Is Theory Guiding Our Work? A Scoping Review on the Use of Implementation Theories, Frameworks, and Models to Bring Community Health Workers into Health Care Settings

Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association

Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.

Stakeholders' perception of factors influencing adoption of a pediatric weight management intervention: a qualitative study

Background

Childhood obesity is highly prevalent in the United States and disproportionately impacts communities of color and low-income populations; these disparities have worsened during the COVID-19 pandemic. Adoption of effective pediatric weight management interventions (PWMIs) that have been evaluated among low-income diverse populations is needed. The Healthy Weight Clinic PWMI, a package co-developed by the American Academy of Pediatrics and Massachusetts General Hospital, helps health centers establish multidisciplinary Healthy Weight Clinics based on previous randomized controlled trials which demonstrated effectiveness. We sought to identify the factors influencing successful adoption of this PWMI and understand adaptations needed prior to implementation in new sites.

Methods

We interviewed 20 stakeholders, 10 from two health centers in Mississippi where the Healthy Weight Clinic PWMI will be piloted (pre-implementation sites) and 10 from health centers that have previously implemented it (sites in maintenance stages). Separate interview guides informed by the Consolidated Framework for Implementation Research (CFIR) were developed for the pre-implementation sites and those in maintenance stages, including questions related to adaptations of the PWMI in response to the COVID-19 pandemic. Qualitative data analysis was conducted using directed content analysis based on CFIR constructs. Adaptations in response to the pandemic were categorized using Framework for Reporting Adaptations and Modifications-Expanded (FRAME).

Results

In pre-implementation sites, an inner setting facilitator mentioned was a positive learning climate. Characteristics of individuals that can facilitate adoption include staff willingness to learn, valuing evidence-based care for childhood obesity, and culturally and weight-sensitive staff. In terms of patient needs and resources (outer setting), social drivers of health are barriers to adoption, but creative solutions were suggested to mitigate these. Other facilitators related to the intervention included its multidisciplinary model and adaptability. Similar themes were elicited from sites in maintenance stages; adaptations brought on by the pandemic, such as telehealth visits and content modification to align with distancing guidelines and the effects of social isolation were also described.

Conclusion

Understanding the factors influencing adoption of an evidence-based PWMI informs necessary adaptations and implementation strategies required to facilitate nationwide dissemination of PWMIs, with the goal of reaching the populations most at-risk.

Evaluating the translation of implementation science to clinical artificial intelligence: a bibliometric study of qualitative research

Introduction

Whilst a theoretical basis for implementation research is seen as advantageous, there is little clarity over if and how the application of theories, models or frameworks (TMF) impact implementation outcomes. Clinical artificial intelligence (AI) continues to receive multi-stakeholder interest and investment, yet a significant implementation gap remains. This bibliometric study aims to measure and characterize TMF application in qualitative clinical AI research to identify opportunities to improve research practice and its impact on clinical AI implementation.

Methods

Qualitative research of stakeholder perspectives on clinical AI published between January 2014 and October 2022 was systematically identified. Eligible studies were characterized by their publication type, clinical and geographical context, type of clinical AI studied, data collection method, participants and application of any TMF. Each TMF applied by eligible studies, its justification and mode of application was characterized.

Results

Of 202 eligible studies, 70 (34.7%) applied a TMF. There was an 8-fold increase in the number of publications between 2014 and 2022 but no significant increase in the proportion applying TMFs. Of the 50 TMFs applied, 40 (80%) were only applied once, with the Technology Acceptance Model applied most frequently (n = 9). Seven TMFs were novel contributions embedded within an eligible study. A minority of studies justified TMF application (n = 51,58.6%) and it was uncommon to discuss an alternative TMF or the limitations of the one selected (n = 11,12.6%). The most common way in which a TMF was applied in eligible studies was data analysis (n = 44,50.6%). Implementation guidelines or tools were explicitly referenced by 2 reports (1.0%).

Conclusion

TMFs have not been commonly applied in qualitative research of clinical AI. When TMFs have been applied there has been (i) little consensus on TMF selection (ii) limited description of selection rationale and (iii) lack of clarity over how TMFs inform research. We consider this to represent an opportunity to improve implementation science's translation to clinical AI research and clinical AI into practice by promoting the rigor and frequency of TMF application. We recommend that the finite resources of the implementation science community are diverted toward increasing accessibility and engagement with theory informed practices. The considered application of theories, models and frameworks (TMF) are thought to contribute to the impact of implementation science on the translation of innovations into real-world care. The frequency and nature of TMF use are yet to be described within digital health innovations, including the prominent field of clinical AI. A well-known implementation gap, coined as the "AI chasm" continues to limit the impact of clinical AI on real-world care. From this bibliometric study of the frequency and quality of TMF use within qualitative clinical AI research, we found that TMFs are usually not applied, their selection is highly varied between studies and there is not often a convincing rationale for their selection. Promoting the rigor and frequency of TMF use appears to present an opportunity to improve the translation of clinical AI into practice.

