The CFIR Card Game: a new approach for working with implementation teams to identify challenges and strategies

Feasibility and acceptability of caring contacts texts for suicide prevention among veterans recently separated from military service

The primary purpose of this single-arm mixed-methods pilot trial was to examine the feasibility, acceptability, and preliminary effects of a text message-based version of Caring Contacts, Caring Contacts texts (CC-t), among veterans recently separated from military service. Twenty-four veterans (Mage = 32.92, SD = 8.16; 75% male; 50% Black; 91.7% non-Hispanic/Latinx) were recruited through the Department of Veterans Affairs (VA) and enrolled in CC-t, which involved approximately five text messages sent by the study team expressing care and concern over the course of 3 months. Participants completed pre- and postintervention assessments and an interview, during which self-reported feasibility and acceptability of CC-t, and preliminary effects of CC-t on health care engagement and suicide risk were assessed. Self-reported feasibility and acceptability of CC-t were also assessed among VA staff involved in the study. Among veterans and VA staff, scores on the Feasibility of Intervention Measure (M = 17.91 and M = 15.67, respectively) and Acceptability of Intervention Measure (M = 18.19; M = 19.33, respectively) were above the mean, suggesting that CC-t was easy to engage in or implement and was well-tolerated. These findings were reinforced in the qualitative feedback, which suggested that veterans found the text messages to be comfortable, convenient, and had a positive impact on their mood. Quantitative results provided preliminary evidence for improved veteran health care engagement following CC-t. CC-t appears to be feasible and acceptable among veterans and VA staff and holds promise as a primary suicide prevention for veterans making the transition from military service to civilian life. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Facilitators and barriers to implementation of early intensive manual therapies for young children with cerebral palsy across Canada

BACKGROUND

Cerebral Palsy (CP) is the most common childhood-onset motor disability. Play-based early intensive manual therapies (EIMT) is an evidence-based practice to improve long-term hand function particularly for children with asymmetric hand use due to CP. For children under two years old, this therapy is often delivered by caregivers who are coached by occupational therapists (OTs). However, why only a few Canadian sites implement this therapy is unclear. There is a need to identify strategies to support implementation of EIMT. The primary objective of this study was to identify the facilitators and barriers to EIMT implementation from the perspectives of (1) caregivers of children with CP (2), OTs and (3) healthcare administrators for paediatric therapy programs.

METHODS

The Consolidated Framework for Implementation Research (CFIR) was used to guide development of an online 5-point Likert scale survey to identify facilitators (scores of 4 and 5) and barriers (scores of 1 and 2) to implementation of EIMT. Three survey versions were co-designed with knowledge user partners for distribution to caregivers, OTs, and healthcare administrators across Canada. The five most frequently endorsed facilitators and barriers were identified for each respondent group.

RESULTS

Fifteen caregivers, 54 OTs, and 11 healthcare administrators from ten Canadian provinces and one territory participated in the survey. The majority of the identified facilitators and barriers were within the 'Inner Setting' CFIR domain, with 'Structural Characteristics' emerging as the most reported CFIR construct. Based on the categorization of the most frequently endorsed facilitators and barriers within the CFIR domains, the key facilitators to EIMT implementation included the characteristics of the intervention and establishing positive workplace relationships and culture. The key barriers included having workplace restrictions on EIMT delivery models and external influences (e.g., funding) on EIMT uptake.

CONCLUSIONS

We identified key facilitators and barriers to implementing EIMT from a multi-level Canadian context. These findings will inform the next steps of designing evidence-informed and theory-driven implementation strategies to support increased delivery of EIMT for children under two years old with asymmetric hand use due to CP across Canada.

Bridging the gap: translating and simplifying CFIR 2.0 for French practitioners in implementation science

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR) 2.0 is widely used in implementation projects but can be difficult for non-researchers to apply due to its complexity. While a French version of the original CFIR exists, CFIR 2.0 had not yet been translated. This study aimed to translate and simplify CFIR 2.0 for healthcare practitioners in French-speaking Switzerland to improve its accessibility and utility.

METHOD

Using the Principles of Good Practice for Translation and Cultural Adaptation, the process included: (1) four independent forward translations, (2) reconciliation of simplified definitions, (3) online survey with 16 clinical nurse specialists to assess the content validity of the simplified definitions, (4) back translation, and (5) harmonization to finalize the French version. The content validity of each construct was assessed using the Content Validity Index (CVI), with further revisions based on feedback.

RESULTS

Most participants found the simplified definitions understandable, with an average score of 1.46 (where 1 is "very easy to understand" and 2 is "easy to understand"). Thirteen items with lower I-CVI scores (≤ 0.78) were revised. The overall S-CVI was 0.87, indicating high content validity. Minor discrepancies in the back translation were resolved.

CONCLUSIONS

This study produced a French translation of CFIR 2.0 with simplified definitions tailored for healthcare practitioners. The high content validity and feedback underscore the need for contextually relevant adaptations to enhance the practical use of the CFIR framework. Further testing in diverse French-speaking contexts is necessary to refine the tool and broaden its applicability in real-world settings.

Facilitators and barriers to implementing the Diabetes Prevention Program in rural church settings: A qualitative study using the Consolidated Framework for Implementation Research

PURPOSE

The CDC's Diabetes Prevention Program (DPP) is an effective lifestyle intervention to prevent type 2 diabetes (T2D). However, DPP implementation in rural areas is limited. This study sought to address this gap by implementing DPP in rural church settings through a community-academic partnership and identifying implementation facilitators and barriers.

