Annual Research Review: The state of implementation science in child psychology and psychiatry: a review and suggestions to advance the field

Enhancing Behavioral Health Implementation in a Care Coordination Program at a Federally Qualified Health Center: A Case Study Applying Implementation Frameworks

Federally Qualified Health Centers are charged with providing comprehensive health care in traditionally underserved areas, underscoring their importance in caring for and promoting health equity for the large portion of historically marginalized communities in this setting. There is a significant need to ensure Federally Qualified Health Centers are equipped to appropriately address the immense behavioral health needs common among patients served. Care coordination is an evidence-based model that is increasingly utilized in Federally Qualified Health Centers to improve care equity and outcomes. Addressing and supporting behavioral health needs is a key aspect of such care coordination models. Context-specific considerations and programmatic supports, particularly those that address the needs of care coordinators and the complex patients they serve, are needed to ensure such models can appropriately meet and address the behavioral health concerns of the diverse populations served. The goal of this study was to present a mixed-methods case study that systematically applies implementation frameworks to conduct a needs and context assessment to inform the development and testing of evidence-based practice strategies and implementation support as part of a care coordination program within a partnered Federally Qualified Health Center.

Clinical Considerations for Integrating Ethical Principles of Beneficence in the Development of Evidence-Based Interventions: The case of Pediatric Misophonia

Misophonia is a condition involving decreased tolerance and intense responses to specific sounds, often those that are human-generated and repetitive in nature. Misophonia frequently onsets during childhood and is associated with significant distress, impairment, and diminished quality of life. While misophonia research remains nascent and no definitive practice guidelines exist at present, extant studies offer several promising potential avenues in intervention development for adults with misophonia. However, such research is comparatively limited for youth. Before widespread adoption of promising treatments, it is important to consider the potential for harm or non-beneficence that may arise from the mis-informed application of such treatments. In this article, we identify several potential pitfalls within intervention development for pediatric misophonia and provide recommendations to circumvent them. To that end, we focus on the following three topic areas: (a) challenges arising when psychological mechanisms are not considered in intervention development, (b) importation of a cognitive-behavior therapy (CBT) framework for obsessive-compulsive spectrum disorders without nuanced tailoring to misophonia, and (c) neglecting to include individuals with lived experience in the process of intervention development research. Considering these key areas within misophonia intervention development will be critical for upholding beneficence and minimizing harm in treatment of misophonia across the lifespan.

A randomized controlled effectiveness trial of transdiagnostic treatment and measurement-based care for adolescents with emotional disorders in community clinics

Objective: This article presents primary outcomes from the Community Study of Outcome Monitoring for Emotional Disorders in Teens, a two-site, randomized controlled trial comparing the effectiveness of the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Adolescents plus measurement-based care (UP-A), measurement-based care alone (TAU+), and treatment as usual (TAU) in community mental health clinics. Method: A total of 174 clinicians were randomized to implement TAU (n = 49), TAU plus an MBC measure (TAU+; n = 63), or UP-A plus MBC (UP-A; n = 62). In addition, 196 adolescents were randomized to receive 16 weeks of either TAU (n = 68), TAU+ (n = 60), or UP-A (n = 68). Independent evaluator-, self-, and caregiver-reported adolescent anxiety and depression symptoms were measured at baseline and Weeks 8, 16, and 28 postenrollment. Results: Adolescents in all groups showed improvement over time, and compared with TAU, adolescents receiving TAU+ and UP-A conditions improved more quickly on adolescent-report measures only. There were no treatment group differences observed on independent evaluator (primary outcome) or caregiver-report measures. In post hoc analyses, moderators of treatment response included treatment duration and complexity of symptom presentation. Conclusions: In one of the largest adolescent-focused, community-located psychotherapy trials conducted in the United States, transdiagnostic treatment plus measurement-based care and measurement-based care alone conferred some adolescent-reported symptom benefits compared with treatment as usual, although adolescents in all conditions exhibited improvements in anxiety and depression. Future directions for subsequent adolescent psychotherapy effectiveness trials for anxiety and depression are discussed. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

"So Many Other Things Improve" with Transdiagnostic Treatment for Sleep and Circadian Problems: Interviews with Community Providers on Treating Clients with Serious Mental Illness

Community mental health centers (CMHCs) offer invaluable, publicly-funded treatment for serious mental illness (SMI). Unfortunately, evidence-based psychological treatments are often not delivered at CMHCs, in part due to implementation barriers, such as limited time, high caseloads, and complex clinical presentations. Transdiagnostic treatments may help address these barriers, because they allow providers to treat symptoms across multiple disorders concurrently. However, little research has investigated CMHC providers' experiences of delivering transdiagnostic treatments "on the ground," particularly for adults with SMI. Thus, the aim of the present study was to assess CMHC providers' perspectives on delivering a transdiagnostic treatment - the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) - to adults diagnosed with SMI. In the context of a larger parent trial, providers were randomized to deliver a standard version of TranS-C (Standard TranS-C) or a version adapted to the CMHC context (Adapted TranS-C). Twenty-five providers from the parent trial participated in a semi-structured interview (n = 10 Standard TranS-C; n = 15 from Adapted TranS-C). Responses were deductively and inductively coded to identify themes related to Proctor's taxonomy of implementation outcomes. Four novel "transdiagnostic take homes" were identified: (1) transdiagnostic targets, such as sleep, can be perceived as motivating and appropriate when treating SMI, (2) strategies to bolster client motivation/adherence and address a wider range of symptom severity may improve transdiagnostic treatments, (3) balancing feasibility with offering in-depth resources is an important challenge for transdiagnostic treatment development, and (4) adapting transdiagnostic treatments to the CMHC context may improve provider perceptions of implementation outcomes.

Attitudes Toward and Usage of Evidence-Based Mental Health Practices for Autistic Youth in Bangladesh and Germany: A Cross-Cultural Comparison

The implementation of evidence-based practices (EBPs) for autistic youth is a critical concern worldwide. Research examining factors facilitating the implementation of EBPs found that providers' attitudes are an important factor. In this study, we evaluated cross-cultural differences in attitudes toward and use of EBPs. We tested socio-demographic factors as predictors of attitudes, and attitudes as predictors of EBPs use among mental health professionals working with autistic youth in Bangladesh and Germany. We used purposeful sampling. Two-hundred-ninety-two professionals who worked in a clinical setting responded to the survey and fulfilled the inclusion criteria (101 in Bangladesh, 191 in Germany). Participants were asked to respond to nine subscales of the Evidence-Based Practice Attitude Scale-36 (EBPAS-36), to indicate which of nine types of treatments they used, and to provide sociodemographic data. Measurement invariance across countries could be established for four subscales of the EBPAS-36. Comparative analyses of attitudes showed that professionals in both countries were open to using EBPs, but German practitioners were more likely to use EBPs when they appealed to them. By contrast, Bangladeshi professionals claimed to be more likely to adopt an EBP when required and to be more willing to learn EBPs to enhance job security. The relationship between caseload and attitudes varied between countries. A broader variety of EBPs was used in Germany. The findings highlight the importance of considering country-specific factors when implementing EBPs. Directions for conducting comparative studies on mental health professionals' attitudes towards EBP including methodological considerations are discussed.

The state of implementation science in major depressive disorder: A narrative review

Major depressive disorder (MDD) is one of the most prevalent and disabling mental disorders with high recurrence rate. There is often a gap between scientific evidence related to the effective and cost-effective treatment of depression and clinical practice. Implementation science is a field of inquiry that aims to advance the process of applying evidence-based interventions to real-world problems. Implementation research consists of two broad phases. The first phase seeks to identify the gaps that exist between evidence and practice and their impact on outcomes. The second phase, building on the first, evaluates the effectiveness of implementation strategies by examining various implementation indicators to support the adoption and scale up of interventions. Although implementation research can facilitate the uptake and adoption of evidence-based interventions, it is underused in depression research. In this narrative review, the authors will introduce the definition of implementation science and the state of implementation science in MDD in order to support more widespread use of implementation science for scaling up evidence-based interventions.

