Development of a comprehensive measure of organizational readiness (motivation × capacity) for implementation: a study protocol

Examining associations between school-level determinants and the implementation of physical activity opportunities

School-based physical activity (PA) opportunities can help students engage in greater amounts of daily PA, meet PA guidelines, and lead to improved health and educational outcomes. However, we do not completely understand the organizational challenges to implementing these opportunities successfully. This exploratory study examined associations between school-level determinants and the implementation of school-based PA opportunities. We analyzed cross-sectional survey data from schools (n = 46) participating in the Healthy Zone School Program (HZSP) (Dallas, Texas, USA) during 2019-2020. Respondents completed an electronic survey that included measures of school-level determinants (e.g. culture, leadership, priority) and the implementation of school-based PA opportunities. We used linear regression models to examine associations between determinants and implementation outcomes (number of PA opportunities delivered, perceived overall success of each PA program/activity used). After adjusting for campus type (i.e. elementary, middle, high, K-12), student race/ethnicity, and percentage of economically disadvantaged students, no constructs were associated with the number of PA opportunities implemented. Linear regression models suggest access to knowledge and information (β = 0.39, P = .012, 95% CI = 0.24-1.44) and implementation climate (β = 0.34, P = .045, 95% CI = 0.02-1.59) were positively associated with the success of school-based PA opportunities. Our findings provide suggestive evidence that access to knowledge and information and a supportive school climate may improve the overall success of PA opportunities provided to students. Future research should examine additional school-level determinants to understand their importance to implementation and inform the development of strategies to improve schools' capacity for implementing PA opportunities successfully.

How Societal Forces of Change Are Transforming Youth Physical Activity Promotion in North America

BACKGROUND

Climate change, increasing recognition of institutionalized discrimination, and the COVID-19 pandemic are large-scale, societal events (ie, forces of change) that affect the timing, settings, and modes of youth physical activity. Despite the impact that forces of change have on youth physical activity and physical activity environments, few studies consider how they affect physical activity promotion.

METHODS

The authors use 2 established frameworks, the ecological model of physical activity and the youth physical activity timing, how, and setting framework, to highlight changes in physical activity patterns of youth in North America that have resulted from contemporary forces of change.

RESULTS

North American countries-Canada, Mexico, and the United States-have faced similar but contextually different challenges for promoting physical activity in response to climate change, increasing recognition of institutionalized discrimination, and the COVID-19 pandemic. Innovative applications of implementation science, digital health technologies, and community-based participatory research methodologies may be practical for increasing and sustaining youth physical activity in response to these forces of change.

CONCLUSIONS

Thoughtful synthesis of existing physical activity frameworks can help to guide the design and evaluation of new and existing physical activity initiatives. Researchers, practitioners, and policymakers are encouraged to carefully consider the intended and unintended consequences of actions designed to respond to forces of change.

"Just because I have a medical degree does not mean I have the answers": Using CBPR to enhance patient-centered care within a primary care setting

Patient-centered care (PCC) is a health care delivery model that is considered a means to reduce inequities in the healthcare system, specifically through its prioritization of patient voice and preference in treatment planning. Yet, there are documented challenges to its implementation. Community-based participatory research (CBPR) is seemingly well-positioned to address such challenges, but there has been limited discussion of utilizing CBPR in this way. This article begins to address this gap. In it, we present three diverse stakeholders' perspectives on a CBPR project to enhance PCC within a primary care clinic serving low-income patients. These perspectives provide insights into benefits, challenges, and lessons learned in using CBPR to implement PCC. Key benefits of using CBPR to implement PCC include increasing the acceptability and feasibility of data collection tools and process, and the generating of high-quality actionable feedback. Important CBPR facilitators of PCC implementation include intentional power-sharing between patients and providers and having invested stakeholders who "champion" CBPR within an organization with empowering practices.

Examining readiness for implementing practice changes in federally qualified health centers: A rapid qualitative study

Implementing evidence-based interventions remains slow in federally qualified health centers (FQHCs). The purpose of this study is to qualitatively examine the R = MC2 (Readiness = motivation × innovation specific capacity × general capacity) heuristic subcomponents in the context of implementing general and colorectal cancer screening (CRCS)-related practice changes in FQHCs. We conducted 17 interviews with FQHC employees to examine (1) experiences with successful or unsuccessful practice change efforts, (2) using approaches to promote CRCS, and (3) opinions about R = MC2 subcomponents. We conducted a rapid qualitative analysis to examine the frequency, depth, and spontaneity of subcomponents. Priority, compatibility, observability (motivation), intra- and interorganizational relationships (innovation-specific capacity), and organizational structure and resource utilization (general capacity) emerged as highly relevant. For example, organizational structure was described as related to an organization's open communication during meetings to help with scheduling procedures. The results contribute to understanding organizational readiness in the FQHC setting and can be helpful when identifying and prioritizing barriers and facilitators that affect implementation.