METHODS

This was a cross-sectional qualitative study. Semistructured interviews guided by the Consolidated Framework for Implementation Research (CFIR) assessed church leaders' and lifestyle coaches' perceptions of implementing DPP in rural churches. Thematic analysis was used to identify key themes through an inductive approach; then, these emergent themes were deductively linked to CFIR constructs. COREQ guidelines were used to report study findings.

FINDINGS

Twenty-five stakeholders participated. Facilitators to implementing DPP included its evidence-based effectiveness in preventing T2D, as well as support from the academic partner in terms of funding, training, and communication. Additionally, DPP's alignment with community needs, along with the active engagement of pastors in participant recruitment, supported implementation. Several barriers hindered DPP implementation, including transportation and childcare issues, as well as program participants' medical conditions/disabilities limiting their participation. Furthermore, rural residents' reluctance to adopt lifestyle changes and loyalty to family churches posed challenges to their engagement in DPP.

CONCLUSIONS

This study identified contextual factors influencing DPP implementation in rural communities. Findings highlight the importance of tailored strategies that leverage facilitators while proactively addressing barriers, including rural residents' reluctance to attend programs outside their church, resistance to lifestyle changes, and transportation issues to ensure successful DPP implementation in rural areas.

Finding the right dose: a scoping review examining facilitation as an implementation strategy for evidence-based stroke care

BACKGROUND

Despite evidence supporting interventions that improve outcomes for patients with stroke, their implementation remains suboptimal. Facilitation can support implementation of research into clinical practice by helping people develop the strategies to implement change. However, variability in the amount (dose) and type of facilitation activities/facilitator roles that make up the facilitation strategies (content), may affect the effectiveness of facilitation. This review aimed to determine if, and how, facilitation dose is measured or reported and the type of facilitation strategies used to support adoption of stroke interventions in hospitals and subacute settings. We also assessed whether the included studies had reporting checklists or guidelines.

METHODS

The scoping review was based on Arksey and O'Malley's framework. Cochrane, CINAHL and MEDLINE databases were searched to identify randomised trials and quasi-experimental studies of stroke interventions published between January 2017 and July 2023. Accompanying publications (quantitative, qualitative, mixed methods or process evaluation papers) from eligible studies were also included. Narrative data synthesis was undertaken.

RESULTS

Ten studies (23 papers) from 649 full-text papers met the inclusion criteria. Only two studies reported the total facilitation dose, measured as the frequency and duration of facilitation encounters. Authors of the remaining eight studies reported only the frequency and/or duration of varying facilitation activities but not the total dose. The facilitation activities included remote external facilitator support via ongoing telecommunication (phone calls, emails, teleconferences), continuous engagement from on-site internal facilitators, face-to-face workshops and/or education sessions from external or internal facilitators. Facilitator roles were broad: site-specific briefing, action planning and/or goal setting; identifying enablers and barriers to change; coaching, training, education or feedback; and network support. Only two studies included reporting checklists/guidelines to support researchers to describe interventions and implementation studies in sufficient detail to enable replication.

CONCLUSIONS

There is a paucity of information on the measurement of facilitation dose and reporting on specific details of facilitation activities in stroke implementation studies. Detailed reporting of dose and content is needed to improve the scientific basis of facilitation as strategic support to enable improvements to stroke care. Development of a standardised measurement approach for facilitation dose would inform future research and translation of findings.

A family-centered approach to social needs awareness in the pediatric emergency department

Objective

We aimed to understand family preferences around reporting and receiving health-related social needs (HRSN) information by assessment modality during pediatric emergency department (PED) visits.

Methods

Families were randomized into paper (control), cell phone, or tablet modality groups by their child's exam room. Nurses alerted families to complete a single HRSN assessment during routine workflow. We used logistic regression and McNemar's test to assess discordance in modality preference.

Results

Forty-seven percent of families disclosed at least one HRSN across a total 611 assessments. Disclosure of HRSN was similar by modality. Twenty-three percent of those assigned tablet preferred cell phone (p < 0.001). Two-thirds of families preferred receiving digitally formatted community resources (email or text). There was no difference in preferred timing of HRSN assessment completion.

Conclusions

Assessment modality did not appear to influence family HRSN disclosure. Families were generally satisfied with all HRSN assessment modalities but demonstrated a particular preference in using personal cell phones over tablets. Digitally formatted community referrals also pose numerous advantages over conventional paper handouts.

Innovation

Use of personal cell phones is a novel, streamlined method of HRSN interventions in the clinical setting, performing similar to more conventional modalities, with a preference among families when compared to tablets.

A new model for the diagnostic assessment services trajectory for neurodevelopmental conditions

Purpose

The Canadian province of Québec faces several issues regarding the accessibility and quality of diagnostic assessment and the efficiency and continuity of evaluation, support, and intervention services for children with neurodevelopmental conditions (NDCs). To address these issues, the Ministry of Health and Social Services mandated a research team to initiate the development of a reference trajectory, i.e., a proposed model pathway based on national and international best practices and research, for the diagnostic assessment of NDCs in children aged 0-7 years.