Training community health navigators in the public health workforce to respond during the COVID-19 pandemic

Aim

To describe the process of engaging underserved communities of color that designs, conducts, and evaluates community-engaged COVID-19 Community Health Navigator training on COVID-19: Vaccination, Prevention, and Contact Tracing.

Subject and methods

The project used a mixed-methods design; 18 community health navigators (CHNs) representing Asian American, Arab American, Black/African American, and Hispanic/Latinx communities completed the pretest, training, and post-test. Demographic characteristics, along with knowledge and confidence level questions regarding COVID-19 issues, were gathered in pre- and post-tests. Qualitative data were collected via open-ended questions in post-tests.

Results

Findings suggest that the community health navigator training successfully increased participants' knowledge of COVID-19-related topic areas and confidence in educating community members regarding COVID-19 vaccination and prevention. Qualitative evaluation contained information learned and found most helpful, and application and utilization plans for CHNs' follow-up work.

Conclusion

The process of community health navigator training and evaluation results adds important insights to the current COVID-19 pandemic workforce literature and can inform future trainings.

Integrating Community Health Workers and Nurse Midwives on the Health-Care Team to Improve Birth and Breastfeeding Outcomes

A plethora of international research has consistently demonstrated the efficacy of both the nurse-midwifery model and the community health worker (CHW) model in improving birth and breastfeeding outcomes, particularly among low-income women. However, these two professional groups rarely work as a team in the U.S. health-care system. Typically, certified nurse midwives are on staff at clinics and hospitals; conversely, CHWs tend to work at non-profit community organizations. Although the Community Preventive Services Task Force concluded that integrating CHWs on clinical care teams is effective, these paraprofessionals remain nearly excluded from the healthcare organization because they are not licensed healthcare professionals, hence, non reimbursable. We integrated these two health professional groups within a small, community-based, nonprofit, and charitable women's clinic in Jackson, Mississippi, serving a predominantly Medicaid population to determine if their combined health services would significantly improve birth and breastfeeding outcomes among an intervention group compared with a control group that received usual standard care from an obstetrician.

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

Using Implementation Science to Promote Integration and Sustainability of Community Health Workers in the HIV Workforce

BACKGROUND

Community health worker (CHW) interventions are an evidence-based practice adopted by health care settings to increase retention in care and viral suppression for people living with HIV (PLWH) from racial/ethnic minority communities. However, disparate funding, unclear roles vis a vis other care team members, limited training and promotion opportunities, and a lack of standards for wages and tasks limit the ability to effectively use CHWs as part of the health care team. Guided by the Exploration, Preparation, Implementation, and Sustainment and Reach, Effectiveness, Adoption, Implementation, and Maintenance frameworks, this study describes the key determinants for CHW integration and sustainability at 3 agencies in Shelby County, TN, to improve viral suppression and reduce disparities among rural and urban people living with HIV.

SETTING

Memphis Transitional Grant Area (TGA) which includes 8 rural and urban counties in west Tennessee, Arkansas, and Mississippi.

METHODS

Seventeen key informants were identified using purposeful and snowball sampling techniques, including community and agency leadership staff, frontline staff, and faith leaders.

RESULTS

Key determinants of CHW integration include establishing clear and standardized CHW roles within and across organizations, facilitating interorganizational networks, and leveraging funds for livable CHW wages and sustainable positions. Training strategies that strengthen the CHW workforce include content related to trauma-informed care, managing stress, and cultural humility.

CONCLUSION

Several inner and outer settings and innovation and bridging factors affect CHW positions. Data collected will inform the implementation and sustainment of future policies and interventions intended to improve HIV care continuum outcomes and reduce disparities for PLWH.

"The More We Know, the More We're Able to Help": Participatory Development of an Evaluation Framework for Community Health Worker Programs

CONTEXT

It is critical to evaluate community health worker (CHW) programs to maximize effectiveness. However, there is little consensus, and structure, for how to evaluate such programs.

OBJECTIVE

The purpose of this study was to develop a flexible framework for evaluating components of CHW programs in community and clinical settings.

DESIGN

Semistructured interviews were conducted with CHWs and their supervisors to determine evaluation categories for the framework. A survey was then administered to pilot the framework at federally qualified health centers and community-based organizations with existing CHW programs.

SETTING

Eighteen federally qualified health centers and community-based organizations in Louisiana, Mississippi, Alabama, and Florida.