Australian Clinicians' Capabilities, Opportunities, and Motivations in Implementing Exposure and Response Prevention for Youth with Obsessive-Compulsive Disorder: An Exploratory Study

Objectives: Informed by implementation science, this exploratory study examined the capabilities, opportunities, and motivations of Australian mental health clinicians (N = 38) associated with the implementation of exposure and response prevention (ERP) for youth (i.e., children and adolescents) with obsessive-compulsive disorder (OCD). It also explored how the capabilities and motivations of mental health clinicians untrained in ERP for youth (i.e., typical clinicians; n = 25) differed from clinicians experienced in the use of ERP for youth (i.e., experienced clinicians; n = 13). Methods: Questionnaires were administered to the entire sample alongside observational role-plays, which assessed observed adherence and competence delivering ERP against published best-practice standards among available participants. Results: In the whole sample, the reported time dedicated to implementing ERP was associated with a range of factors relating to capabilities, opportunities, and motivations to implement ERP. Experienced clinicians had greater knowledge, adherence, competence, and self-reported confidence using ERP and fewer negative beliefs about ERP relative to typical clinicians. They also intended to dedicate greater time to implementing within-session ERP for youth and reported greater within- and between-session time spent doing so compared to typical clinicians. The time intended to dedicate to implementing between-sessions ERP did not significantly differ between the clinician groups. Conclusions: In summary, compared to typical clinicians, experienced clinicians appeared to possess greater levels of capabilities and motivations to implement ERP for youth with OCD. Future research examining barriers and facilitators of ERP implementation in community settings and identifying effective strategies to improve it would benefit service provision and, ultimately, outcomes for youth.

Parent and professional perspectives on implementing the Pediatric Autism Communication Therapy: A mixed-methods analysis

LAY ABSTRACT

Factors influencing the implementation of parent-mediated intervention are insufficiently studied. This study examines for the first-time factors of implementation into clinical practice across the world of Pediatric Autism Communication Therapy, an internationally disseminated, evidence-based, parent-mediated therapy. From both the parents' and the professionals' perspectives, parents attitudes (e.g. self-reflection abilities and videotaping management) and life-circumstances (e.g. stressed families condition and time) were central factors. In this type of therapy, the target is a child's development; still, this improvement is dependent on the parent's behavior when interacting with their child. What's more, Pediatric Autism Communication Therapy method (video reflection, empowerment of parent, play-based) was enabler according to most of the parents. And more, most professionals report factors linked to the Implementation Process that is planning, execution, reflection and assessment in implementation of a new therapy. Indeed, the professionals underlined barriers related to the population seen in practice, flexibility of schedule, support from colleagues and manager. All these factors could be improved and addressed with a formal implementation plan including factors related to the parents of each country.

Implementation of a parent training intervention (SPARCK) to prevent childhood mental health problems: study protocol for a pragmatic implementation trial in Norwegian municipalities

BACKGROUND

Effective evidence-based interventions (EBI) are necessary to prevent and avoid negative life trajectories for children with mental health problems. Even though many EBIs prove effective when tested, few are successfully implemented and used in real-world clinical practice. As a result, many children and families do not receive the best care in due time or at all. To reduce this research-practice gap, a combined RCT and implementation study of Supportive Parents-Coping Kids (SPARCK), a parent training intervention to prevent childhood mental health problems, will be performed. This study protocol concerns the implementation part of the larger effectiveness-implementation project.

METHODS

The study is a correlational multi-site implementation study of SPARCK performed alongside a two-armed RCT, in 24 Norwegian municipalities. A quantitative three-wave longitudinal web-based data collection will be conducted among SPARCK practitioners and leaders in relevant services. We will investigate the relations between theory-driven and empirical implementation determinants and implementation outcomes, measured by fidelity, acceptability, appropriateness, and feasibility. In addition, we will examine how these implementation determinants and outcomes are associated with the clinical outcomes of SPARCK.

DISCUSSION

The current study will investigate implementation determinants and their relation to indicators of implementation success, while simultaneously investigating effectiveness of an intervention optimized to the needs of both the target group and relevant stakeholders. Together, this may improve clinical effect, contextual fit, implementation success, and reduce the time lag between research findings and application in real-world settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05800522. Registered on 2023.03.23.

Developing a Set of Standardized Core Principles and Methods Across Multiple Training and Technical Assistance Centers

Despite a growing body of research demonstrating the value of using evidence-based programs and practices (EBPPs) to address health and education issues, the gap between research evidence and practice in education and human services continues to be a vexing problem. Technical assistance (TA) is widely accepted as a key strategy to support evidence-based programs and practices (EBPP) uptake and implementation. However, little is known about how TA practices are used in TA delivery. Moreover, little attention has been paid to building the capacity of TA providers and assessing the fidelity of the implementation of TA practices. The case example presented in this article describes one organization's efforts to develop common language and definitions of TA services, core principles, and methods, and to standardize the delivery of TA by enhancing the capacity and retention of TA providers. We conclude with recommendations about how like organizations can employ similar efforts to improve the quality and consistency of TA delivery, thereby establishing a foundation for building a strong evidence base.

Clinician attitudes towards adoption of evidence-based practice: a nationwide multiprofessional cross-sectional study of child and adolescent mental health services in Sweden

BACKGROUND

Implementation of evidence-based practice (EBP) in child and adolescent mental health services (CAMHS) is a priority to improve service delivery and outcomes. Clinicians' EBP attitudes are likely to play a crucial role in implementation but are poorly understood. This study aimed to assess variation in EBP attitudes in a large national sample of CAMHS clinicians in Sweden, and to compare these findings to findings from the United States of America (USA).

METHODS

CAMHS clinicians (n = 799; 60% response rate) completed the Evidence-Based Practice Attitude Scale (EBPAS) and items from the Organizational Readiness for Change Scale (ORC) ahead of an EBP for depression implementation effort across Sweden. EBPAS scores were compared with the USA study. Predictors of global and specific attitudes (gender, age, working years, education, profession, perceived benefit of diagnosis and organizational readiness and type of service) were examined using simple and multiple linear regressions.

RESULTS

Clinicians had positive attitudes towards EBP on the four-dimensional subscales of the EBPAS, somewhat more so than their American counterparts. Clinician and organizational characteristics were related to at least one attitudinal dimension in both models, with perceived utility of diagnosis being the strongest and most consistent predictor across dimensions and models.

CONCLUSIONS

Results from this large-scale national study underscore the need to consider cultural, contextual, and individual variations in attitudes towards EBP when planning implementation efforts. Such efforts may need to be tailored to the working contexts, needs, and values of CAMHS clinicians, particularly their views on the utility of diagnosis.

Participatory logic model for a precision child and youth mental health start-up: scoping review, case study, and lessons learned

Background

The precision child and youth mental health (PCYMH) paradigm has great potential to transform CYMH care and research, but there are numerous concerns about feasibility, sustainablity, and equity. Implementation science and evaluation methodology, particularly participatory logic models created with stakeholders, may help catalyze PCYMH-driven system transformation. This paper aims to: (1) report results of a PCYMH logic model scoping review; (2) present a case study illustrating creation of a participatory logic model for a PCYMH start-up; and (3) share the final model plus lessons learned.

Methods

Phase 1: Preparation for the logic model comprised several steps to develop a preliminary draft: scoping review of PCYMH logic models; two literature reviews (PCYMH and implementation science research); an environmental scan of our organization's PCYMH research; a gap analysis of our technological capability to support PCYMH research; and 57 stakeholder interviews assessing PCYMH perspectives and readiness. Phase 2: Participatory creation of the logic model integrated Phase 1 information into a draft from which the final logic model was completed through iterative stakeholder co-creation.

Results

Phase 1: The scoping review identified 0 documents. The PCYMH literature review informed our Problem and Impact Statements. Reviewing implementation and evaluation literature resulted in selection of the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Behavior Change Wheel (BCW) frameworks to guide model development. Only 1.2% (5/414) of the organization's research projects involved PCYMH. Three technological infrastructure gaps were identified as barriers to developing PCYMH research. Stakeholder readiness interviews identified three themes that were incorporated into the draft. Phase 2: Eight co-creation cycles with 36 stakeholders representing 13 groups and a consensus decision-making process were used to produce the final participatory logic model.

Conclusions

This is the first study to report the development of a participatory logic model for a PCYMH program, detailing involvement of stakeholders from initial planning stages to the final consensus-based product. We learned that creating a participatory logic model is time- and labour-intensive and requires a multi-disciplinary team, but the process produced stakeholder-program relationships that enabled us to quickly build and implement the PCYMH start-up. Our processes and final model can inform similar efforts at other sites.