Methods

The present study focused on the development of a logic model to operationalize the diagnostic services trajectory using a community-based participatory research approach and informed by implementation science. This involved representatives from multiple stakeholder groups (e.g., parents, professionals, physicians, administrators, researchers). Project steps included an analysis of best practices from a literature review on diagnostic trajectories, focus groups and interviews with stakeholders, and a validation process to ensure the appropriateness of the final model.

Results

The integration of existing research and stakeholder input resulted in a logic model for a new diagnostic services trajectory for children aged 0-7 years suspected of NDCs and identified key ingredients that should be present in its future implementation.

Conclusion

The proposed model for a diagnostic services trajectory is expected to address several systemic issues identified previously. Its implementation will need to be evaluated to ensure its sustained focus on the needs of families and its ability to promote their quality of life, well-being, and involvement.

Supporting psychosis research, implementation, and training through an academic intermediary-purveyor organization

Intermediary-purveyor organizations (IPOs) are a type of dissemination support system that are intended to enhance the adoption and sustainment of empirically supported treatments (ESTs) by deploying empirically supported strategies to remediate implementation challenges. Despite the recent proliferation of government-funded IPOs for other psychiatric populations, IPOs that can redress the substantial science-to-practice gap among clients who experience psychotic disorders are not well documented. This article provides an overview of an IPO in an R1 academic medical center whose mission is to enhance access to evidence-based interventions for individuals who have or are at risk for a psychotic disorder. The article spotlights the functions of an IPO and illustrates these functions with a use case, cognitive behavioral therapy for psychosis. We highlight IPO-led activities related to cognitive behavioral therapy for psychosis purveyance, professional development, quality improvement, public awareness education and training, research and evaluation, as well as program and policy development. Finally, we address the advantages and disadvantages of establishing IPOs of this nature in academic medical centers, the importance of academic-community partnerships in advancing EST implementation, and present considerations for replication. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

"Hypertension is such a difficult disease to manage": federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model

BACKGROUND

Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City.

METHODS

During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares.

CONCLUSIONS

This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.

Preference for daily (1HP) vs. weekly (3HP) isoniazid-rifapentine among people living with HIV in Uganda

BACKGROUND

Both 1 month of daily (1HP) and 3 months of weekly (3HP) isoniazid-rifapentine are recommended as short-course regimens for TB prevention among people living with HIV (PLHIV). We aimed to assess acceptability and preferences for 1HP vs. 3HP among PLHIV.

METHODS

In a cross-sectional survey among PLHIV at an HIV clinic in Kampala, Uganda, participants were randomly assigned to a hypothetical scenario of receiving 1HP or 3HP. Participants rated their level of perceived intention and confidence to complete treatment using a 0-10 Likert scale, and chose between 1HP and 3HP.

RESULTS

Among 429 respondents (median age: 43 years, 71% female, median time on ART: 10 years), intention and confidence were rated high for both regimens. Intention to complete treatment was rated at least 7/10 by 92% (189/206 randomized to 1HP) and 93% (207/223 randomized to 3HP). Respectively 86% (178/206) and 93% (208/223) expressed high confidence to complete treatment. Overall, 81% (348/429) preferred 3HP over 1HP.

CONCLUSIONS

Both 1HP and 3HP were highly acceptable regimens, with 3HP preferred by most PLHIV. Weekly, rather than daily, dosing appears preferable to shorter duration of treatment, which should inform scale-up and further development of short-course regimens for TB prevention.

A grounded theory-based qualitative approach for examining local implementation of public health policies during crises

Background

COVID-19's emergence questions the agility of health policy deployment in a context of urgency. This exceptional pandemic offers a unique Implementation Science study opportunity. It reveals how actors adapt, coordinate, and mitigate an unknown global threat to safeguard populations from an initially mysterious virus. Limited research has explored how involved players act and adapt their practices to fulfil health protection missions during a global health crisis. Bridging the gap between public policy expectations and achievements requires a methodology for stakeholder identification and implementation practice description.

Objective

Focusing on COVID-19 management in France's second-largest region, we investigate ministerial recommendation implementation and the emergence of new links, coordination modes, and practices.

Methods

Due to the novel subject, we adopted grounded theory. Initial documentary data collection identifies stakeholders for subsequent interviews. Open-ended coding of collected discourse enables content analysis.

Results

Findings reveal a crisis-driven re-evaluation of stakeholder relationships. This research identifies three levels of implementation of health policies at the local level (administrative, organizational and operational) and reveals different types of coordination specific to each of these levels. Our results provide insights on how to better coordinate and implement healthcare policies in a period of crisis. Recommendations include real-life simulations of large-scale crises.

Conclusion

Our work establishes a methodological foundation for analysing coordination dynamics. Future research could compare these findings with other unpredictable health emergencies, such as episiotomic veterinary health crises.•The first step of the method is to analyse the guidelines of health policy implementation during the Covid-19 crisis and to identify the main stakeholders in charge of the local health policy implementation.•The second step consists of interviewing these stakeholders using a co-constructed sample and structural coding of their speech to reveal the forms of coordination between stakeholders.

