Evaluating the implementation of a community health worker-delivered intervention integrating asthma care in West Philadelphia public schools.

OBJECTIVE: Schools are an important setting because students spend much of their time in school and engage in physical activity during the school day that could exacerbate asthma symptoms. Our objective is to understand the barriers and facilitators to implementing an experimental community health worker-delivered care coordination program for students with asthma within the context of the West Philadelphia Controls Asthma study. METHODS: Surveys (n = 256) and semi-structured interviews (n = 41) were completed with principals, teachers, nurses, and community health workers from 21 public and charter schools in West Philadelphia between January 2019 and September 2021. Survey participants completed the Evidence Based Practice Attitudes Scale, the Implementation Leadership Scale, and Organizational Climate Index. Semi-structured qualitative interview guides were developed, informed by the Consolidated Framework for Implementation Research. RESULTS: Participant responses indicate that they perceived benefits for schools and students related to the community health worker-based care coordination program. Several barriers and facilitators to implementing the program were noted, including challenges associated with incorporating the program into school nurse workflow, environmental triggers in the school environment, and challenges communicating with family members. An important facilitator that was identified was having supportive school administrators and staff who were engaged and saw the benefits of the program. CONCLUSIONS: This work can inform implementation planning for other locales interested in implementing community-based pediatric asthma control programs delivered by community health workers in schools.

Acceptability of Dyad Care Management After Preterm Birth: A Qualitative Study.

OBJECTIVES: Care management programs for medically complex infants interact with parents after complicated pregnancies, when gaps in maternal health care are well documented. These care managers may have the relationships and skills to promote postpartum and interconception health and health care access. It is unknown whether expanding these care management models to address maternal needs would be acceptable. METHODS: We conducted qualitative interviews with women with a history of preterm birth and clinicians. For women with a history of preterm birth, additional inclusion criteria were Medicaid-insured infant in one health system and English proficiency. We purposively oversampled women whose infants received care management. Clinicians worked in two geographically adjacent health systems. Interviews explored priorities after preterm birth and perceived acceptability of mother-infant dyad care management. Interviews were audio recorded, transcribed, and coded following an integrated approach in which we applied a priori codes and captured emergent themes. RESULTS: We interviewed 33 women (10/2018-7/2021) and 24 clinicians (3/2021-8/2021). Women were predominantly non-Hispanic Black, and 15 had infants receiving care management. Clinicians included physicians, nurses, and social workers from Pediatrics, Obstetrics, and Family Medicine. Subgroups converged thematically, finding care management acceptable. Tailoring programs to address stress and sleep, emphasizing care managers with strong interpersonal skills and shared experiences with care management users, and program flexibility would contribute to acceptability. CONCLUSIONS FOR PRACTICE: Dyad care management after preterm birth is acceptable to potential program end-users and clinicians. Dyad health promotion may contribute to improved birth outcomes, infant, and parent health.

Bystander intervention to prevent firearm injury: A qualitative study of 4-H shooting sports participants.

This qualitative study examines how youth and adult members of 4-H Shooting Sports clubs perceive firearm injury risk and risk reduction, and the applicability of a bystander intervention (BI) risk reduction framework in this community. Semistructured interviews were conducted with 11 youth and 13 adult members of 4-H Shooting Sports clubs across nine US states from March to December of 2021 until thematic saturation was reached. Deductive and inductive thematic qualitative analyses were performed. Six overarching themes emerged: (1) The tendency to view firearm injury as predominantly unintentional in nature; (2) Acknowledgment of a wide array of risks for firearm injury; (3) Perceived barriers to bystander action to prevent firearm injury including knowledge, confidence, and consequences of action; (4) Facilitators of bystander action including a sense of civic responsibility; (5) Direct and indirect strategies to address potential risks for firearm injury; and (6) Belief that BI skills training would be useful for 4-H Shooting Sports. Findings lay the groundwork for applying BI skills training as an approach to firearm injury prevention in 4-H Shooting Sports, similar to how BI has been applied to other types of injury (i.e., sexual assault). 4-H Shooting Sports club members' sense of civic responsibility is a key facilitator. Prevention efforts should attend to the broad array of ways in which firearm injury occurs, including suicide, mass shootings, homicide, and intimate partner violence, as well as unintentional injury.