Randomized Trial of an Organizational Implementation Strategy to Improve Measurement-Based Care Fidelity and Youth Outcomes in Community Mental Health

OBJECTIVE

Measurement-based care (MBC), which collects session-by-session symptom data from patients and provides clinicians with feedback on treatment response, is a highly generalizable evidence-based practice with significant potential to improve the outcomes of mental health treatment in youth when implemented with fidelity; however, it is rarely used in community settings. This study tested whether an implementation strategy targeting organizational leadership and organizational implementation climate could improve MBC fidelity and clinical outcomes for youth in outpatient mental health clinics.

METHOD

In a cluster randomized trial, 21 clinics were assigned to the Leadership and Organizational Change for Implementation strategy plus training and technical assistance in MBC (k = 11, n = 117) or training and technical assistance only (k = 10, n = 117). Primary outcomes of MBC fidelity (assessed via electronic metadata) and youth symptom improvement (assessed via caregiver-reported change on the Shortform Assessment for Children Total Problem Score) were collected for consecutively enrolled youths (ages 4-18 years) who initiated treatment in the 12 months following MBC training. Outcomes of each youth were assessed for 6 months following baseline.

RESULTS

A total of 234 youths were enrolled and included in intent-to-treat analyses. At baseline, there were no significant differences by condition in clinic, clinician, or youth characteristics. Youths in clinics using the Leadership and Organizational Change for Implementation strategy experienced significantly higher MBC fidelity compared with youths in control clinics (23.1% vs 3.4%, p = .014), and exhibited significantly greater reductions in symptoms from baseline to 6 months (d = 0.31, 95% CI: 0.04-0.58, p = .023).

CONCLUSION

Implementation strategies targeting organizational leadership and focused implementation climate can improve fidelity to evidence-based practices and clinical outcomes of youth mental health services.

PLAIN LANGUAGE SUMMARY

Measurement-based care is an evidence-based intervention that has been shown to improve the outcomes of mental health services in dozens of randomized trials; however, it is not widely used in routine practice. In this randomized controlled trial of 21 outpatient mental health clinics and 234 youth, the authors found an organizational intervention which trained clinic leaders in skills to support the use of measurement-based care increased the extent to which patients received measurement-based care compared to control clinics where clinic leaders did not receive this training (23% vs. 3%). Youth receiving services in the clinics that received the organizational intervention also had greater reductions in mental health symptoms.

CLINICAL TRIAL REGISTRATION INFORMATION

Working to Implement and Sustain Digital Outcome Measures (WISDOM); https://clinicaltrials.gov/; NCT04096274.

Lessons learned from a multimodal sensor-based eHealth approach for treating pediatric obsessive-compulsive disorder

Introduction

The present study investigates the feasibility and usability of a sensor-based eHealth treatment in psychotherapy for pediatric obsessive-compulsive disorder (OCD), and explores the promises and pitfalls of this novel approach. With eHealth interventions, therapy can be delivered in a patient's home environment, leading to a more ecologically valid symptom assessment and access to experts even in rural areas. Furthermore, sensors can help indicate a patient's emotional and physical state during treatment. Finally, using sensors during exposure with response prevention (E/RP) can help individualize therapy and prevent avoidance behavior.

Methods

In this study, we developed and subsequently evaluated a multimodal sensor-based eHealth intervention during 14 video sessions of cognitive-behavioral therapy (CBT) in 20 patients with OCD aged 12-18. During E/RP, we recorded eye movements and gaze direction via eye trackers, and an ECG chest strap captured heart rate (HR) to identify stress responses. Additionally, motion sensors detected approach and avoidance behavior.

Results

The results indicate a promising application of sensor-supported therapy for pediatric OCD, such that the technology was well-accepted by the participants, and the therapeutic relationship was successfully established in the context of internet-based treatment. Patients, their parents, and the therapists all showed high levels of satisfaction with this form of therapy and rated the wearable approach in the home environment as helpful, with fewer OCD symptoms perceived at the end of the treatment.

Discussion

The goal of this study was to gain a better understanding of the psychological and physiological processes that occur in pediatric patients during exposure-based online treatment. In addition, 10 key considerations in preparing and conducting sensor-supported CBT for children and adolescents with OCD are explored at the end of the article. This approach has the potential to overcome limitations in eHealth interventions by allowing the real-time transmission of objective data to therapists, once challenges regarding technical support and hardware and software usability are addressed.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier (NCT05291611).

Multilevel barriers to guideline implementation: a nationwide multi-professional cross-sectional study within child and adolescent psychiatry

BACKGROUND

Despite efforts to promote guideline use, guideline adoption is often suboptimal due to failure to identify and address relevant barriers. Barriers vary not only between guidelines but also between settings, intended users, and targeted patients. Multi-professional guidelines are often used in child and adolescent mental health services (CAMHS), making the implementation process more difficult. Despite this, there is a lack of knowledge about which barriers to consider or if barriers vary by profession. The aim of this study was to address these gaps by examining barriers to adopting a multi-professional depression guideline in the context of a nationwide implementation study.

METHODS

440 CAMHS clinicians across Sweden (52%) completed the Barriers and Facilitators Assessment Instrument (BFAI) ahead of an implementation endeavour. BFAI is a widely used and validated measure of guideline implementation on four scales: Innovation, Provider, Context, and Patient. Barriers were calculated at scale and at item levels. ANOVA and chi-square tests were used to analyse differences by profession and effect sizes were calculated.

RESULTS

Overall, clinicians were optimistic about guideline uptake, particularly about guideline characteristics and their own adoption ability. Barriers were related to the patient and the context domains, as well as to individual clinician knowledge and training. Perceptions differed across professions; psychiatrists were most, and counsellors were least positive about guideline embeddedness.

CONCLUSION

This large-scale quantitative study suggests that CAMHS clinicians have an overall favourable attitude towards guideline adoption but highlights the need for adaptations to certain patient groups. Strategies to improve guideline use should primarily address these patient issues while securing proper support to the implementation. Implementation efforts, particularly those targeting staff knowledge, training, and involvement, may benefit from being tailored to different professional needs. These findings may inform implementation projects in CAMHS and future research.

Teamwork and implementation of innovations in healthcare and human service settings: a systematic review

BACKGROUND

Implementation of new practices in team-based settings requires teams to work together to respond to new demands and changing expectations. However, team constructs and team-based implementation approaches have received little attention in the implementation science literature. This systematic review summarizes empirical research examining associations between teamwork and implementation outcomes when evidence-based practices and other innovations are implemented in healthcare and human service settings.

METHODS

We searched MEDLINE, CINAHL, APA PsycINFO and ERIC for peer-reviewed empirical articles published from January 2000 to March 2022. Additional articles were identified by searches of reference lists and a cited reference search for included articles (completed in February 2023). We selected studies using quantitative, qualitative, or mixed methods to examine associations between team constructs and implementation outcomes in healthcare and human service settings. We used the Mixed Methods Appraisal Tool to assess methodological quality/risk of bias and conducted a narrative synthesis of included studies. GRADE and GRADE-CERQual were used to assess the strength of the body of evidence.

RESULTS

Searches identified 10,489 results. After review, 58 articles representing 55 studies were included. Relevant studies increased over time; 71% of articles were published after 2016. We were unable to generate estimates of effects for any quantitative associations because of very limited overlap in the reported associations between team variables and implementation outcomes. Qualitative findings with high confidence were: 1) Staffing shortages and turnover hinder implementation; 2) Adaptive team functioning (i.e., positive affective states, effective behavior processes, shared cognitive states) facilitates implementation and is associated with better implementation outcomes; Problems in team functioning (i.e., negative affective states, problematic behavioral processes, lack of shared cognitive states) act as barriers to implementation and are associated with poor implementation outcomes; and 3) Open, ongoing, and effective communication within teams facilitates implementation of new practices; poor communication is a barrier.

CONCLUSIONS

Teamwork matters for implementation. However, both team constructs and implementation outcomes were often poorly specified, and there was little overlap of team constructs and implementation outcomes studied in quantitative studies. Greater specificity and rigor are needed to understand how teamwork influences implementation processes and outcomes. We provide recommendations for improving the conceptualization, description, assessment, analysis, and interpretation of research on teams implementing innovations.

TRIAL REGISTRATION

This systematic review was registered in PROSPERO, the international prospective register of systematic reviews.

REGISTRATION NUMBER

CRD42020220168.

Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): a modified Delphi study

BACKGROUND

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

METHOD

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability and inclusion (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

RESULTS

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

DISCUSSION

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review

Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.

Future Directions for Community-Engaged Research in Clinical Psychological Science with Youth

Despite advances in clinical science, the burden of mental health problems among youth is not improving. To tackle this burden, clinical science with youth needs methods that include youth and family perspectives on context and public health. In this paper, we illustrate how community-engaged research (CEnR) methods center these perspectives. Although CEnR methods are well-established in other disciplines (e.g. social work, community psychology), they are underutilized in clinical science with youth. This is due in part to misperceptions of CEnR as resource-intensive, overly contextualized, incompatible with experimentally controlled modes of inquiry, or irrelevant to understanding youth mental health. By contrast, CEnR methods can provide real-world impact, contextualized clinical solutions, and sustainable outcomes. A key advantage of CEnR strategies is their flexibility-they fall across a continuum that centers community engagement as a core principle, and thus can be infused in a variety of research efforts, even those that center experimental control (e.g. randomized controlled trials). This paper provides a brief overview of this continuum of strategies and its application to youth-focused clinical science. We then discuss future directions of CEnR in clinical science with youth, as well as structural changes needed to advance this work. The goals of this paper are to help demystify CEnR and encourage clinical scientists to consider adopting methods that better consider context and intentionally engage the communities that our work seeks to serve.

Effects of Training in Cognitive Behavioural Therapy and Motivational Interviewing on Mental Health Practitioner Behaviour: A Systematic Review and Meta-Analysis

Effective training of mental health professionals is crucial for bridging the gap between research and practice when delivering cognitive behavioural therapy (CBT) and motivational interviewing (MI) within community settings. However, previous research has provided inconclusive evidence regarding the impact of training efforts. The current study aimed to systematically search, review and synthesize the literature on CBT and MI training to assess its effect on practitioner behavioural outcomes. Following prospective registration, a literature search was conducted for studies where mental health practitioners were exposed to training in face-to-face CBT or MI, reporting on at least one quantitative practitioner behavioural outcome. A total of 116 studies were eligible for the systematic review, and 20 studies were included in four meta-analyses. The systematic review highlights the need to establish psychometrically valid outcome measures for practitioner behaviour. Results of the meta-analyses suggest that training has a greater effect on practitioner behaviour change compared to receiving no training or reading a treatment manual. Training combined with consultation/supervision was found to be more effective than training alone, and no differences were found between face-to-face and online training. Results should be interpreted with caution due to methodological limitations in the primary studies, large heterogeneity, and small samples in the meta-analyses. Future directions are discussed.

How can a behavioral economics lens contribute to implementation science?

BACKGROUND

Implementation science in health is an interdisciplinary field with an emphasis on supporting behavior change required when clinicians and other actors implement evidence-based practices within organizational constraints. Behavioral economics has emerged in parallel and works towards developing realistic models of how humans behave and categorizes a wide range of features of choices that can influence behavior. We argue that implementation science can be enhanced by the incorporation of approaches from behavioral economics. Main body First, we provide a general overview of implementation science and ways in which implementation science has been limited to date. Second, we review principles of behavioral economics and describe how concepts from BE have been successfully applied to healthcare including nudges deployed in the electronic health record. For example, de-implementation of low-value prescribing has been supported by changing the default in the electronic health record. We then describe what a behavioral economics lens offers to existing implementation science theories, models and frameworks, including rich and realistic models of human behavior, additional research methods such as pre-mortems and behavioral design, and low-cost and scalable implementation strategies. We argue that insights from behavioral economics can guide the design of implementation strategies and the interpretation of implementation studies. Key objections to incorporating behavioral economics are addressed, including concerns about sustainment and at what level the strategies work.

CONCLUSION

Scholars should consider augmenting implementation science theories, models, and frameworks with relevant insights from behavioral economics. By drawing on these additional insights, implementation scientists have the potential to boost efforts to expand the provision and availability of high quality care.

Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial

BACKGROUND

Theory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested LOCI's hypothesized mechanisms of change, namely: (1) LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI's effect on implementation climate, which in turn will (3) mediate LOCI's effect on MBC fidelity.

METHODS

Twenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders' implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses.

RESULTS

LOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps < .01), producing large effects (range of ds = 0.76 to 1.34). LOCI's effects on transformational leadership were small at 4 months (d = 0.31, p = .019) and nonsignificant thereafter (ps > .05). LOCI's improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p = .004). Transformational leadership did not mediate LOCI's effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI's effect on MBC fidelity during the same period (pm = 0.71, p = .045).

CONCLUSIONS

LOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019.

Supervisory Alliance as a Moderator of the Effects of Behavioral Rehearsal on TF-CBT Fidelity: Results from a Randomized Trial of Supervision Strategies

Exposure is an important element of treatment for many evidence-based treatments but can be challenging to implement. Supervision strategies to support exposure delivery may be an important tool to facilitate the use of exposure techniques; however, they must be considered and used in the context of the supervisory alliance. The present study examined relations between supervisory alliance and fidelity to the trauma narrative (TN; i.e., imaginal exposure) component of Trauma-Focused Cognitive Behavioral Therapy. We also examined how supervisory alliance moderated the effect of behavioral rehearsal use in supervision on TN fidelity. We analyzed data from a randomized controlled trial, in which forty-two supervisors and their clinicians (N = 124) from 28 Washington State community-based mental health offices participated. Clinicians were randomized to receive one of two supervision conditions-symptom and fidelity monitoring (SFM) or SFM with behavioral rehearsal (SFM + BR). Supervisory alliance alone did not predict delivery (i.e., occurrence) or extensiveness of delivery of the trauma narrative. Client-focused supervisory alliance moderated the effectiveness of behavioral rehearsal-as client-focused alliance increased, the odds of delivering the TN also increased significantly. Future research should further investigate how to appropriately match supervision techniques with supervisory dyads and explore the interplay of alliance with supervision techniques a supervisor might employ.

Action recommendations review in community-based therapy and depression and anxiety outcomes: a machine learning approach

BACKGROUND

While the positive impact of homework completion on symptom alleviation is well-established, the pivotal role of therapists in reviewing these assignments has been under-investigated. This study examined therapists' practice of assigning and reviewing action recommendations in therapy sessions, and how it correlates with patients' depression and anxiety outcomes.

METHODS

We analyzed 2,444 therapy sessions from community-based behavioral health programs. Machine learning models and natural language processing techniques were deployed to discern action recommendations and their subsequent reviews. The extent of the review was quantified by measuring the proportion of session dialogues reviewing action recommendations, a metric we refer to as "review percentage". Using Generalized Estimating Equations modeling, we evaluated the correlation between this metric and changes in clients' depression and anxiety scores.

RESULTS

Our models achieved 76% precision in capturing action recommendations and 71.1% in reviewing them. Using these models, we found that therapists typically provided clients with one to eight action recommendations per session to engage in outside therapy. However, only half of the sessions included a review of previously assigned action recommendations. We identified a significant interaction between the initial depression score and the review percentage (p = 0.045). When adjusting for this relationship, the review percentage was positively and significantly associated with a reduction in depression score (p = 0.032). This suggests that more frequent review of action recommendations in therapy relates to greater improvement in depression symptoms. Further analyses highlighted this association for mild depression (p = 0.024), but not for anxiety or moderate to severe depression.

CONCLUSIONS

An observed positive association exists between therapists' review of previous sessions' action recommendations and improved treatment outcomes among clients with mild depression, highlighting the possible advantages of consistently revisiting therapeutic homework in real-world therapy settings. Results underscore the importance of developing effective strategies to help therapists maintain continuity between therapy sessions, potentially enhancing the impact of therapy.

Four Steps To My Future (4STMF): acceptability, feasibility and exploratory outcomes of a universal school-based mental health and well-being programme, delivered to young adolescents in South Africa

OBJECTIVE

Mental health disorders affect many children in South Africa, where vulnerability is high, and treatment is limited. We sought to determine the feasibility and acceptability of a universally delivered classroom-based programme for the promotion of mental health in young adolescents.

METHOD

We pilot tested an 8 session, cognitive-behavioural therapy-based programme, 4 Steps To My Future (4STMF) in two schools. Participants were grade 5 learners (n = 222; Meanage  = 10.62 (Standard deviation = 0.69)). 4STMF was delivered in class time by trained psychology postgraduates. Feasibility (rates of parental opt-out, child assent, assessment completion at baseline and follow-up, programme completion, session attendance and programme fidelity), acceptability (teacher feedback and focus groups with learners), as well as demographic data and data on a battery of a psychological measures were collected at baseline, postintervention and at one-month follow-up.