The role of organizational capacity in intervention efficacy in a church-based cancer education program: A configurational analysis

It is well-established in the field of implementation science that the context in which an intervention is delivered can play a crucial role in how well it is implemented. However, less is known about how organizational context or capacity relates to efficacy outcomes, particularly with health promotion interventions delivered outside of healthcare settings. The present study examined whether organizational capacity indicators were linked to key efficacy outcomes in an evidence-based cancer control intervention delivered in 13 African American churches in Maryland. Outcomes included increases in colorectal cancer knowledge and self-report colonoscopy screening behavior from baseline to follow-up. We used Coincidence Analysis to identify features of organizational capacity that uniquely distinguished churches with varying levels of cancer knowledge and screening. Indicators of organizational capacity (e.g., congregation size, prior health promotion experience) were from an existing measure of church organizational capacity for health promotion. A single solution pathway accounted for greater increases in colorectal cancer knowledge over 12 months, a combination of two conditions: conducting 3 or more health promotion activities in the prior 2 years together with not receiving any technical assistance from outside partners in the prior 2 years. A single condition accounted for greater increases in colonoscopy screening over 24 months: churches that had conducted health promotion activities in 1-4 different topical areas in the prior 2 years. Findings highlight aspects of organizational capacity (e.g., prior experience in health promotion) that may facilitate intervention efficacy and can help practitioners identify organizational settings most promising for intervention impact.

Community-based integrated care for patients with diabetes and depression (CIC-PDD): study protocol for a cluster randomized controlled trial

BACKGROUND

Managing the multimorbidity of diabetes and depression remains a clinical challenge for patients and healthcare professionals due to the fragmented healthcare delivery system. To effectively cope with multimorbidity, there is an urgent need for the health system to transform into people-centered integrated care (PCIC) system globally. Therefore, this paper describes the protocol of community-based integrated care for patients with diabetes and depression (CIC-PDD) project, an integrated and shared-care intervention project.

METHODS/DESIGN

CIC-PDD project is conducted in two phases, namely "care model development" and "implementation and evaluation." In the first phase, CIC-PDD model was designed and developed based on the four criteria of collaborative care model (CCM) and was subsequently adjusted to align with the context of China. The second phase entails a pragmatic, two-arm, cluster randomized controlled implementation trial, accompanied by parallel mixed-methods process evaluation and cost-effectiveness analysis.

DISCUSSION

We anticipate CIC-PDD project will facilitate the development and innovation of PCIC model and related theories worldwide, particularly in low- and middle-income countries (LMICs). In addition, CIC-PDD project will contribute to the exploration of primary health care (PHC) in addressing the multimorbidity of physical and mental health issues.

TRIAL REGISTRATION

ClinicalTrials.gov registration ChiCTR2200065608 (China Clinical Trials Registry https://www.chictr.org.cn ). Registered on November 9, 2022.

Improving retention and HIV viral load suppression among adolescents living with HIV in TASO Soroti and TASO Mbale centers of excellence using Operation Triple Zero model: a before and after study protocol

BACKGROUND

Retention in care and HIV viral load suppression remains sub-optimal among HIV positive adolescents in many settings including TASO Uganda, despite the implementation of interventions such as regimen optimization and community-based approaches like multi-month drug dispensing. To this end, the implementation of additional intervention is urgently required to address gaps in current programming which include inadequate centralization of the HIV positive adolescents and their caregivers in the designs. This study, thus, proposes to adapt and implement the Operation Triple Zero (OTZ) model in TASO Soroti and Mbale centers to improve both retention and viral load suppression among the adolescents living with HIV.

METHODOLOGY

A before and after study design is preferred, employing both qualitative and quantitative approaches. To identify barriers and facilitators to retention and HIV viral load suppression among the HIV positive adolescents, secondary data, focused group discussions, and key informant interviews will be used to understand perspectives of the adolescents, their caregivers, and the health-workers. The Consolidated Framework for Implementation Research (CFIR) will help in designing the intervention, while Knowledge to Action (K2A) will support the adaptation process. To test the intervention, Reach, Effectiveness, Adaption, Implementation and Maintenance (RE-AIM) framework will be used. A paired t-test will be used to compare means of retention and viral load suppression in the before and after study periods.

DISCUSSION

This study aims at adapting and implementing the OTZ model in TASO Soroti and Mbale Centers of Excellence (COEs) to attain optimal retention and HIV viral load suppression rates among the HIV positive adolescents in care. Uganda is yet to adapt the touted OTZ model and findings from this study will be important in providing the necessary lessons to inform a policy shift for potential scale up of the model. Furthermore, results of this study could provide additional evidence for the effectiveness of OTZ in attaining optimal HIV treatment outcomes among the adolescents living with HIV.

Identifying Methods to Select and Tailor Implementation Strategies to Context-Specific Determinants in Child Mental Health Settings: A Scoping Review

This scoping review describes the state of the literature regarding Implementation Strategy Mapping Methods (ISMMs) within the context of child mental health practice delivery. Goals included (a) identify and describe ISMMs addressing determinants of implementing mental health evidence-based interventions (MH-EBIs) for children and (b) describe the scope of the literature (e.g., outcomes, remaining gaps) related to identified ISMMs. Following PRISMA-ScR guidelines, 197 articles were identified. After removing 54 duplicates, 152 titles and abstracts were screened, yielding 36 articles that were screened during the full-text review. The final sample included four studies and two protocol papers (n = 6). A data charting codebook was developed a priori to capture relevant information (e.g., outcomes) and content analysis was utilized to synthesize findings. Six ISMMs were identified: innovation tournament, concept mapping, modified conjoint analysis, COAST-IS, focus group, and intervention mapping. ISMMs were successful in leading to the identification and selection of implementation strategies at participating organizations, and all ISMMs included stakeholders throughout these processes. Findings revealed the novelty of this research area and highlighted numerous areas for future investigation. Implications related to implementation, service, and client outcomes are discussed, including the possible impact of utilizing ISMMs to increase access to MH-EBIs for children receiving services in community settings. Overall, these findings contribute to our understanding of one of the five priority areas within implementation strategy research-enhancing methods used to design and tailor implementation strategies-by providing an overview of methods that may be utilized to facilitate MH-EBI implementation in child mental health care settings. Trial Registration: Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-023-00086-3.

