Browsing by Subject "Implementation science"
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Item Open Access A Comprehensive Needs Assessment to Identify Priority Program Targets for Mosquito Vector Control and related Diseases in Belmopan, Belize(2017) Schooler, Mary ElizabethThis was a mixed-methods study aimed to comprehensively assess factors associated with mosquito control in Belmopan, Belize, in order to better inform stakeholders on the effectiveness of their efforts. A knowledge, attitudes, and perceptions (KAP) survey was employed within the four target communities of San Martin, Salvapan, Maya Mopan, and Las Flores. Additional epidemiological and entomological data was provided by relevant stakeholders. A total of 228 households were surveyed among the four target communities. Only 1/3 of respondents were able to demonstrate proficient knowledge. Knowledge was attained mostly through TV, Ministry of Health, hospital, and radio sources. Over 90% of respondents believed that mosquitos and the diseases they carry were a real issue for the community. Respondents living in Salvapan and Las Flores were more likely to have contracted Dengue Fever, Malaria, Chikungunya, or Zika than in other areas. Fan usage and regularly cleaning the yard were the two most employed practices for preventing mosquito bites and breeding. Approximately 85% of those surveyed viewed insecticide spraying to be effective. This assessment provides valuable insight into the needs of at- risk communities in regards to vector control. An increased focus on community outreach, education, and behavioral change can greatly impact the effectiveness of current vector control efforts. Stakeholders must work together and pool resources in order to effectively employ control interventions. Continued evaluation and community involvement is necessary to control mosquitos and prevent disease outbreaks.
Item Open Access A Feasibility Assessment of a Traumatic Brain Injury Predictive Modelling Tool at Kilimanjaro Christian Medical Center and Duke University Hospital(2020) O'Leary, PaigeTraumatic brain injury (TBI) is the most common cause of death and disability globally. TBI is a leading cause of resource consumption and disproportionately affects LMICs. Innovative solutions are required to address this high burden of TBI. Prognostic models could provide a solution since the models enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a prognostic model developed in Tanzania for TBI patients amongst Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke affiliated healthcare providers. Duke health system participants were included primarily to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows co-design interviews were conducted with emergency physicians and nursing staff. Qualitatively, the tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC and the potential use of HCD in implementation research.
Item Open Access Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): protocol for a stepped wedge cluster randomized trial.(BMC psychiatry, 2020-01-08) Dorsey, Shannon; Gray, Christine L; Wasonga, Augustine I; Amanya, Cyrilla; Weiner, Bryan J; Belden, C Micha; Martin, Prerna; Meza, Rosemary D; Weinhold, Andrew K; Soi, Caroline; Murray, Laura K; Lucid, Leah; Turner, Elizabeth L; Mildon, Robyn; Whetten, KathrynBACKGROUND:The mental health treatment gap-the difference between those with mental health need and those who receive treatment-is high in low- and middle-income countries. Task-shifting has been used to address the shortage of mental health professionals, with a growing body of research demonstrating the effectiveness of mental health interventions delivered through task-shifting. However, very little research has focused on how to embed, support, and sustain task-shifting in government-funded systems with potential for scale up. The goal of the Building and Sustaining Interventions for Children (BASIC) study is to examine implementation policies and practices that predict adoption, fidelity, and sustainment of a mental health intervention in the education sector via teacher delivery and the health sector via community health volunteer delivery. METHODS:BASIC is a Hybrid Type II Implementation-Effectiveness trial. The study design is a stepped wedge, cluster randomized trial involving 7 sequences of 40 schools and 40 communities surrounding the schools. Enrollment consists of 120 teachers, 120 community health volunteers, up to 80 site leaders, and up to 1280 youth and one of their primary guardians. The evidence-based mental health intervention is a locally adapted version of Trauma-focused Cognitive Behavioral Therapy, called Pamoja Tunaweza. Lay counselors are trained and supervised in Pamoja Tunaweza by local trainers who are experienced in delivering the intervention and who participated in a Train-the-Trainer model of skills transfer. After the first sequence completes implementation, in-depth interviews are conducted with initial implementing sites' counselors and leaders. Findings are used to inform delivery of implementation facilitation for subsequent sequences' sites. We use a mixed methods approach including qualitative comparative analysis to identify necessary and sufficient implementation policies and practices that predict 3 implementation outcomes of interest: adoption, fidelity, and sustainment. We also examine child mental health outcomes and cost of the intervention in both the education and health sectors. DISCUSSION:The BASIC study will provide knowledge about how implementation of task-shifted mental health care can be supported in government systems that already serve children and adolescents. Knowledge about implementation policies and practices from BASIC can advance