Implementation of a novel program to support colorectal cancer screening in a community health center consortium before and after the onset of COVID-19: a qualitative study of stakeholders' perspectives

BACKGROUND

In 2017, the San Francisco Cancer Initiative (SF CAN) established the Colorectal Cancer (CRC) Screening Program to provide technical assistance and financial support to improve CRC screening processes, and outcomes in a consortium of community health centers (CHCs) serving low-income communities in San Francisco. The purpose of this study was twofold: to evaluate the perceived influence of the support provided by the CRC Screening Program's Task Force on CRC screening processes and outcomes in these settings and to identify facilitators and barriers to SF CAN-supported CRC screening activities before and after the onset of the COVID-19 pandemic.

METHODS

Semi-structured key informant interviews were conducted with consortium leaders, medical directors, quality improvement team members, and clinic screening champions. Interviews were audio-recorded, professionally transcribed, and analyzed for themes. The Consolidated Framework for Implementation Research (CFIR) was used to develop the interview questions and organize the analysis.

RESULTS

Twenty-two participants were interviewed. The most commonly cited facilitators of improved screening processes included the expertise, funding, screening resources, regular follow-up, and sustained engagement with clinic leaders provided by the task force. The most salient barriers identified were patient characteristics, such as housing instability; staffing challenges, such as being understaffed and experiencing high staff turnover; and clinic-level challenges, such as lack of ability to implement and sustain formalized patient navigation strategies, and changes in clinic priorities due to the COVID-19 pandemic and other competing health care priorities.

CONCLUSIONS

Implementing CRC screening programs in a consortium of CHCs is inherently challenging. Technical assistance from the Task Force was viewed positively and helped to mitigate challenges both before and during the pandemic. Future research should explore opportunities to increase the robustness of technical assistance offered by groups such as SF CAN to support cancer screening activities in CHCs serving low-income communities.

Organizational readiness to implement task-strengthening strategy for hypertension management among people living with HIV in Nigeria

BACKGROUND

Hypertension (HTN) is highly prevalent among people living with HIV (PLHIV), but there is limited access to standardized HTN management strategies in public primary healthcare facilities in Nigeria. The shortage of trained healthcare providers in Nigeria is an important contributor to the increased unmet need for HTN management among PLHIV. Evidence-based TAsk-Strengthening Strategies for HTN control (TASSH) have shown promise to address this gap in other resource-constrained settings. However, little is known regarding primary health care facilities' capacity to implement this strategy. The objective of this study was to determine primary healthcare facilities' readiness to implement TASSH among PLHIV in Nigeria.

METHODS

This study was conducted with purposively selected healthcare providers at fifty-nine primary healthcare facilities in Akwa-Ibom State, Nigeria. Healthcare facility readiness data were measured using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA is based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework that identifies evidence, context, and facilitation as the key factors for effective knowledge translation. Quantitative data were analyzed using descriptive statistics (including mean ORCA subscales). We focused on the ORCA context domain, and responses were scored on a 5-point Likert scale, with 1 corresponding to disagree strongly.

FINDINGS

Fifty-nine healthcare providers (mean age 45; standard deviation [SD]: 7.4, 88% female, 68% with technical training, 56% nurses, 56% with 1-5 years providing HIV care) participated in the study. Most healthcare providers provide care to 11-30 patients living with HIV per month in their health facility, with about 42% of providers reporting that they see between 1 and 10 patients with HTN each month. Overall, staff culture (mean 4.9 [0.4]), leadership support (mean 4.9 [0.4]), and measurement/evidence-assessment (mean 4.6 [0.5]) were the topped-scored ORCA subscales, while scores on facility resources (mean 3.6 [0.8]) were the lowest.

CONCLUSION

Findings show organizational support for innovation and the health providers at the participating health facilities. However, a concerted effort is needed to promote training capabilities and resources to deliver services within these primary healthcare facilities. These results are invaluable in developing future strategies to improve the integration, adoption, and sustainability of TASSH in primary healthcare facilities in Nigeria.

TRIAL REGISTRATION

NCT05031819.