Evaluation of opportunities to implement community-wide mass drug administration for interrupting transmission of soil-transmitted helminths infections in India

BACKGROUND

The World Health Organization Neglected Tropical Disease (NTD) guidelines recommend control of soil transmitted helminth (STH)-associated morbidity with targeted deworming of preschool and school-aged children who are disproportionately affected by STH-associated morbidity. However, this strategy leaves many adults untreated and reinfection within communities perpetuates transmission even when mass drug administration (MDA) coverage of children is high. Evidence suggests that it may be possible to interrupt STH transmission by expanding MDA to a community-wide MDA (cMDA).

METHODS

This multi-methods study of organizational readiness survey, key informant interviews, and program mapping, were conducted with government stakeholders in three Indian states, Goa, Sikkim, and Odisha, to assess readiness of the states for transitioning from school-based MDA to cMDA and identify opportunities to leverage existing infrastructure from other NTD programs like lymphatic filariasis (LF) for STH cMDA.

PRINCIPAL FINDINGS

Overall, all three states indicated a highly favorable policy environment, effective leadership structure, adequate material resources, demonstrated technical capacity, and adequate community infrastructure needed to launch a STH cMDA program. The findings indicated a high-level of health system readiness to implement provided human resources and financial resources to deliver cMDA is strengthened. Areas with a significant overlap between LF and STH MDA platforms, particularly at the community-level, may be best primed for transitioning. Immunization, maternal child health, and non-communicable disease control programs were the other programs for possible integration of cMDA. States indicated having effective leadership structures in place at the state-level, however, engaging local leaders and community groups were considered crucial for successful implementation of cMDA. In-migration was a perceived challenge for estimating drug requirement and preventing possible stockouts.

CONCLUSIONS

Findings from this study are intended to proactively support government decision making, prioritization, and program planning across heterogenous implementation contexts in India to speed the translation of research findings into practice.

CLINICAL TRIAL REGISTRATION

NCT03014167; ClinicalTrials.gov.

Prescription of potentially addictive medications after a multilevel community intervention in general practice

OBJECTIVE

To evaluate the long-term effects of a multilevel community intervention to improve the quality of prescription practice of potentially addictive medications (PAMs).

DESIGN

We conducted a retrospective study, using anonymized data from the Norwegian prescription registry.

SETTING

Based on an initiative from the GPs in Molde Municipality in Norway, a multilevel community intervention was initiated by the municipal chief physician in 2018. The intervention targeted GPs, patients, and the public.

SUBJECTS

We retrieved prescription data from 26 of 36 GPs.

MAIN OUTCOME MEASURES

By using the standardized defined daily dose (DDD), we compared prescription of three groups of PAMs from before the intervention (2017) throughout the intervention in 2018, and through 2020 to determine long-term effects.

RESULTS

Three years after the intervention, the GPs in our study sample prescribed 26% less opioids, 38% less benzodiazepines, and 16% less z-hypnotics. Overall prescription of PAMs decreased by 27%. The number of individuals receiving at least 90 DDD of benzodiazepines and z-hypnotics were reduced from 9 to 7 and 34 to 24 per 1000, respectively. Also, the number of individuals receiving two and three PAMs concomitantly were reduced.

CONCLUSION

Addressing prescription practice among GPs in a community as a joint intervention, combined with addressing patients and the public may be a feasible method to obtain long-term reduction of PAM prescriptions.Key pointsNon-therapeutic prescriptions of potentially addictive medications (PAMs) are both a public health concern and a frequent challenge in general practice.A multilevel community intervention, targeting general practitioners, patients, and the public, led to 27% reduction in prescription of PAMs.Both the number of daily users and concomitant use of several PAMs were reduced.The reduction in prescription persisted for three years.

Implementing trauma-focused cognitive behavioral therapy in Philadelphia: A 10-year evaluation