the science of implementation in low-resource contexts. TRIAL REGISTRATION:Trial Registration: ClinicalTrials.gov Identifier: NCT03243396. Registered 9th August 2017, https://clinicaltrials.gov/ct2/show/NCT03243396.Item Open Access Evaluating the impact of evidence-based practice and policy in public health: A case study on parent-child interaction therapy(2012-05-17) Jung, Sol BeeThe purpose of this study was to explore the evidence-based practice movement and its implications for the realm of public health. The paper first described the evidence-based practice movement and examined its pros and cons, including some of the barriers to implementation. A case study on Parent-Child Interaction Therapy (PCIT), an evidence-based practice (EBP), was then conducted to examine whether an EBP resulted in better outcomes than treatment as usual for clients from one agency in Durham. The findings from the data analyses showed that PCIT did not necessarily result in better outcomes than treatment as usual based on the AAPI results. PCIT also did not serve all racial groups equally well. Latino families achieved greater improvement on most subscales from treatment as usual than from PCIT, whereas African American and Caucasian clients achieved more improvement from PCIT than from the comparison treatment. Analysis of satisfaction surveys showed that PCIT clients expressed greater satisfaction than comparison treatment clients in two aspects. PCIT clients tended to believe that their providers were more knowledgeable and that their providers respected the family’s way of doing things. No significant provider effects could be observed from the data analysis.Item Open Access Factors Impacting Sustainable Implementation of Adolescent Mental Health Interventions: A Qualitative Stakeholder Analysis(2021) Kenney, CordeliaBackground: Mental health challenges comprise a significant share of the global disease burden among adolescents. In many global settings, mental health services are limited and few adolescent mental health interventions (AMH) exist or have been sustained. This qualitative study sought to explore stakeholder perspectives on factors that influence sustainable implementation of AMH interventions in East and Southern Africa, and to explore youth leaders’ perspectives on and experiences with delivering a mental health intervention tailored to adolescents living with HIV in Tanzania. Methods: In-depth interviews lasting between 30-60 minutes were conducted virtually with 12 participants. One focus group discussion with six participants lasting 1.5 hours was conducted in Tanzania. Data were recorded and transcribed and then coded and analyzed using Nvivo 12 Pro software. Results: Sufficient political will, civil society involvement, multisectoral approaches, health system integration, and mental health awareness are important factors for sustainable implementation. Major constraints to sustainable implementation include the absence of these factors, as well as stigma, low mental health literacy, and insufficient funding and health system capacity. Conclusions: Mental health awareness, contextual fit, and the meaningful engagement of key stakeholders influences the sustainable implementation of AMH interventions. These findings have several important implications for policy and practice.
Item Open Access Factors influencing support for the implementation of community-based out-of-hospital cardiac arrest interventions in high- and low-performing counties.(Resuscitation plus, 2024-03) Ezem, Natalie; Lewinski, Allison A; Miller, Julie; King, Heather A; Oakes, Megan; Monk, Lisa; Starks, Monique A; Granger, Christopher B; Bosworth, Hayden B; Blewer, Audrey LAim of the study
Survival to hospital discharge from out-of-hospital cardiac arrest (OHCA) after receiving treatment from emergency medical services (EMS) is less than 10% in the United States. Community-focused interventions improve survival rates, but there is limited information on how to gain support for new interventions or program activities within these populations. Using data from the RAndomized Cluster Evaluation of Cardiac ARrest Systems (RACE-CARS) trial, we aimed to identify the factors influencing emergency response agencies' support in implementing an OHCA intervention.Methods
North Carolina counties were stratified into high-performing or low-performing counties based on the county's cardiac arrest volume, percent of bystander-cardiopulmonary resuscitation (CPR) performed, patient survival to hospital discharge, cerebral performance in patients after cardiac arrest, and perceived engagement in the RACE-CARS project. We randomly selected 4 high-performing and 3 low-performing counties and conducted semi-structured qualitative interviews with emergency response stakeholders in each county.Results
From 10/2021 to 02/2022, we completed 29 interviews across the 7 counties (EMS (n = 9), telecommunications (n = 7), fire/first responders (n = 7), and hospital representatives (n = 6)). We identified three themes salient to community support for OHCA intervention: (1) initiating support at emergency response agencies; (2) obtaining support from emergency response agency staff (senior leadership and emergency response teams); and (3) and maintaining support. For each theme, we described similarities and differences by high- and low-performing county.Conclusions
We identified techniques for supporting effective engagement of emergency response agencies in community-based interventions for OHCA improving survival rates. This work may inform future programs and initiatives around implementation of community-based interventions for OHCA.Item Open Access Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial.(Implementation science communications, 2023-10) Webb, Sara; Drake, Connor; Coffman, Cynthia J; Sullivan, Caitlin; Sperber, Nina; Tucker, Matthew; Zullig, Leah L; Hughes, Jaime M; Kaufman, Brystana G; Pura, John A; Anderson, Livia; Hastings, Susan N; Van Houtven, Courtney H; Abbate, Lauren M; Hoenig, Helen; Ballengee, Lindsay A; Wang, Virginia; Allen, Kelli DBackground