Implementation science in pediatric oncology: A narrative review and future directions.

Implementation science (IS) has garnered attention within oncology, and most prior IS work has focused on adult, not pediatric, oncology. This narrative review broadly characterizes IS for pediatric oncology. It includes studies through 2020 using the following search terms in PubMed, Ovid Medline, and Cochrane: "implementation science," "pediatric," "childhood," "cancer," and "oncology." Systematic review was not performed due to the limited number of heterogeneous studies. Of 216 articles initially reviewed, nine were selected as specific to IS and pediatric oncology. All nine examined oncologic supportive care, cancer prevention, or cancer control. The supportive care focus is potentially due to the presence of cooperative study groups such as the Children's Oncology Group, which efficiently drive cancer-directed therapy changes through clinical trials. Future IS within pediatric oncology should embrace this ecosystem and focus on cancer control interventions that benefit patients across multiple cancer types and patients treated outside cooperative group studies.

Clinical Supervision in Community Mental Health: Characterizing Supervision as Usual and Exploring Predictors of Supervision Content and Process.

Clinical supervision can be leveraged to support implementation of evidence-based practices in community mental health settings, though it has been understudied. This study focuses on 32 supervisors at 23 mental health organizations in Philadelphia. We describe characteristics of supervisors and organizations and explore predictors of supervision content and process. Results highlight a low focus on evidence-based content and low use of active supervision processes. They underscore the need for further attention to the community mental health context when designing supervision-targeted implementation strategies. Future work should assess whether supervision models specific to community mental health are needed.

Applying NUDGE to Inform Design of EBP Implementation Strategies in Community Mental Health Settings.

We demonstrate the application of NUDGE (Narrow, Understand, Discover, Generate, Evaluate), a behavioral economics approach to systematically identifying behavioral barriers that impede behavior enactment, to the challenge of evidence-based practice (EBP) use in community behavioral health. Drawing on 65 clinician responses to a system-wide crowdsourcing challenge about EBP underutilization, we applied NUDGE to discover, synthesize and validate specific behavioral barriers to EBP utilization that directly inform the design of tailored implementation strategies. To our knowledge, this is the first study to apply behavioral economic insights to clinician-proposed solutions to implementation challenges in order to design implementation strategies. The study demonstrates the successful application of NUDGE to implementation strategy design and provides novel targets for intervention.

Where Is the Implementation Science? An Opportunity to Apply Principles During the COVID-19 Pandemic.

The coronavirus disease 2019 pandemic represents a global crisis that has received extraordinary response from healthcare workers and scientists. One critical but potentially overlooked field in a pandemic is implementation science-the study of methods to reduce the research-to-practice gap. In this Viewpoint, we discuss the important role of implementation science during this and future pandemics and highlight considerations to maximize the utility of implementation research.

Early Childhood Sleep Intervention in Urban Primary Care: Caregiver and Clinician Perspectives.

BACKGROUND: Despite significant income-related disparities in pediatric sleep, few early childhood sleep interventions have been tailored for or tested with families of lower socio-economic status (SES). This qualitative study assessed caregiver and clinician perspectives to inform adaptation and implementation of evidence-based behavioral sleep interventions in urban primary care with families who are predominantly of lower SES. METHODS: Semi-structured interviews were conducted with (a) 23 caregivers (96% mothers; 83% Black; 65% ≤125% U.S. poverty level) of toddlers and preschoolers with insomnia or insufficient sleep and (b) 22 urban primary care clinicians (physicians, nurse practitioners, social workers, and psychologists; 87% female; 73% White). Guided by the Consolidated Framework for Implementation Research, the interview guide assessed multilevel factors across five domains related to intervention implementation. Qualitative data were analyzed using an integrated approach to identify thematic patterns across participants and domains. RESULTS: Patterns of convergence and divergence in stakeholder perspectives emerged across themes. Participants agreed upon the importance of child sleep and intervention barriers (family work schedules; household and neighborhood factors). Perspectives aligned on intervention (flexibility; collaborative and empowering care) and implementation (caregiver-to-caregiver support and use of technology) facilitators. Clinicians identified many family barriers to treatment engagement, but caregivers perceived few barriers. Clinicians also raised healthcare setting factors that could support (integrated care) or hinder (space and resources) implementation. CONCLUSIONS: Findings point to adaptations to evidence-based early childhood sleep intervention that may be necessary for effective implementation in urban primary care. Such adaptations could potentially reduce significant pediatric sleep-related health disparities.