Background: In 2012, Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) developed an initiative to implement an evidence-based treatment for posttraumatic stress disorder (PTSD), trauma-focused cognitive behavioral therapy (TF-CBT), across the city's behavioral health system. This report evaluates the initiative's 10-year implementation and effectiveness outcomes. Method: The Exploration, Preparation, Implementation, and Sustainment framework guided our implementation evaluation. The implementation outcomes include adoption, reach, and sustainment; these were obtained during regular evaluation data collection from publicly funded behavioral health agencies participating in the TF-CBT initiative. We analyze effectiveness outcomes (i.e., changes in PTSD symptoms) from a subset of patients receiving TF-CBT, which were collected in 6-month intervals by our research team between 2013 and 2021. Results: From 2012 to 2021, DBHIDS trained 478 clinicians in TF-CBT across 20 behavioral health agencies. During this time, 23,401 youths were screened for potentially traumatic events and PTSD symptoms, and 7,550 youths received TF-CBT. Through the TF-CBT initiative, the city expanded the network of TF-CBT providers from 3 to 20 agencies. DBHIDS sustained this network by maintaining the participation of 16 behavioral health agencies over the course of a decade. The subset of 202 youths who were evaluated to assess TF-CBT effectiveness was drawn from 94 therapists and 20 agencies across Philadelphia. All participating youths completed a baseline assessment, and 151 (75%) completed at least one follow-up assessment. Linear mixed-effects models accounting for observations nested within participants and nested within clinicians found that treatment significantly reduced PTSD symptoms. Conclusion: Between 2012 and 2021, DBHIDS successfully implemented and sustained TF-CBT across the city's behavioral health system. Adoption, reach, and sustainment of TF-CBT were high. Despite the considerable adverse experiences faced by youths seeking treatment in Philadelphia's behavioral health system, TF-CBT was effective. Future directions to improve TF-CBT implementation in the next iteration of the initiative are described.

Optimising the Conceptualisation of Context Comment on "Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-country Analysis"

Context matters. Therefore, efforts to develop greater conceptual clarity are important for science and practice. In this commentary, we outline some key issues that were prompted by Squire's et al.'s contribution. Specifically, we reinforce context as an interactive concept and therefore something that is hard to 'pin down', the problematic nature of conceptualising context in implementation and de-implementation, and a requirement for the development of culturally sensitive understandings. Finally, we suggest it is vital that continued investment into providing a more comprehensive list of determinants needs to be accompanied by an equal effort in developing practical methods and tools to support use and application.

The impacts of implementing recovery innovations: a conceptual framework grounded in qualitative research

Background

Implementing mental health recovery into services is a policy priority in Canada and globally. To that end, a 5 year study was undertaken with seven organisations providing mental health and housing services to people living with a mental health challenge to implement guidelines for the transformation of services and systems towards a recovery-orientation. Multi-stakeholder implementation teams were established and a facilitated process guided teams to choosing and planning for the implementation of one recovery innovation. The recovery innovations chosen were hiring peer support workers, Wellness Recovery Action Planning (WRAP), a family support group, and staff recovery training.

Methods

This study reports on data collected at the post-implementation stage. 90 service users, service providers, family members, managers, other actors and knowledge users participated in 41 group, individual or dyad semi-structured interviews. The interview guides included open-ended questions eliciting participants’ impressions regarding the impact of implementing the innovation on service users, service providers and organisations. We applied a collaborative qualitative content analysis approach in NVivo12 to coding and interpreting the data generated from these questions.

Results

Eighteen impacts of implementing recovery innovations from the perspectives of diverse stakeholder groups were identified. Three impacts of working as an implementation team member and as part of a research project were also identified. Impacts were developed into a conceptual framework organised around four overall categories of impact: Ways of being, Ways of interacting, Ways of thinking, and Ways of operating and doing business.

Conclusions

The IMpacts of Recovery Innovations (IMRI) framework version 1 can assist researchers, evaluators and decision-makers identify, explore and understand impact in the context of recovery innovations. The framework helps fill a gap in conceptualising service and organisation-level impacts. Future research is needed to validate the framework and map it to existing methods for studying impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00559-2.

Parkinson rehabilitation in nursing homes: a qualitative exploration of the experiences of patients and caregivers

PURPOSE

Worldwide, an increasing number of people are diagnosed with atypical Parkinsonism or idiopathic Parkinson's disease (PD). Periods of acute functional decline, triggered by acute disease, are common. Rehabilitation is often necessary to restore functioning. Skilled nursing facilities (SNFs) in the Netherlands have developed evidence-based geriatric rehabilitation for Parkinson (GR-P) programs. However, data on the experiences and needs of patients and their caregivers are lacking. This study aims to address these, in order to propose recommendations for improvement.

METHODS

We performed a qualitative study, using semi-structured interviews in two Dutch SNFs offering GR-P. Nine patients with PD and six informal caregivers were included. We subjected verbatim transcripts of 15 interviews to qualitative analysis.

RESULTS

Data saturation was reached after 15 interviews. Three overarching themes emerged: (1) autonomy, (2) sharing information and (3) contact with others. Loss of autonomy was linked to the underlying disease and the rehabilitation environment itself. Patients and caregivers felt overwhelmed by events before and during rehabilitation, expressing a need to receive information and discuss prior experiences. They considered communication between hospitals and SNFs to be poor. Patients did not always appreciate contact with peers. Both patients and caregivers appreciated empathic healthcare personnel with a firm knowledge on PD.

CONCLUSIONS

Autonomy, sharing information and contact with others are central themes for patients and caregivers during GR-P in SNFs. We recommend actively exploring these three central themes with every patient and caregiver entering a GR-P program and offering staff continuing education on PD, in order to improve care.

Implementation strategy mapping methods to improve autism intervention use in community settings: a study protocol

Background

Implementation strategies are purported to facilitate adoption and use of evidence-based practices (EBPs) across settings. The use of tailored implementation strategies may be particularly effective, as they are selected with the explicit purpose of addressing setting-specific implementation determinants. However, methods to select and tailor implementation strategies, including in community settings, remain understudied. This project will identify and describe implementation strategy mapping methods (ISMMs) from extant peer-reviewed literature and pilot test a method to match implementation strategies with determinants in low-resourced community mental health (CMH) agencies that deliver services to children on the autism spectrum.