PARTICIPANTS

Participants consisted of 23 CHWs and 19 CHW supervisors.

RESULTS

Interview participants directly informed the development of an evaluation framework for CHW programs. The framework consists of 7 evaluation categories: client relations, intraorganizational relations, interorganizational relations, capacity development, program effectiveness, cost-efficiency, and sustainability. Survey respondents specified best practices for program implementation for each evaluation category. Recommendations for CHW program evaluation include tailoring evaluation efforts and data collection methods to program context, using mixed-methods approaches for collecting evaluation data, and streamlining evaluation efforts with an organization's existing evaluation systems.

CONCLUSIONS

The evaluation framework is a flexible and practical model for collecting information needed for monitoring and evaluating CHW programs. By relying on practitioners' perspectives, this study contributes to an evidence base for implementing and evaluating CHW programs.

Outcomes from the Adaptation of an Evidence-Based Peer Linkage & Re-Engagement Intervention for Women of Color with HIV in Three Urban Clinics

Peer interventions have demonstrated efficacy with improving HIV health outcomes. Yet, little is known about factors associated with their uptake into the clinic setting. Three urban sites in the US were funded to adapt, implement and evaluate a peer intervention to improve HIV health outcomes for 173 out of care and newly diagnosed women of color. Peers worked with cis and transgender women of color for four months to achieve the goals of linkage and retention in HIV case management and medical care. Results were 96% of women were linked to medical care, 73% were retained in care and 81% were virally suppressed post 12 months. The average duration of the peer intervention was seven months. Women who received four peer encounters had a 10% increase in retention in care and viral suppression. The findings highlight key elements such as dose and duration of client interaction for peer staff as part of the health care team.

Ending the HIV Epidemic: One Southern Community Speaks

Memphis, Tennessee and its surrounding counties have been profoundly affected by the HIV epidemic. Using a participatory research approach this study identified from a community perspective: 1) the barriers and facilitators for providing support to achieve viral suppression to the most at-risk groups living with HIV in the Memphis Transitional Grant Area and 2) opportunities to strengthen the health care system through the use of community health workers (CHWs) to do outreach and engage with people living with HIV. Themes of barriers include intersectional stigma, HIV criminal laws, abstinence-only sex education, housing, transportation, and limited access to HIV case management and mental health services. Strategies to address these barriers included HIV education to youth in schools and community-wide campaigns, more testing sites, involving faith leaders, funding for housing options, innovative transportation services, rapid start of culturally appropriate HIV medical treatment, intensive case management services, and mental health counseling. Two opportunities to utilize CHWs to address the barriers identified in this geographic area are as policy advocates and as an integrated member of the HIV primary care team. The findings of this study can inform a strategy to build the CHW workforce which may have widespread implications for ending the HIV epidemic in this geographic area and across the United States.

Future directions for implementation science at the National Cancer Institute: Implementation Science Centers in Cancer Control

The National Cancer Institute (NCI) Cancer Moonshot initiative seeks to accelerate cancer research for the USA. One of the scientific priorities identified by the Moonshot's Blue Ribbon Panel (BRP) of scientific experts was the implementation of evidence-based approaches. In September 2019, the NCI launched the Implementation Science Centers in Cancer Control (ISC3 or "Centers") initiative to advance this Moonshot priority. The vision of the ISC3 is to promote the development of research centers to build capacity and research in high-priority areas of cancer control implementation science (e.g., scale-up and spread, sustainability and adaptation, and precision implementation), build implementation laboratories within community and clinical settings, improve the state of measurement and methods, and improve the adoption, implementation, and sustainment of evidence-based cancer control interventions. This paper highlights the research agenda, vision, and strategic direction for these Centers and encourages transdisciplinary scientists to learn more about opportunities to collaborate with these Centers.

Processes for Implementing Community Health Worker Workforce Development Initiatives

Introduction: The objective of this observational, cross-sectional study was to identify, document, and assess the progress made to date in implementing various processes involved in statewide community health worker (CHW) workforce development initiatives.

Methods: From September 2017 to December 2020, we developed and applied a conceptual model of processes involved in implementing statewide CHW initiatives. One or more outputs were identified for each model process and assessed across the 50 states, D.C., and Puerto Rico using peer-reviewed and gray literature available as of September 2020.

Results: Twelve statewide CHW workforce development processes were identified, and 21 outputs were assessed. We found an average of eight processes implemented per state, with seven states implementing all 12 processes. As of September 2020, 45 states had a multi-stakeholder CHW coalition and 31 states had a statewide CHW organization. In 20 states CHWs were included in Medicaid Managed Care Organizations or Health Plans. We found routine monitoring of statewide CHW employment in six states.