Knee osteoarthritis (OA) is a leading cause of chronic pain and disability and one of the most common conditions treated in outpatient physical therapy (PT). Because of the high and growing prevalence of knee OA, there is a need for efficient approaches for delivering exercise-based PT to patients with knee OA. A prior randomized controlled trial (RCT) showed that a 6-session Group Physical Therapy Program for Knee OA (Group PT) yields equivalent or greater improvements in pain and functional outcomes compared with traditional individual PT, while requiring fewer clinician hours per patient to deliver. This manuscript describes the protocol for a hybrid type III effectiveness-implementation trial comparing two implementation packages to support delivery of Group PT.Methods
In this 12-month embedded trial, a minimum of 16 Veterans Affairs Medical Centers (VAMCs) will be randomized to receive one of two implementation support packages for their Group PT programs: a standard, low-touch support based on Replicating Effective Programs (REP) versus enhanced REP (enREP), which adds tailored, high-touch support if sites do not meet Group PT adoption and sustainment benchmarks at 6 and 9 months following launch. Implementation outcomes, including penetration (primary), adoption, and fidelity, will be assessed at 6 and 12 months (primary assessment time point). Additional analyses will include patient-level effectiveness outcomes (pain, function, satisfaction) and staffing and labor costs. A robust qualitative evaluation of site implementation context and experience, as well as site-led adaptations to the Group PT program, will be conducted.Discussion
To our knowledge, this study is the first to evaluate the impact of tailored, high-touch implementation support on implementation outcomes when compared to standardized, low-touch support for delivering a PT-based intervention. The Group PT program has strong potential to become a standard offering for PT, improving function and pain-related outcomes for patients with knee OA. Results will provide information regarding the effectiveness and value of this implementation approach and a deeper understanding of how healthcare systems can support wide-scale adoption of Group PT.Trial registration
This study was registered on March 7, 2022 at ClinicalTrials.gov (identifier NCT05282927 ).Item Open Access Improving cardiovascular outcomes by using team-supported, EHR-leveraged, active management: Disseminating a successful quality improvement project.(Contemporary clinical trials communications, 2021-03) Lewinski, Allison A; Bosworth, Hayden B; Goldstein, Karen M; Gierisch, Jennifer M; Jazowski, Shelley; McCant, Felicia; White-Clark, Courtney; Smith, Valerie A; Zullig, Leah LBackground
Uncontrolled blood pressure (BP) is common among Veterans. Rural Veterans are at risk for suboptimal care coordination as successful programs may be implemented at lower rates due to individual- and system-level factors. There is strong evidence to support the use of remotely delivered support and patient-generated data from home BP monitors and virtual BP visits to manage BP.Objective
The purpose of this project is to augment the current approach to addressing uncontrolled BP so that existing clinical staff can reach a larger patient population.Methods
Our project will address uncontrolled BP by leveraging team-based care, the Veteran's Health Administration Electronic Health Record, and patient-centered medical home data to address patient, provider, and system barriers to cardiovascular disease (CVD) preventive care. We will implement this project in cardiovascular disease practices in three rural Veterans Health Administration clinics. We will evaluate implementation processes as well as patient-level (e.g., clinical outcomes, referrals to specialty services) outcomes in a one-arm, pre-post design.Discussion
This manuscript describes our process in expanding the implementation of a successful project to improve BP control in high-risk, rural Veterans. Findings from our study will inform an understanding of both implementation and clinical effectiveness outcomes of a potentially scalable BP intervention in rural, community-based clinics. Appropriate management of Veterans with uncontrolled BP can reduce morbidity and mortality related to CVD. In turn, improvements in BP, can lead to improved quality metrics and potentially decrease costs for a healthcare system.Item Open Access Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients.(Implementation science communications, 2022-05) Damschroder, Laura J; Sussman, Jeremy B; Pfeiffer, Paul N; Kurlander, Jacob E; Freitag, Michelle B; Robinson, Claire H; Spoutz, Patrick; Christopher, Melissa LD; Battar, Saraswathy; Dickerson, Kimberly; Sedgwick, Christopher; Wallace-Lacey, Ashleigh G; Barnes, Geoffrey D; Linsky, Amy M; Ulmer, Christi S; Lowery, Julie CBackground
The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies.Methods
For each trial, we will recruit 8-12 clinics (24-36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act.Process
(LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently.Discussion
MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings.Trial registration