Using cognitive interviews to improve a measure of organizational readiness for implementation

BACKGROUND

Organizational readiness is a key factor for successful implementation of evidence-based interventions (EBIs), but a valid and reliable measure to assess readiness across contexts and settings is needed. The R = MC² heuristic posits that organizational readiness stems from an organization's motivation, capacity to implement a specific innovation, and its general capacity. This paper describes a process used to examine the face and content validity of items in a readiness survey developed to assess organizational readiness (based on R = MC²) among federally qualified health centers (FQHC) implementing colorectal cancer screening (CRCS) EBIs.

METHODS

We conducted 20 cognitive interviews with FQHC staff (clinical and non-clinical) in South Carolina and Texas. Participants were provided a subset of items from the readiness survey to review. A semi-structured interview guide was developed to elicit feedback from participants using "think aloud" and probing techniques. Participants were recruited using a purposive sampling approach and interviews were conducted virtually using Zoom and WebEx. Participants were asked 1) about the relevancy of items, 2) how they interpreted the meaning of items or specific terms, 3) to identify items that were difficult to understand, and 4) how items could be improved. Interviews were transcribed verbatim and coded in ATLAS.ti. Findings were used to revise the readiness survey.

RESULTS

Key recommendations included reducing the survey length and removing redundant or difficult to understand items. Additionally, participants recommended using consistent terms throughout (e.g., other units/teams vs. departments) the survey and changing pronouns (e.g., people, we) to be more specific (e.g., leadership, staff). Moreover, participants recommended specifying ambiguous terms (e.g., define what "better" means).

CONCLUSION

Use of cognitive interviews allowed for an engaged process to refine an existing measure of readiness. The improved and finalized readiness survey can be used to support and improve implementation of CRCS EBIs in the clinic setting and thus reduce the cancer burden and cancer-related health disparities.

Facilitators and Barriers to Implementation and Sustainability of Nutrition and Physical Activity Interventions in Early Childcare Settings: a Systematic Review

A stronger understanding of the factors influencing implementation of interventions in community-based early childcare settings is needed. The purpose of this systematic review was to synthesize existing research on facilitators and barriers to implementation and sustainability of nutrition and physical activity interventions in early childcare settings targeting 2-5-year-old children, including considerations for equitable implementation. This review adhered to PRISMA 2020 guidelines. Peer-reviewed literature was searched in PubMed, EMBASE, CINAHL, ERIC, and PsycINFO databases up to September 2020. Primary research studies that examined facilitators and barriers (or related synonyms) to the implementation and sustainability of nutrition and physical activity interventions in early childcare settings were eligible for inclusion. The search yielded 8092 records that were screened by four analysts in Covidence software with a final review of 24 studies. Two independent reviewers conducted study selection, data extraction, and quality appraisal (Mixed Methods Appraisal Tool). A "best fit" framework was applied using the Consolidated Framework for Implementation Research (CFIR) constructs to code barriers and facilitators. The most salient constructs were (1) "Available Resources," which was composed of time, staffing, space, and staff trainings; (2) adaptability; and (3) compatibility, the latter two indicating that easily modifiable interventions facilitated a smoother "fit" and were more likely to be successful, given adequate site-level resources. Only nine (28%) reported the use of a theory, model, or framework to guide evaluation; six studies (24%) included factors related to sustainability; and nine studies (38%) conducted their interventions with low-income or minoritized groups. The findings point to the need for intervention evaluations examining nutrition and physical activity to more consistently consider (a) sustainability factors early on in design and adoption phases; (b) use of theory, model, or framework to guide evaluation; and (c) equity-related frameworks and considerations for how equitable implementation.

Implementation mapping for tobacco cessation in a federally qualified health center

Background

Implementation mapping (IM) is a promising five-step method for guiding planning, execution, and maintenance of an innovation. Case examples are valuable for implementation practitioners to understand considerations for applying IM. This pilot study aimed to determine the feasibility of using IM within a federally qualified health center (FQHC) with limited funds and a 1-year timeline.

Methods

An urban FQHC partnered with an academic team to employ IM for implementing a computerized strategy of tobacco cessation: the 5A's (Ask, Advise, Assess, Assist, Arrange). Each step of IM was supplemented with theory-driven methods and frameworks. Data collection included surveys and interviews with clinic staff, analyzed via rapid data analysis.