Methods

Aim 1: A scoping review, following PRISMA guidelines, will be conducted to identify implementation strategy mapping methods (ISMMs) utilized in child mental health settings. Data extraction will identify and describe each ISMM, including identifying methodological and procedural steps, analyzing the frequency of ISMM use, and identifying outcomes measured in eligible ISMM studies.

Aim 2: Using scoping review findings, select and pilot test one ISMM within five community mental health agencies in Michigan that provide services to autistic children. We will recruit five directors/agency leaders, supervisors, and direct providers at each of the eligible agencies (expected N = 25). A sequential explanatory (QUAN➔ QUAL) mixed methods design will be used. Participants will complete a demographics and client survey, as well as a needs assessment to identify implementation determinants. The impact of the ISMM on organizational readiness for change (from pre- to post-ISMM), as well as implementation outcomes of the ISMM (feasibility, acceptability, appropriateness, usability), will be examined. Semi-structured interviews will elicit stakeholder perspectives on the mapping method.

Discussion

The current project aims to advance our knowledge of methods for selecting, tailoring, and mapping implementation strategies to address context-specific determinants to implementation. Additionally, this project will contribute to growing science found at the intersection of implementation science and autism research by utilizing the implementation determinants framework, the CFIR, to guide data collection, analysis, and interpretation of findings. Finally, these findings may support future EBP implementation efforts within low-resourced communities, with the ultimate goal of increasing equity in access to EBPs for autistic children.

Economic Precarity, Financial Strain, and Job-Related Stress Among Philadelphia's Public Mental Health Clinicians

OBJECTIVE

Efforts to improve mental health treatment delivery come at a time of rising inequality and cuts or insufficient increases to mental health funding. Public mental health clinicians face increased demands, experience economic stress, and treat underresourced patients disproportionately burdened by trauma. The authors sought to understand clinicians' current economic and psychological conditions and the relationship of these conditions to the delivery of an evidence-based intervention (EBI) designed to treat posttraumatic stress disorder among youths.

METHODS

In July 2020, 49 public mental health clinicians from 16 Philadelphia clinics who were trained in an EBI, trauma-focused cognitive-behavioral therapy (TF-CBT), were surveyed by e-mail. Respondents reported on their economic precarity, financial strain, burnout, secondary traumatic stress (i.e., the stress response associated with caring for people exposed to trauma), and TF-CBT use. Associations between clinicians' job-related stressors and their use of TF-CBT were examined with mixed models. Content coding was used to organize clinicians' open-ended responses to questions regarding financial strain related to the COVID-19 pandemic.

RESULTS

Clinicians' economic precarity, financial strain, and job-related stress were high; 37% of clinicians were independent contractors, 44% of whom wanted a salaried position. Of 37 clinicians with education debt, 38% reported owing ≥$100,000. In the past year, 29% of clinicians reported lack of personal mental health care because of cost, and 22% met the cutoff for experiencing secondary traumatic stress symptoms. Education debt was negatively associated with use of TF-CBT (p<0.001).

CONCLUSIONS

The stress of providing care in underresourced clinical settings may interfere with efforts to integrate scientific evidence into mental health care.

Can We Be at Peace With Unsolvable Suffering? A Qualitative Study Exploring the Effectiveness of Supportive Communication and Resilience Building

The authors provided six 180-minute interpersonal assistance workshops using teaching materials from the End-of-Life Care Association: 90 minutes each on supportive communication and role-playing. The content included the following: ・ Suffering people are "at peace" with someone who understands their suffering, which starts with building a relationship through empathetic listening. The goal is not to "understand them" but for them to "feel understood." ・ Realizing the suffering of others and recognizing the internal moral and emotional strength of those who live with suffering. ・ Resilience building: helping caregivers face difficulties even when helpless; remembering one's support networks and valuing oneself. Participants (n = 114) wrote reflective journals after each session. Two domains and 10 key themes were identified through thematic analysis. The domains comprised topics on the importance of using listening techniques, such as repetition, waiting in silence, and asking questions (not to understand but for dialogue). The 3-month postinterviews revealed that participants could ease their sense of weakness by helping suffering people, which is relevant to work, grief care, and daily life. Changes in relationships between participants and patients were also identified. Role-playing can teach supportive communication, such as listening attentively and accepting others, which may help supporters engage with people experiencing incurable suffering.

Identifying essential implementation strategies: a mixed methods process evaluation of a multi-strategy policy implementation intervention for schools

BACKGROUND

Physically Active Children in Education (PACE) is composed of eight implementation strategies that improves schools' implementation of a government physical activity policy. A greater understanding of each discrete implementation strategy could inform improvements to PACE for delivery at-scale. This study aimed to: (A) measure the dose delivered, fidelity, adoption and acceptability of each strategy using quantitative data; (B) identify implementation barriers and facilitators using qualitative data; and (C) explore the importance of each strategy by integrating both data sets (mixed methods).