ClinicalTrials.gov: NCT05065502 . Registered October 4, 2021-retrospectively registered.Item Open Access Ready, set, go! The role of organizational readiness to predict adoption of a family caregiver training program using the Rogers' diffusion of innovation theory.(Implementation science communications, 2023-06) Van Houtven, Courtney H; Drake, Connor; Malo, Teri L; Decosimo, Kasey; Tucker, Matthew; Sullivan, Caitlin; D'Adolf, Josh; Hughes, Jaime M; Christensen, Leah; Grubber, Janet M; Coffman, Cynthia J; Sperber, Nina R; Wang, Virginia; Allen, Kelli D; Hastings, S Nicole; Shea, Christopher M; Zullig, Leah LBackground
Caregivers FIRST is an evidence-based program addressing gaps in caregivers' skills. In 2020, the Veterans Health Administration Caregiver Support Program (CSP) nationally endorsed Caregivers FIRST, offering credit in leadership performance plans to encourage all VA medical centers (VAMCs) to implement locally. This study examines the association of organizational readiness with VAMC adoption of Caregivers FIRST.Methods
In a cohort observational study, we surveyed CSP managers about their facilities' readiness to implement using the Organizational Readiness for Implementing Change (ORIC) instrument and compared change commitment and change efficacy domains among VAMCs "adopters" defined as delivering Caregivers FIRST within 1 year of the national announcement to those that did not ("non-adopters"). Within "adopters," we categorized time to adoption based on Rogers' diffusion of innovation theory including "innovators," "early adopters," "early majority," "late adopters," and "laggards." Organizational readiness and site characteristics (facility complexity, staffing levels, volume of applications for caregiver assistance services) were compared between "adopters," "non-adopters," and between time to adoption subcategories. Separate logistic regression models were used to assess whether ORIC and site characteristics were associated with early adoption among "adopters."Results
Fifty-one of 63 (81%) VAMCs with CSP manager survey respondents adopted Caregivers FIRST during the first year. ORIC change commitment and efficacy were similar for "adopters" and "non-adopters." However, sites that adopted earlier (innovators and early adopters) had higher ORIC change commitment and efficacy scores than the rest of the "adopters." Logistic regression results indicated that higher ORIC change commitment (odds ratio [OR] = 2.57; 95% confidence interval [CI], 1.11-5.95) and ORIC change efficacy (OR = 2.60; 95% CI, 1.12-6.03) scores were associated with increased odds that a VAMC was an early adopter (categorized as an "innovator," "early adopter", or "early majority"). Site-level characteristics were not associated with Caregivers FIRST early adoption.Conclusions
To our knowledge, this study is the first to prospectively assess organizational readiness and the timing of subsequent program adoption. Early adoption was associated with higher ORIC change commitment and change efficacy and not site-level characteristics. These findings yield insights into the role of organizational readiness to accelerate program adoption.Trial registration
ClinicalTrials.gov, NCT03474380. Registered on March 22, 2018.Item Open Access Translating knowledge into action for child obesity treatment in partnership with Parks and Recreation: study protocol for a hybrid type II trial.(Implementation science : IS, 2023-02) Neshteruk, Cody D; Skinner, Asheley C; Counts, Julie; D'Agostino, Emily M; Frerichs, Leah; Howard, Janna; Story, Mary; Armstrong, Sarah CBackground
Safe and effective treatment exists for childhood obesity, but treatment recommendations have largely not been translated into practice, particularly among racial and ethnic minorities and low-wealth populations. A key gap is meeting the recommended treatment of ≥26 h of lifestyle modification over 6-12 months. Fit Together is an effective treatment model that meets these recommendations by integrating healthcare and community resources. Pediatric providers screen children for obesity, deliver counseling, and treat co-morbidities, while Parks and Recreation partners provide recreation space for a community nutrition and physical activity program.Methods
This study will use a hybrid type II implementation-effectiveness design to evaluate the effectiveness of an online implementation platform (the Playbook) for delivering Fit Together. Clinical and community partners in two North Carolina communities will implement Fit Together, using the Playbook, an implementation package designed to facilitate new partnerships, guide training activities, and provide curricular materials needed to implement Fit Together. An interrupted time series design anchored in the Process Redesign Framework will be used to evaluate implementation and effectiveness outcomes in intervention sites. Implementation measures include semi-structured interviews with partners, before and after the implementation of Fit Together, and quantitative measures assessing several constructs within the Process Redesign Framework. The participants will be children 6-11 years old with obesity and their families (n=400). Effectiveness outcomes include a change in child body mass index and physical activity from baseline to 6 and 12 months, as compared with children receiving usual care. Findings will be used to inform the design of a dissemination strategy guided by the PCORI Dissemination Framework.Discussion
This project addresses the knowledge-to-action gap by developing evidence-based implementation tools that allow clinicians and communities to deliver effective pediatric obesity treatment recommendations. Future dissemination of these tools will allow more children who have obesity and their families to have access to effective, evidence-based care in diverse communities.Trial registration
ClinicalTrials.gov identifier: NCT05455190 . Registered on 13 July 2022.