Results

Medical assistants and clinicians were identified as primary implementers of the 5A's intervention. Salient determinants of change included the perceived compatibility and relative priority of 5A's. Performance objectives and change objectives were derived to address these determinants, along with a suite of implementation strategies. Despite indicators of adoptability and acceptability of the 5A's, reductions in willingness to adopt the implementation package occurred over time and the intervention was not adopted by the FQHC within the study timeframe. This is likely due to the strain of the COVID-19 pandemic altering health clinic priorities.

Conclusions

Administratively, the five IM steps are feasible to conduct with FQHC staff within 1 year. However, this study did not obtain its intended outcomes. Lessons learned include the importance of re-assessing barriers over time and ensuring a longer timeframe to observe implementation outcomes.

Using Implementation Mapping to Build Organizational Readiness

Organizational readiness is essential for high-quality implementation of innovations (programs, policies, practices, or processes). The R = MC² heuristic describes three readiness components necessary for implementation—the general functioning of the organization (general capacities), the ability to deliver a particular innovation (innovation-specific capacities), and the motivation to implement the innovation. In this article, we describe how we used the Readiness Building System (RBS) for assessing, prioritizing, and improving readiness and Implementation Mapping (IM), a systematic process for planning implementation strategies, to build organizational readiness for implementation of sexual assault prevention evidence-based interventions (EBIs). While RBS provides an overarching approach for assessing and prioritizing readiness constructs (according to the R = MC² heuristic; Readiness = Motivation x general Capacity × innovation specific Capacity), it does not provide specific guidance on the development and/or selection and tailoring of strategies to improve readiness. We used the five IM tasks to identify and prioritize specific readiness goals and develop readiness-building strategies to improve subcomponents described in the R = MC² heuristic. This article illustrates how IM can be used synergistically with the RBS in applied contexts to plan implementation strategies that will improve organizational readiness and implementation outcomes. Specifically, we provide an example of using these two frameworks as part of the process of building organizational readiness for implementation of sexual assault prevention EBIs.

A Mixed-Methods Formative Evaluation of a Dementia-Friendly Congregation Program for Black Churches

Black churches have traditionally been a haven for Black American families; however, many churches do not currently have programs to support families living with dementia. Alter™ was established to assist faith communities in meeting the needs of these families and becoming a viable resource to promote their health and wellness. Alter™ achieves this aim through a three-pronged approach: (1) conducting educational sessions, (2) modifying Black churches to be dementia-inclusive spaces, and (3) providing ongoing support. The principal goal of Alter™ is to offer guidance to churches in adapting their community to reflect a supportive environment for families affected by dementia. Alter™ uses a partnership checklist to encourage activities that incorporate dementia education opportunities, environmental modifications, and dementia resources and support. This paper reports on a formative mixed-methods evaluation of church partners enrolled in Alter™. Church partner ambassadors within the faith communities participated in the evaluation survey (n = 8) and two focus groups (n = 11). Ambassadors are appointed by church leadership to lead the implementation of program activities. Data were collected concerning the levels of helpfulness, difficulty, usefulness, or utility of checklist activities and modifications and the ease of program implementation. The evaluation also assessed the COVID-19 pandemic’s impact on each church’s ability to implement activities and modifications. The survey results revealed that most required partnership activities and modifications were found to be at least moderately helpful. Some of the items (themes) that differed across church partners included barriers to implementing activities, the support provided and needed, and the use of program funding. This evaluation provides key insights to consider in developing and refining community-based, dementia-friendly communities (including faith communities). As implementation science expands and improves, the need to evaluate the implementation of programs continues to be highlighted. Our formative evaluation shed light on key areas in which modifications to our original programming would lead to program improvement and sustainability. Additionally, implementing the modifications identified in our evaluation will facilitate the achievement of the mission of Alter™ to improve the well-being of older adults affected by dementia and their families. Other programs would reap substantial benefits from engaging in similar formative evaluation efforts.

Assessing Firm Readiness to Adopt Cluster-Based Innovative Projects: A Segmentation Analysis

As innovation has garnered substantial attention on corporate success and sustainability, organizations must evaluate internal contexts to determine potential innovative practices and benefits. Firms need to investigate the determining factors of innovation preparedness as organizational innovation practices are catalyzed through internal elements. This study evaluates small and medium firms’ readiness to adopt and execute collaborative innovative projects within a future cluster and its impacts on organizational advantages, intentions, and attributes. Thereby, three dimensions were considered in examining organizational preparedness, namely, climate, culture, and motivation. A total of 70 firms operating in the labeled agri-food sector in Morocco were interviewed and homogenously classified using integrated hierarchical and non-hierarchical algorithms, following a segmentation approach. Three segments were identified, stressing the degree of organizational readiness to undertake innovative projects within future service clusters. The segments varied according to the firm’s sub-sector, experience, and resources. Considering the association of readiness with benefits and practical aims, the results broaden firm preparedness understanding to adopt innovative projects. The results also illustrate the relevance of adapting both innovative and beneficial project arrangements for firms with minor to moderate experience while addressing current issues across different segments.