RESULTS

Most eligible learners at both schools agreed to participate (85% - school 1; 91% - school 2) with more than 80% completing postintervention measures. Learner session attendance and programme fidelity were high. Teachers rated facilitators highly on confidence, preparedness, enthusiasm and classroom management and observed children to be enjoying the programme. Focus group data suggest that learners liked the programme, could recall the content and had shared some of the content with their family. An exploratory analysis of outcomes showed significant pre-post differences on self-esteem at school 1 and on emotion regulation at school 1 and school 2, maintained at follow-up.

CONCLUSIONS

This pilot study has shown that 4STMF can acceptably and feasibly be delivered, at classroom level, as a universal school-based prevention programme to young adolescent learners in South African primary schools. The programme could fit in with school context, could be delivered by nonspecialists, showed significant improvements on self-esteem and emotion regulation and was liked by the learners.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 3: study protocol to evaluate sustainment in a hybrid type 2 effectiveness-implementation cluster-randomized trial

BACKGROUND

Although research on the implementation of evidence-based psychological treatments (EBPTs) has advanced rapidly, research on the sustainment of implemented EBPTs remains limited. This is concerning, given that EBPT activities and benefits regularly decline post-implementation. To advance research on sustainment, the present protocol focuses on the third and final phase-the Sustainment Phase-of a hybrid type 2 cluster-randomized controlled trial investigating the implementation and sustainment of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for patients with serious mental illness and sleep and circadian problems in community mental health centers (CMHCs). Prior to the first two phases of the trial-the Implementation Phase and Train-the-Trainer Phase-TranS-C was adapted to fit the CMHC context. Then, 10 CMHCs were cluster-randomized to implement Standard or Adapted TranS-C via facilitation and train-the-trainer. The primary goal of the Sustainment Phase is to investigate whether adapting TranS-C to fit the CMHC context predicts improved sustainment outcomes.

METHODS

Data collection for the Sustainment Phase will commence at least three months after implementation efforts in partnering CMHCs have ended and may continue for up to one year. CMHC providers will be recruited to complete surveys (N = 154) and a semi-structured interview (N = 40) on sustainment outcomes and mechanisms. Aim 1 is to report the sustainment outcomes of TranS-C. Aim 2 is to evaluate whether manipulating EBPT fit to context (i.e., Standard versus Adapted TranS-C) predicts sustainment outcomes. Aim 3 is to test whether provider perceptions of fit mediate the relation between treatment condition (i.e., Standard versus Adapted TranS-C) and sustainment outcomes. Mixed methods will be used to analyze the data.

DISCUSSION

The present study seeks to advance our understanding of sustainment predictors, mechanisms, and outcomes by investigating (a) whether the implementation strategy of adapting an EBPT (i.e., TranS-C) to the CMHC context predicts improved sustainment outcomes and (b) whether this relation is mediated by improved provider perceptions of treatment fit. Together, the findings may help inform more precise implementation efforts that contribute to lasting change.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05956678 . Registered on July 21, 2023.

A scoping review of theories, models and frameworks used or proposed to evaluate knowledge mobilization strategies

BACKGROUND

Evaluating knowledge mobilization strategies (KMb) presents challenges for organizations seeking to understand their impact to improve KMb effectiveness. Moreover, the large number of theories, models, and frameworks (TMFs) available can be confusing for users. Therefore, the purpose of this scoping review was to identify and describe the characteristics of TMFs that have been used or proposed in the literature to evaluate KMb strategies.

METHODS

A scoping review methodology was used. Articles were identified through searches in electronic databases, previous reviews and reference lists of included articles. Titles, abstracts and full texts were screened in duplicate. Data were charted using a piloted data charting form. Data extracted included study characteristics, KMb characteristics, and TMFs used or proposed for KMb evaluation. An adapted version of Nilsen (Implement Sci 10:53, 2015) taxonomy and the Expert Recommendations for Implementing Change (ERIC) taxonomy (Powell et al. in Implement Sci 10:21, 2015) guided data synthesis.

RESULTS

Of the 4763 search results, 505 were retrieved, and 88 articles were eligible for review. These consisted of 40 theoretical articles (45.5%), 44 empirical studies (50.0%) and four protocols (4.5%). The majority were published after 2010 (n = 70, 79.5%) and were health related (n = 71, 80.7%). Half of the studied KMb strategies were implemented in only four countries: Canada, Australia, the United States and the United Kingdom (n = 42, 47.7%). One-third used existing TMFs (n = 28, 31.8%). According to the adapted Nilsen taxonomy, process models (n = 34, 38.6%) and evaluation frameworks (n = 28, 31.8%) were the two most frequent types of TMFs used or proposed to evaluate KMb. According to the ERIC taxonomy, activities to "train and educate stakeholders" (n = 46, 52.3%) were the most common, followed by activities to "develop stakeholder interrelationships" (n = 23, 26.1%). Analysis of the TMFs identified revealed relevant factors of interest for the evaluation of KMb strategies, classified into four dimensions: context, process, effects and impacts.

CONCLUSIONS

This scoping review provides an overview of the many KMb TMFs used or proposed. The results provide insight into potential dimensions and components to be considered when assessing KMb strategies.

Treatment mechanism of the WHO caregiver skills training intervention for autism delivered in community settings

This study examined the mechanism of effect of the WHO Caregiver Skills Training (CST) through secondary analysis of a pilot RCT conducted in community settings. Participants were 86 caregivers (77% mothers) of children with ASD (78% male, mean age: 44.8 months) randomized to CST (n = 43) or treatment as usual (n = 43). The primary outcomes, measured at baseline (t1), immediately post-intervention (t2), and 3 months post-intervention (t3), were derived from the coding of caregiver-child free play interactions with the Brief Observation of Social-Communication Change (BOSCC) and the Joint Engagement Rating Inventory scale (JERI). At t3 positive treatment main effects had been observed for caregiver skills supportive of the interaction and for flow of the interaction (JERI), albeit only non-significant changes in the expected direction for child outcomes: autism phenotypic behaviors (BOSCC), joint engagement and availability to interact (JERI). This study tested the theory of change of CST, hypothesizing that the intervention would lead to an improvement on all child and dyad outcomes through an increase in the caregiver skills supportive of the interaction. Serial mediation analyses revealed that the effect of the intervention was significantly influenced by change in caregiver skills. Participation in the intervention led to notable increases in caregiver skills at t2 and t3, which subsequently contributed to improvements at t3 in flow of the interaction, autism phenotypic behavior, joint engagement, and availability to interact. We confirmed our a priori hypothesis showing that change in caregiver skills significantly mediated the effect of treatment on the dyad primary outcome, as well as on the other child outcomes that had shown non-significant changes in the expected direction. Implications for intervention design and policy making in the context of public health services are discussed.

Uncovering determinants of perceived feasibility of TF-CBT through coincidence analysis

Introduction

A mental health provider's perception of how well an intervention can be carried out in their context (i.e., feasibility) is an important implementation outcome. This article aims to identify determinants of feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) through a case-based causal approach.

Method

Data come from an implementation-effectiveness study in which lay counselors (teachers and community health volunteers) implemented a culturally adapted manualized mental health intervention, TF-CBT, delivered to teens who were previously orphaned and were experiencing posttraumatic stress symptoms and prolonged grief in Western Kenya. The intervention team identified combinations of determinants that led to feasibility among teacher- and community health volunteer-counselors through coincidence analysis.

Results

Among teacher-counselors, organizational-level factors (implementation climate, implementation leadership) determined moderate and high levels of feasibility. Among community health volunteer-counselors, a strong relationship between a clinical supervisor and the supervisee was the most influential determinant of feasibility.

Conclusion

Methodology and findings from this article can guide the assessment of determinants of feasibility and the development of implementation strategies for manualized mental health interventions in contexts like Western Kenya.