Discussion: Stakeholders have advanced statewide CHW workforce development initiatives using the processes reflected in our conceptual model. Our results could help to inform future CHW initiative design, measurement, monitoring, and evaluation efforts, especially at the state level.

Organizational Readiness for Community Health Worker Workforce Integration Among Medicaid Contracted Health Plans and Provider Networks: An Arizona Case Study

Understanding and building organizational capacity for system change and the integration of the Community Health Worker (CHW) workforce within the health scare sector requires a supportive organizational culture among sector leaders and providers. The aim of this mixed-methods study was to assess organizational readiness for CHW workforce integration into Arizona Medicaid health systems and care teams. This collaborative effort was in direct response to emergent state and national CHW workforce policy opportunities, and the shifting health care landscape in Arizona – which merged behavior and physical health. Specifically, and in collaboration with a broad-based, statewide CHW workforce coalition, led by the CHW professional association, we assessed 245 licensed health care professionals with experience working with CHWs and 16 Medicaid-contracted health plan leadership. Our goal was to generate a baseline understanding of the knowledge, attitudes and beliefs these stakeholders held about the integration of CHWs into systems and teams. Our findings demonstrate a high level of organizational readiness and action toward integration of CHWs within the Arizona health care system and care teams. CHWs have emerged as a health care workforce able to enhance the patient experience of care, improve population health, reduce cost of care, and improve the experience of providing care among clinicians and staff.

Postgraduate Employment Outcomes of Undergraduate and Graduate Public Health Students : A Scoping Review

OBJECTIVES

A key goal of schools and programs of public health is to prepare graduates for careers in the public health workforce after graduation, but are they achieving this goal? We assessed how the employment outcomes of students earning public health degrees are collected and described in the literature.

METHODS

Using the Kirkpatrick model of training evaluation as a framework, we conducted a 6-step scoping review: (1) formulating the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, (5) collating and summarizing the results, and (6) consulting stakeholders. We included articles published from January 1, 1993, through July 4, 2020, that provided data on employment status, employment sector/industry, job function, or salary of public health graduates. We excluded articles that were not written in English and were about dual-degree (ie, doctor of medicine-master of public health) students. We found and reviewed 630 articles.

RESULTS

We found 33 relevant articles. Most articles focused on a single school and combined multiple graduating classes, focused on subspecializations of public health, or focused on graduates' satisfaction with their curriculum but not employment outcomes. Data were inconsistently categorized, and studies were difficult to compare.

CONCLUSIONS

Research on public health graduates' employment outcomes is scarce and does not follow consistent protocols. New standards should be adopted to systematize the collection of data on employment outcomes of public health graduates.

Implementation of Healthy Eating Interventions in Center-Based Childcare: The Selection, Application, and Reporting of Theories, Models, and Frameworks

PURPOSE

To explore the selection, use, and reporting of theories, models, and frameworks (TMFs) in implementation studies that promoted healthy eating in center-based childcare.

DATA SOURCE

We searched 11 databases for articles published between January 1990 and October 2018. We also conducted a hand search of studies and consulted subject matter experts.

STUDY INCLUSION AND EXCLUSION CRITERIA

We included studies in center-based settings for preschoolers that addressed the development, delivery, or evaluation of interventions or implementation strategies related to healthy eating and related subjects and that explicitly used TMF. Exclusion criteria include not peer reviewed or abstracts and not in English, French, German, and Korean.

DATA EXTRACTION

The first author extracted the data using extraction forms. A second reviewer verified data extraction.

DATA SYNTHESIS

Direct content analysis and narrative synthesis.

RESULTS

We identified 8222 references. We retained 38 studies. Study designs included quasi-experimental, randomized controlled trials, surveys, case studies, and others. The criteria used most often for selecting TMFs were description of a change process (n = 12; 23%) or process guidance (n = 8; 15%). Theories, models, and frameworks used targeted different socioecological levels and purposes. The application of TMF constructs (e.g., factors, steps, outcomes) was reported 69% (n = 34) of times.

CONCLUSION

Reliance on TMFs focused on individual-level, poor TMF selection, and application and reporting for the development of implementation strategies could limit TMF utility.

Opportunities for community health workers to contribute to global efforts to end tuberculosis

Tuberculosis (TB) has emerged as the leading infectious cause of death globally. New paradigms are needed to reduce TB rates and mortality. Programs harnessing the potential of community health workers (CHWs) to enhance TB prevention and care have shown great promise. In this perspective article, we review the history of CHW-based efforts to prevent and treat TB, present evidence illustrating the effectiveness of CHWs across the entire cascade of TB care, and outline additional opportunities for CHWs to address challenges particular to the TB pandemic. Despite many promising studies, knowledge gaps persist and we suggest an agenda for future research on the role of CHWs in TB prevention and care.