METHODS

This study used data from a cluster randomised noninferiority trial comparing PACE with an adapted version (Adapted PACE) that was delivered with reduced in-person external support to reduce costs and increase scalability. Data were collected from both trials arms for between-group comparison. Descriptive statistics were produced using surveys of principals, in-school champions and teachers; and project records maintained by PACE project officers (objective A). Thematic analysis was performed using in-school champion and project officer interviews (objective B). Both data sets were integrated via a triangulation protocol and findings synthesized in the form of meta-inferences (objective C).

RESULTS

Eleven in-school champions and six project officers completed interviews; 33 principals, 51 in-school champions and 260 teachers completed surveys. Regardless of group allocation, implementation indicators were high for at least one component of each strategy: dose delivered =100%, fidelity ≥95%, adoption ≥83%, acceptability ≥50%; and several implementation barriers and facilitators were identified within three broad categories: external policy landscape, inner organizational structure/context of schools, and intervention characteristics and processes. All strategies were considered important as use varied by school, however support from a school executive and in-school champions' interest were suggested as especially important for optimal implementation.

CONCLUSION

This study highlights the importance of both executive support and in-school champions for successful implementation of school physical activity policies. In particular, identifying and supporting an in-school champion to have high power and high interest is recommended for future implementation strategies. This may reduce the need for intensive external support, thus improving intervention scalability.

Translating mental health recovery guidelines into recovery-oriented innovations: A strategy combining implementation teams and a facilitated planning process

Recovery is the focus of mental health strategies internationally. However, little translation of recovery knowledge has occurred in mental health services. The purpose of this research is to bridge the gap between recovery guidelines and practice by developing a new implementation strategy involving the formation of implementation teams made up of different stakeholders (service users, service providers, managers, knowledge users) and facilitating a 12-meeting implementation planning process. Sevenmental health organizations across Canada successfully completed the process of translating the guidelines into a recovery-oriented innovation that was implemented. Fifty-five implementation team members were interviewed upon completion of the 12-meeting process. Findings indicate that implementation team members perceived the structured planning process as positive. Nevertheless, the language of implementation science remains difficult to understand for a non-academic audience. Key elements of the 12-meeting process included the value of consensus building among implementation team members and the subsequent shifting power relationships. While working with diverse stakeholders came with certain challenges, the process in itself was a form of system transformation. This type of engaged planning process was a significant departure from the more top-down approaches to organizational change that staff were used to.

De-implementing low-value care in cancer care delivery: a systematic review

BACKGROUND

Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings.

METHODS

We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies' key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care.

RESULTS

Out of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers' behavior, and 1 de-implementation intervention focused on changing the patients' behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias.

CONCLUSIONS

This review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).

Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely Interventions across Canadian hospitals

BACKGROUND

Choosing Wisely (CW) is an international movement comprised of campaigns in more than 20 countries to reduce low-value care (LVC). De-implementation, the reduction or removal of a healthcare practice that offers little to no benefit or causes harm, is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations.

METHODS

Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis.

FINDINGS

Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not 'patient facing'; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, providing insight into the complexities and nuances of harm, resources and prevalence. Harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions.

CONCLUSIONS

This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

BACKGROUND

There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care.

METHODS

We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review.

RESULTS

Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently.

CONCLUSIONS

This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

Identifying and understanding the contextual factors that shaped mid-implementation outcomes during the COVID-19 pandemic in organizations implementing mental health recovery innovations into services

BACKGROUND

Seven housing and health services organizations were guided through a process of translating Chapter Six of the Canadian Guidelines for Recovery-Oriented Practice into a recovery-oriented innovation and plan for its implementation. At the time of the COVID-19 outbreak and lockdown measures, six of the seven organizations had begun implementing their chosen innovation (peer workers, wellness recovery action planning facilitator training, staff training and a family support group). This mid-implementation study used the Consolidated Framework for Implementation Research (CFIR) to identify contextual factors that influenced organizations to continue or postpone implementation of recovery-oriented innovations in the early months of the COVID-19 pandemic.

METHODS

Twenty-seven semi-structured 45-min interviews were conducted between May and June 2020 (21 implementation team members and six providers of the innovation (trainers, facilitators, peer workers). Interview guides and analysis were based on the CFIR. Content analysis combined deductive and inductive approaches. Summaries of coded data were given ratings based on strength and valence of the construct's impact on implementation. Ratings were visualized by mid-implementation outcome and recovery innovation to identify constructs which appear to distinguish between sites with a more or less favorable mid-implementation outcomes.

RESULTS

Four mid-implementation outcomes were observed at this snapshot in time (from most to least positive): continued implementation with adaptation (one site), postponement with adaptation and estimated relaunch date (four sites), indefinite postponement with no decision on relaunch date (one site), and no implementation of innovation yet (one site). Two constructs had either a negative influence (external policies and incentives-renamed COVID-19-related external policy for this study) or a positive influence (leadership engagement), regardless of implementation outcome. Four factors appeared to distinguish between more or less positive mid-implementation outcome: adaptability, implementation climate and relative priority, available resources, and formally appointed internal implementation leaders (renamed "engaging implementation teams during the COVID-19 pandemic" for this study).

CONCLUSIONS

The COVID-19 pandemic is an unprecedented outer setting factor. Studies that use the CFIR at the mid-implementation stage are rare, as are studies focusing on the outer setting. Through robust qualitative analysis, we identify the key factors that shaped the course of implementation of recovery innovations over this turbulent time.