Elementary Schools' Response to Student Wellness Needs during the COVID-19 Shutdown: A Qualitative Exploration Using the R = MC2 Readiness Heuristic

During spring of 2020, the COVID-19 pandemic and accompanying public health advisories forced K-12 schools throughout the United States to suspend in-person instruction. School personnel rapidly transitioned to remote provision of academic instruction and wellness services such as school meals and counseling services. The aim of this study was to investigate how schools responded to the transition to remote supports, including assessment of what readiness characteristics schools leveraged or developed to facilitate those transitions. Semi-structured interviews informed by school wellness implementation literature were conducted in the spring of 2020. Personnel (n = 50) from 39 urban and rural elementary schools nationwide participated. The readiness = motivation capacity² (R = MC²) heuristic, developed by Scaccia and colleagues, guided coding to determine themes related to schools' readiness to support student wellness in innovative ways during the pandemic closure. Two distinct code sets emerged, defined according to the R = MC² heuristic (1) Innovations: roles that schools took on during the pandemic response, and (2) Readiness: factors influencing schools' motivation and capacity to carry out those roles. Schools demonstrated unprecedented capacity and motivation to provide crucial wellness support to students and families early in the COVID-19 pandemic. These efforts can inform future resource allocation and new strategies to implement school wellness practices when schools resume normal operations.

Evidence to Practice for Mental Health Task-Sharing: Understanding Readiness for Change among Accredited Social Health Activists in Sehore District, Madhya Pradesh, India

Involvement of community health workers (CHWs) within task-sharing to bridge the mental health treatment gap has been proven to be efficacious in randomized controlled trials. The impact of mental health programs based on task-sharing paradigm greatly depends on the performance of CHWs which, in-turn, is influenced by their readiness for change. However, there is dearth of literature assessing the role of readiness for change as an important predicator of CHW performance. The aim of this study is to examine the applicability of the readiness for change model and investigate its cultural and contextual nuances among Accredited Social Health Activists (ASHAs), a cadre of CHWs in India, to understand their engagement in mental health task-sharing. We conducted in-depth, semi-structured interviews with a purposive sample of n = 12 key informants including ASHAs and other healthcare professionals in Sehore district, India. The interview guide consisted of open-ended questions based on the readiness for change factors including ASHAs' attitudes towards their role in mental health care, perception of capability to implement mental health task-sharing, of support from the public health system, etc. Framework analysis with a combined inductive-deductive approach was employed to code the data and generate themes. Participants endorsed three readiness for change themes relevant to task-sharing among ASHAs including change valence or value ascribed to task-sharing, change-efficacy or the perceived ability to implement task-sharing, and job valence or value ascribed to their regular job role. In addition, they provided insights into the culturally and contextually salient aspects of these factors. Themes of personal empowerment, gaining respect and trust from community, professional duty, relationship with supervisors, and lack of resources availability were majorly highlighted. This is the first study to qualitatively investigate the applicability of the readiness for change model and its culture- and context-specific nuances among a cadre of non-specialist health workers in India. Our findings posit that implementation science models should strongly consider the culture and context within which they are being applied to enhance fit and relevance. Further, our results should be taken into consideration to adapt and validate measurement tools and build readiness for change in this population.

R = MC2 readiness building process: A practical approach to support implementation in local, state, and national settings

Effective implementation of evidence-based interventions is a persistent challenge across community settings. Organizational readiness - or, the motivation and collective capacity of an entity to adopt and sustain an innovation - is important to facilitate implementation. Drawing on the R = MC² readiness framework, we developed a readiness building process to tailor support for implementation. The process is composed of the following stages: assessment, feedback and prioritization, and strategize. In this article, we describe the application of the readiness building process through three case examples representing interventions at different ecological levels: local, state, and national. The case examples illuminate challenges and practical considerations for using the readiness building process, including the significance of on-going leadership engagement and collaboration between support system and delivery system staff. To further the research and practice of implementation readiness, we suggest examining the impact of readiness building on implementation outcomes and developing an empirically-informed repository of change management strategies matched to readiness constructs.