Plain Language Summary

A mental health provider's perception of how easy a therapy is to use in their work setting (i.e., feasibility) can impact whether the provider uses the therapy in their setting. Implementation researchers have recommended finding practices and constructs that lead to important indicators that a therapy will be used. However, limited research to our knowledge has searched and found practices and constructs that might determine feasibility of a therapy. This article uses existing data from a large trial looking at the continued use of a trauma-focused therapy to find practices and constructs that lead to moderate and high levels of feasibility. We found that in settings with a strong organizational structure that organization and leadership support for the therapy led to teachers in Kenya to perceive the therapy as easy to use. On the other hand, in settings with a weaker organizational structure, outside support from a clinical supervisor led to community health volunteers in Kenya perceiving the therapy as easy to use. The findings from this article can guide context-specific recommendations for increasing perceived therapy feasibility at the provider-, organization-, and policy levels.

Pilot evaluation of the Fiscal Mapping Process for sustainable financing of evidence-based youth mental health treatments: A comparative case study analysis

Background

Sustained delivery of evidence-based treatments (EBTs) is essential to addressing the public health impacts of youth mental health problems, but is complicated by the limited and fragmented funding available to youth mental health service agencies. Supports are needed that can guide service agencies in accessing sustainable funding for EBTs. We conducted a pilot evaluation of the Fiscal Mapping Process, an Excel-based strategic planning tool that helps service agency leaders identify and coordinate financing strategies for their EBT programs.

Method

Pilot testing of the Fiscal Mapping Process was completed with 10 youth mental health service agencies over a 12-month period, using trauma-focused cognitive-behavioral therapy or parent-child interaction therapy programs. Service agency representatives received initial training and monthly coaching in using the tool. We used case study methods to synthesize all available data (surveys, focus groups, coaching notes, document review) and contrast agency experiences to identify key findings through explanation building.

Results

Key evaluation findings related to the process and outcomes of using the Fiscal Mapping Process, as well as contextual influences. Process evaluation findings helped clarify the primary use case for the tool and identified the importance-and challenges-of engaging external collaborators. Outcome evaluation findings documented the impacts of the Fiscal Mapping Process on agency-reported sustainment capacities (strategic planning, funding stability), which fully explained reported improvements in outcomes (extent and likelihood)-although these impacts were incremental. Findings on contextual factors documented the influence of environmental and organizational capacities on engagement with the tool and concerns about equitable impacts, but also the view that the process could usefully generalize to other EBTs.

Conclusions

Our pilot evaluation of the Fiscal Mapping Process was promising. In future work, we plan to integrate the tool into EBT implementation initiatives and test its impact on long-term sustainment outcomes across various EBTs, while increasing attention to equity considerations.

Impact of a Virtual Suicide Safety Planning Training on Clinician Knowledge, Self-Efficacy, and Use of Safety Plans in Community Mental Health Clinics

OBJECTIVE

Safety planning is a critical evidence-based intervention used to prevent suicide among individuals who report suicidal ideation or behavior. There is a dearth of research on optimal ways to disseminate and implement safety plans in community settings. The present study examined one implementation strategy, a 1-hour virtual pre-implementation training, designed to teach clinicians to effectively use an electronic safety plan template (ESPT), integrated with suicide risk assessment tools, in the context of a measurement feedback system. We examined the effect of this training on clinician knowledge and self-efficacy in use of safety planning as well as ESPT completion rates.

METHOD

Thirty-six clinicians across two community-based clinical psychology training clinics completed the virtual pre-implementation training as well as pre- and post-training knowledge and self-efficacy assessments. Twenty-six clinicians completed a 6-month follow-up term.

RESULTS

Clinicians reported significant improvements in self-efficacy and knowledge from pre- to post-training. They retained significant improvements in self-efficacy and a trend toward greater knowledge at the 6-month follow-up. Of the clinicians who worked with suicidal youth, 81% attempted to use an ESPT and 63% successfully completed all sections of the ESPT. Reasons for partial completion included technological difficulties and time constraints.

CONCLUSION

A brief virtual pre-implementation training can improve clinician knowledge and self-efficacy in use of an ESPT with youth at risk for suicide. This strategy also holds the potential to improve the adoption of this novel evidence-based intervention in community-based settings.

An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER)

BACKGROUND

Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation.

METHODS

We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews).

DISCUSSION

Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes.

TRIAL REGISTRATION

Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.

Navigating the multiple dimensions of the creativity-mental disorder link: a Convergence Mental Health perspective

BACKGROUND

This paper discusses a paradox in mental health. It manifests as a relationship between adverse "bad" effects (suffering, clinical costs, loss of productivity) in individuals and populations and advantageous "good" aspects of mental disorders. These beneficial aspects (scientific, artistic and political accomplishments) emanate at the societal level through the frequently unprecedented creativity of people suffering from mental disorders and their relatives. Such gains can contribute to societal innovation and problem-solving. Especially in times of accelerated social-ecological change, approaches are needed that facilitate best-possible mental health care but also recognize creative ideas conducive to beneficial clinical and social-ecological innovations as soon as possible.

DISCUSSION

This paper emphasizes the need to account for creativity as a crucial component in evolving mental health systems and societies. It highlights the need for wide-ranging approaches and discusses how research targeting multiple facets (e.g., brain level, cognitive neuroscience, psychiatry, neurology, socio-cultural, economic and other factors) might further our understanding of the creativity-mental disorder link and its importance for innovating mental health systems and societies.

CONCLUSION

Our discussion clarifies that considerable research will be needed to obtain a better understanding of how creativity associated with mental disorders may help to create more sustainable societies on a fast-changing planet through innovative ideas. Given the current-state-of-the-art of research and healthcare management, our discussion is currently speculative. However, it provides a basis for how pros and cons might be studied in the future through transdisciplinary research and collaborations across sectors of society.

Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): A modified Delphi study

Background

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

Method

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

Results

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

Discussion

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

Setting and Provider Predictors of Implementation Success for an Eating Disorder Prevention Program Delivered by College Peer Educators

INTRODUCTION

College students face increased risk for a variety of mental health problems but experience barriers to treatment access. Prevention programs, including those implemented by peer educators, may decrease treatment needs and increase service access. We examined the implementation of an evidence-based eating disorder prevention program, Body Project, delivered by college peer educators at 63 colleges/universities, comparing three levels of implementation support: (1) Train-the-Trainer (TTT) training; (2) TTT plus a technical assistance workshop (TTT + TA); and (3) TTT + TA with one year of quality assurance calls (TTT + TA + QA). The present study tested the degree to which indicators proposed by the Consolidated Framework for Implementation Research (CFIR) were associated with core implementation outcomes.

METHOD

We tested whether indices of CFIR domains (i.e., perceived intervention characteristics, outer and inner setting factors, provider characteristics, and implementation process) were correlated with three implementation outcomes (program reach, fidelity, effectiveness) during a 1-year implementation period.

RESULTS

Greater program reach was associated with implementation process, specifically the completion of more implementation activities (β = 0.46). Greater program fidelity was associated with higher positive (β = 0.44) and lower negative (β = - 0.43) perceptions of the Body Project characteristics, and greater reported general support for evidence-based practices (β = 0.41). Greater effectiveness was associated with lower negative perceptions of Body Project characteristics (d = 0.49).

CONCLUSIONS

Several implementation determinants proposed by the CFIR model predicted outcomes, especially intervention fidelity. Across the outcomes of interest, implementation determinants related to peer educator and supervisor perceived characteristics of the specific intervention and general attitudes towards evidence-based practices emerged as robust predictors to inform future work investigating ongoing implementation and sustainability of programs in university settings.

External and Internal Validity Considerations in Youth Effectiveness Trials: Lessons Learned from the COMET Study

OBJECTIVE

Effectiveness trials aim to increase the generalizability and public health impact of interventions. However, challenges associated with this design present threats to external and internal validity. This paper illustrates these challenges using data from a two-site randomized effectiveness trial, the Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET) and presents recommendations for future research.

METHOD

COMET was a randomized effectiveness trial conducted in 19 community mental health clinics in two states comparing three interventions: treatment as usual (TAU), TAU with measurement-based care (TAU+), and the Unified Protocol forTransdiagnostic Treatment of Emotional Disorders in Adolescents with MBC (UPA). Participants included 176 clinicians (mean age = 35.5; 85.8% cisgender female; 53.0% racially and/or ethnically minorized) and 196 adolescents (mean age = 14.7; 65.3% cisgender female; 69.4% racially and/or ethnically minorized). Analyses outlined participant flow from recruitment to study completion, described participant characteristics, and examined site differences.

