision to be refined and evolve over time. Through highlighting critical gaps that can be addressed by integrating modern theoretical and methodological approaches across disciplines in behavioral medicine, we hope to inspire the development and funding of innovative research on more potent and implementable behavior change interventions for optimal population and individual health.
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Affiliation(s)
- Jun Ma
- Department of Health Policy and Administration, Institute for Health Research and Policy, University of Illinois at Chicago, IL, USA
| | | | - Joshua M Smyth
- Department of Biobehavioral Health and Medicine, the Pennsylvania State University, PA, USA
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50
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Daley EM, Vamos CA, Thompson E, Vázquez-Otero C, Griner SB, Merrell L, Kline N, Walker K, Driscoll A, Petrila J. The Role of Dental Providers in Preventing HPV-Related Diseases: A Systems Perspective. J Dent Educ 2019; 83:161-172. [PMID: 30709991 DOI: 10.21815/jde.019.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/08/2018] [Indexed: 01/22/2023]
Abstract
Successfully educating dental providers and patients about the link between human papillomavirus (HPV) and oropharyngeal cancer requires coordinated efforts to increase HPV-related prevention practices. The aim of this study was to identify, using a systems perspective, the multi-level determinants related to how dental providers can promote HPV prevention in dental practices. Data for this qualitative study were collected in 2015-16 from focus groups with dentists (four focus groups, n=33), focus groups with dental hygienists (four focus groups, n=48), and in-depth interviews with dental opinion leaders (n=13). Results were triangulated and mapped along micro, meso, and macro system levels. At the micro level, participants identified patient characteristics and low self-efficacy as influential determinants when discussing HPV prevention. At the meso level, relationships among dentists, dental hygienists, and the physical practice environment were factors affecting dental providers' HPV prevention efforts. At the macro level, professional organizations impacted how dental providers interacted with their patients on this topic. These results suggest that improving HPV prevention among dental providers requires a multi-level approach that considers the distinctive context of dental settings, dental training, and perceptions of professional roles. The findings suggested that the macro- and meso-level determinants may be challenging to modify due to the distinctive culture and practice models of dentistry. Nevertheless, the association between HPV and oral cancer requires an expansion of prevention strategies used in dental practices. Improving dental providers' self-efficacy to communicate HPV prevention through continuing education and integration of skill-guided training in dental and dental hygiene curricula could facilitate this process.
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Affiliation(s)
- Ellen M Daley
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX.
| | - Cheryl A Vamos
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - Erika Thompson
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - Coralia Vázquez-Otero
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - Stacey B Griner
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - Laura Merrell
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - Nolan Kline
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - Kimberly Walker
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - Annelise Driscoll
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
| | - John Petrila
- Ellen M. Daley is Professor, Department of Community and Family Health, and Associate Dean of Research and Practice, College of Public Health, University of South Florida; Cheryl A. Vamos is Assistant Professor, Department of Community and Family Health, College of Public Health, University of South Florida; Erika Thompson is Assistant Professor, Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center; Coralia Vázquez-Otero is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Stacey B. Griner is a doctoral research assistant, Department of Community and Family Health, College of Public Health, University of South Florida; Laura Merrell is Assistant Professor, Department of Health Sciences, James Madison University; Nolan Kline is Assistant Professor, Department of Anthropology, Rollins College; Kimberly Walker is Assistant Professor, Zimmerman School of Advertising & Mass Communications, University of South Florida; Annelise Driscoll is Clinical Assistant Professor, Restorative Dental Sciences, College of Dentistry, University of Florida; and John Petrila is Vice President of Adult Policy, Meadows Mental Health Policy Institute, Dallas, TX
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