RESULTS

Analysis of participant flow suggested that recruitment and retention of clinicians and adolescents was challenging, raising questions about whether participants were representative of participating clinics. Both the clinician and adolescent samples were racially and ethnically diverse and adolescents were low income and clinically complex. Significant site differences were observed in clinician and adolescent characteristics.

CONCLUSIONS

While this study was successful in recruiting a diverse and historically under-represented sample, difficulties in recruitment and retention raise questions about external validity and site differences present challenges to internal validity of study findings. Suggestions for future effectiveness studies, drawing from implementation science approaches, are discussed.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 3: Study protocol to evaluate sustainment in a hybrid type 2 effectiveness-implementation cluster-randomized trial

treatments (EBPTs) has advanced rapidly, research on the sustainment of implemented EBPTs remains limited. This is concerning, given that EBPT activities and benefits regularly decline post-implementation. To advance research on sustainment, the present protocol focuses on the third and final phase - the Sustainment Phase - of a hybrid type 2 cluster-randomized controlled trial investigating the implementation and sustainment of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for patients with serious mental illness and sleep and circadian problems in community mental health centers (CMHCs). Prior to the first two phases of the trial - the Implementation Phase and Train-the-Trainer Phase - TranS-C was adapted to fit the CMHC context. Then, 10 CMHCs were cluster-randomized to implement Standard or Adapted TranS-C via facilitation and train-the-trainer. The primary goal of the Sustainment Phase is to investigate whether adapting TranS-C to fit the CMHC context predicts improved sustainment outcomes.

Methods

Data collection for the Sustainment Phase will commence at least three months after implementation efforts in partnering CMHCs have ended and may continue for up to one year. CMHC providers will be recruited to complete surveys (N = 154) and a semi-structured interview (N = 40) on sustainment outcomes and mechanisms. Aim 1 is to report the sustainment outcomes of TranS-C. Aim 2 is to evaluate whether manipulating EBPT fit to context (i.e., Standard versus Adapted TranS-C) predicts sustainment outcomes. Aim 3 is to test whether provider perceptions of fit mediate the relation between treatment condition (i.e., Standard versus Adapted TranS-C) and sustainment outcomes. Mixed methods will be used to analyze the data.

Discussion

The present study seeks to advance our understanding of sustainment predictors, mechanisms, and outcomes by investigating (a) whether the implementation strategy of adapting an EBPT (i.e., TranS-C) to the CMHC context predicts improved sustainment outcomes and (b) whether this relation is mediated by improved provider perceptions of treatment fit. Together, the findings may help inform more precise implementation efforts that contribute to lasting change.

Trial Registration

ClinicalTrials.gov identifier: NCT05956678. Registered on July 21, 2023. https://classic.clinicaltrials.gov/ct2/show/NCT05956678?term=NCT05956678&draw=2&rank=1.

Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World

Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.

De-implementation of Low-Value Practices for Autism Spectrum Disorder

Due to a variety of factors, Autism Spectrum Disorder (ASD) has long been tethered to use of low-value practice (LVP), arguably moreso than any other psychiatric or neurodevelopmental condition. Although dissemination of empirically supported treatments (EST) for autistic individuals has expanded markedly over the past decade, there has not been concomitant reduction in the use of LVP. It is critical that clinicians and scientists not only promote the implementation of EST, but also facilitate the de-implementation (abandonment and/or divestment) of ineffective or harmful practices. In this review, we describe a data-driven approach that can be used to identify LVP, drawing from established criteria for identification of evidence-based treatments (e.g., APA Division 12, National Clearinghouse on Autism Evidence and Practice; SAMHSA), as well as broader considerations such as social validity, cost, and parsimony. Herein, a data-based approach to LVP identification is proposed with a goal of improving quality of service access. Within an implementation science framework, we identify specific facilitators that sustain LVP use, and recommendations for subsequent de-implementation strategies are offered.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: study protocol for a hybrid type 2 effectiveness-implementation cluster-randomized trial using train-the-trainer

BACKGROUND

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes and (b) providers' perceptions of fit.

METHODS

TTT will be implemented in nine CMHCs in California, USA (N = 60 providers; N = 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality), and (3) evaluate other possible moderators.

DISCUSSION

This trial has potential to (a) inform the process of embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) add to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advance our understanding of providers' perceptions of EBPT "fit" across TTT generations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05805657 . Registered on April 10, 2023.

Needs assessment for behavioral parent training for ADHD in Brazil

Introduction

Attention-Deficit/Hyperactivity Disorder (ADHD) is a debilitating condition affecting children and their families worldwide. Behavioral parent training is a recommended form of empirically supported non-pharmacological intervention for young children with mild to moderate ADHD. However, access to such treatment is limited in many countries. Here we identify the treatment needs of Brazilian families with children demonstrating symptoms of ADHD, and the barriers families face in accessing behavioral treatment.

Methods

A qualitative needs assessment was undertaken with parents (n = 23), educators (n = 15), and healthcare providers (n = 16). Semi-structured telephone interviews were conducted, and common themes were identified through inductive coding of participants' responses.

Results

Participants reported a lack of accessible behavioral treatment, and delays in accessing treatment when available. The majority of parents had not received behavioral parent training, despite it being a recommended form of treatment. Parents, educators and healthcare providers strongly endorsed a need for practical tools to manage the behavior of children with ADHD.

Conclusion

Existing services might not meet the needs of children with ADHD and their families in Brazil. Easily accessed behavioral parent training programs are recommended to address the identified treatment gap for Brazilian children with ADHD and their families.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: Study protocol for a hybrid type 2 effectiveness-implementation cluster- randomized trial using train-the-trainer

Background

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes (b) providers' perceptions of fit.

Methods

TTT will be implemented in nine CMHCs in California, United States (N= 60 providers; N= 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will: (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality); and (3) evaluate other possible moderators.

Discussion

This trial has potential to inform the process of (a) embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) adding to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advancing our understanding of providers' perceptions of EBPT 'fit' across TTT generations.

Trial registration

Clinicaltrials.gov identifier: NCT05805657. Registered on April 10, 2023. https://clinicaltrials.gov/ct2/show/NCT05805657.

Intentional practice: a common language, approach and set of methods to design, adapt and implement contextualised wellbeing solutions

Reducing the "science-to-practice" gap has gained significant attention across multi-disciplinary settings, including school psychology and student wellbeing, trauma-informed practice, community and human services, and clinically focused health care. There has been increasing calls for complexity and contextualisation to be integrated within the implementation science literature. This includes the design and implementation of interventions spanning "systems" (whole-of-community capacity building initiatives), "programs" (e.g., evidence-based programs, clinical interventions) and "moment-to-moment" support or care. The latter includes responses and communication designed to deliver specific learning, growth or wellbeing outcomes, as personalised to an individual's presenting needs and context (e.g., trauma-informed practice). Collectively, this paper refers to these interventions as "wellbeing solutions". While the implementation science literature offers a range of theories, models and approaches to reduce the science-to-practice gap in wellbeing solution design and implementation, they do not operationalise interventions into the "moment", in a manner that honours both complexity and contextualisation. Furthermore, the literature's language and content is largely targeted towards scientific or professional audiences. This paper makes the argument that both best-practice science, and the frameworks that underpin their implementation, need to be "sticky", practical and visible for both scientific and non-scientific knowledge users. In response to these points, this paper introduces "intentional practice" as a common language, approach and set of methods, founded upon non-scientific language, to guide the design, adaptation and implementation of both simple and complex wellbeing solutions. It offers a bridge between scientists and knowledge users in the translation, refinement and contextualisation of interventions designed to deliver clinical, wellbeing, growth, therapeutic and behavioural outcomes. A definitional, contextual and applied overview of intentional practice is provided, including its purported application across educational, wellbeing, cross-cultural, clinical, therapeutic, programmatic and community capacity building contexts.

Team-focused implementation strategies to improve implementation of mental health screening and referral in rural Children's Advocacy Centers: study protocol for a pilot cluster randomized hybrid type 2 trial

BACKGROUND

Children's Advocacy Centers (CACs) use multidisciplinary teams to investigate and respond to maltreatment allegations. CACs play a critical role in connecting children with mental health needs to evidence-based mental health treatment, especially in low-resourced rural areas. Standardized mental health screening and referral protocols can improve CACs' capacity to identify children with mental health needs and encourage treatment engagement. In the team-based context of CACs, teamwork quality is likely to influence implementation processes and outcomes. Implementation strategies that target teams and apply the science of team effectiveness may enhance implementation outcomes in team-based settings.

METHODS

We will use Implementation Mapping to develop team-focused implementation strategies to support the implementation of the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), a standardized screening and referral protocol. Team-focused strategies will integrate activities from effective team development interventions. We will pilot team-focused implementation in a cluster-randomized hybrid type 2 effectiveness-implementation trial. Four rural CACs will implement the CPM-PTS after being randomized to either team-focused implementation (n = 2 CACs) or standard implementation (n = 2 CACs). We will assess the feasibility of team-focused implementation and explore between-group differences in hypothesized team-level mechanisms of change and implementation outcomes (implementation aim). We will use a within-group pre-post design to test the effectiveness of the CPM-PTS in increasing caregivers' understanding of their child's mental health needs and caregivers' intentions to initiate mental health services (effectiveness aim).

CONCLUSIONS

Targeting multidisciplinary teams is an innovative approach to improving implementation outcomes. This study will be one of the first to test team-focused implementation strategies that integrate effective team development interventions. Results will inform efforts to implement evidence-based practices in team-based service settings.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05679154 . Registered on January 10, 2023.

Misalignment in Community Mental Health Leader and Therapist Ratings of Psychological Safety Climate Predicts Therapist Self-Efficacy with Evidence-Based Practices (EBPs)

Therapist self-efficacy in delivering evidence-based practices (EBPs) is associated with implementation outcomes, including adoption and sustainment in community mental health settings. Inner context organizational climate, including psychological safety, can proximally shape therapist learning experiences within EBP implementation. Psychologically safe environments are conducive to learning behaviors including taking risks, admitting mistakes, and seeking feedback. Organization leaders are instrumental in facilitating psychological safety, but may have differing perspectives of organizational climate than front-line therapists. Discrepant leader and therapist views of psychological safety may have independent associations with therapist EBP learning and implementation outcomes over and above average therapist perceptions of climate. This study examined survey data from 337 therapists and 123 leaders from 49 programs contracted to deliver multiple EBPs within a study examining determinants of sustainment within a large system-driven implementation. Both leaders and therapists completed measures of psychological safety climate and therapists reported on their self-efficacy in delivering multiple EBPs in children's mental health services. Polynomial regression and response surface analysis models were conducted to examine the associations of therapist and leader reports of psychological safety and therapist EBP self-efficacy. Greater discrepancies between leader and therapist reports of psychological safety, in either direction, were associated with lower therapist EBP self-efficacy. Alignment in leader and therapist views of psychological safety climate may impact EBP implementation outcomes. Strategies for improving alignment in perceptions and priorities among organizational members can be included in organizational implementation interventions and may represent unexamined implementation mechanisms of action.

Protocol for a randomised pilot study of a novel Parent-Child Interaction Therapy (PCIT) 're-implementation' intervention

BACKGROUND

Despite a number of clinicians having been trained in Parent-Child Interaction Therapy (PCIT) in Aotearoa/New Zealand, few are regularly delivering the treatment, with barriers to use including a lack of suitable equipment and lack of professional support. This pragmatic, parallel-arm, randomised, controlled pilot trial includes PCIT-trained clinicians who are not delivering, or only rarely utilising, this effective treatment. The study aims to assess the feasibility, acceptability and cultural responsivity of study methods and intervention components and to collect variance data on the proposed future primary outcome variable, in preparation for a future, larger trial.

METHODS

The trial will compare a novel 're-implementation' intervention with a refresher training and problem-solving control. Intervention components have been systematically developed to address barriers and facilitators to clinician use of PCIT using implementation theory, and a draft logic model with hypothesised mechanisms of action, derived from a series of preliminary studies. The intervention includes complimentary access to necessary equipment for PCIT implementation (audio-visual equipment, a 'pop-up' time-out space, toys), a mobile senior PCIT co-worker and an optional weekly PCIT consultation group, for a 6-month period. Outcomes will include the feasibility of recruitment and trial procedures; acceptability of the intervention package and data collection methods to clinicians; and clinician adoption of PCIT.

DISCUSSION

Relatively little research attention has been directed at interventions to resurrect stalled implementation efforts. Results from this pragmatic pilot RCT will refine and shape knowledge relating to what it might take to embed the ongoing delivery of PCIT in community settings, providing more children and families with access to this effective treatment.

TRIAL REGISTRATION

ANZCTR, ACTRN12622001022752, registered on July 21, 2022.

The Interaction Between General and Strategic Leadership and Climate on Their Multilevel Associations with Implementer Attitudes Toward Universal Prevention Programs for Youth Mental Health: A Cross-Sectional Study

Emerging literature has highlighted the importance of discerning general and strategic organizational context (OC) factors (e.g., leadership and climate) and their interaction effect on individual implementation behaviors (e.g., attitudes toward evidence-based practices; EBPs) in youth mental healthcare. This study aimed to examine how leadership and climate (general and strategic) are associated with implementer attitudes toward EBPs across the individual and organizational levels and their interaction effect in schools. A series of multilevel models (MLMs) were fitted on a diverse sample of schools actively implementing universal prevention programs for youth mental health (441 implementers from 52 schools). The organization-level aggregates and individual educators' perceptions of general and strategic leadership and climate, and their interaction terms, were entered as level-2 and level-1 predictors of four attitudinal dimensions (Requirement, Openness, Appeal, and Divergence) based on their level of measurement. At the organizational level, higher levels of strategic leadership and climate, but not their general counterparts, were consistently associated with more favorable attitudes in all four dimensions. At the individual/within-school level, higher levels of perceived general and strategic leadership and climate were associated with more favorable attitudes of Requirement and Openness. At the organizational/between-school level, general climate moderated the positive effect of strategic climate on implementers' perception of appeal and divergence of EBPs. Our findings indicate that leaders should make data-based decisions to allocate resources on strategic and/or general leadership and climate to foster favorable staff attitudes toward EBPs based on the level of measurement, implementation-specificity, and attitudinal dimensions.

Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study

BACKGROUND

Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations.

METHODS

We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns.

RESULTS

Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine.

CONCLUSION

The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.

A Pre-Implementation Enhancement Strategy to Increase the Yield of Training and Consultation for School-Based Behavioral Preventive Practices: a Triple-Blind Randomized Controlled Trial

As the most common setting where youth access behavioral healthcare, the education sector frequently employs training and follow-up consultation as cornerstone implementation strategies to promote the implementation of evidence-based practices (EBPs). However, these strategies alone are not sufficient to promote desirable implementation (e.g., intervention fidelity) and youth behavioral outcomes (e.g., mitigated externalizing behaviors). Theory-informed pragmatic pre-implementation enhancement strategies (PIES) are needed to prevent the lackluster outcomes of training and consultation. Specifically, social cognitive theory explicates principles that inform the design of PIES content and specify mechanisms of behavior change (e.g., "intentions to implement" (ITI)) to target increasing providers' responsiveness to training and consultation. This triple-blind parallel randomized controlled trial preliminarily examined the efficacy of a pragmatic PIES based on social cognitive theories (SC-PIES) to improve implementation and youth behavioral outcomes from universal preventive EBPs in the education sector. Teachers from a diverse urban district were recruited and randomly assigned to the treatment (SC-PIES; ntreatment = 22) or active control condition (administrative meeting; ncontrol = 21). Based on the condition assigned, teachers received the SC-PIES or met with administrators before their EBP training. We assessed teachers' ITI, intervention fidelity, and youth behavioral outcome (academic engagement as an incompatible behavior to externalizing disorders) at baseline, immediately after training, and 6 weeks afterward. A series of ANCOVAs detected sizeable effects of SC-PIES, where teachers who received SC-PIES demonstrated significantly larger improvement in their ITI, intervention fidelity, and youth behaviors as compared to the control. Conditional analyses indicated that teachers' ITI partially mediated the effect of SC-PIES on intervention fidelity, which in turn led to improved youth behaviors. Findings suggest that theory-informed pragmatic PIES targeting providers' ITI can boost their responsiveness to implementation strategies, as reflected in improved implementation behaviors and youth behavioral outcomes. The results have implications for targeting motivational mechanisms of behavior change and situating preventive implementation strategies at the intersection between the preparation and active implementation stages of an implementation process. Limitations and implications for research and practice are discussed. Clinicaltrials.gov: NCT05240222. Registered on: 2/14/2022. Retrospectively registered.  https://clinicaltrials.gov/show/NCT05240222.