Perspectives from firearm stakeholders on firearm safety promotion in pediatric primary care as a suicide prevention strategy: a qualitative study.

The primary objective of the current study was to examine the perspective of firearm stakeholders, including firearm safety course instructors, members of law enforcement, and firearm retailers, with regard to the implementation of an evidence-based approach to firearm safety promotion, the Firearm Safety Check, as a universal suicide prevention strategy in pediatric primary care. Twelve firearm stakeholders participated in semi-structured interviews. Using an integrated analytic approach, several themes emerged from the interviews. With regard to acceptability of the intervention, participants generally found counseling caregivers to store firearms safely and the provision of firearm locking mechanisms to be acceptable, but expressed concern about screening for firearm ownership in health systems. Participants identified distinct roles of responsibility for firearm advocacy groups, firearm owners, healthcare clinicians, and caregivers with regard to the promotion and execution of safe firearm storage. Participants called for partnerships between healthcare systems and firearm stakeholders, and also identified potential threats to these partnerships, including lack of trust firearm owners may have in health systems and the government. Finally, participants suggested strategies for preventing firearm-related suicides. Findings support a growing body of literature suggesting the value in researchers, health systems, and firearm stakeholders partnering around a shared agenda of firearm safety promotion as a strategy to prevent suicide.

Benchmarking Treatment Effectiveness of Community-Delivered Trauma-Focused Cognitive Behavioral Therapy.

It is critical for urban youth with post-traumatic stress disorder (PTSD) living in poverty to have access to evidence-based interventions for their traumatic stress. However, there is limited research on the effectiveness of these interventions when provided in urban, community settings. The objectives of the current study are to (a) evaluate the effectiveness of trauma-focused cognitive behavioral therapy delivered from 2013 to 2016 in 15 behavioral health agencies on youth (N = 114) PTSD as well as  general mental health symptoms and  functioning, and (b) benchmark these clinical outcomes against other published efficacy and effectiveness trials. Effectiveness data are from the Philadelphia County Community Behavioral Health System, a system that has invested significantly in the training and ongoing support of clinicians providing high-quality trauma services to youth since 2012. From baseline to last assessment, youth PTSD symptom severity (d = 0.34), PTSD functional impairment (d = 0.38), and overall mental health problem severity (d = 0.29) improved. The effect sizes of  improvements were smaller than effect sizes observed in efficacy and effectiveness studies. This study is the first benchmarking study of TF-CBT and provides preliminary findings with regard to the effectiveness, and transportability, of TF-CBT to urban community settings that serve youth in poverty.

Concordance Between Administrator and Clinician Ratings of Organizational Culture and Climate.

Organizational culture and climate are important determinants of behavioral health service delivery for youth. The Organizational Social Context measure is a well validated assessment of organizational culture and climate that has been developed and extensively used in public sector behavioral health service settings. The degree of concordance between administrators and clinicians in their reports of organizational culture and climate may have implications for research design, inferences, and organizational intervention. However, the extent to which administrators' and clinicians' reports demonstrate concordance is just beginning to garner attention in public behavioral health settings in the United States. We investigated the concordance between 73 administrators (i.e., supervisors, clinical directors, and executive directors) and 247 clinicians in 28 child-serving programs in a public behavioral health system. Findings suggest that administrators, compared to clinicians, reported more positive cultures and climates. Organizational size moderated this relationship such that administrators in small programs (<466 youth clients served annually) provided more congruent reports of culture and climate in contrast to administrators in large programs (≥466 youth clients served annually) who reported more positive cultures and climates than clinicians. We propose a research agenda that examines the effect of concordance between administrators and clinicians on organizational outcomes in public behavioral health service settings.

Applying the Policy Ecology Framework to Philadelphia's Behavioral Health Transformation Efforts.

Raghavan et al. (Implement Sci 3(26):1-9, 2008) proposed that effective implementation of evidence-based practices requires implementation strategies deployed at multiple levels of the "policy ecology," including the organizational, regulatory or purchaser agency, political, and social levels. However, much of implementation research and practice targets providers without accounting for contextual factors that may influence provider behavior. This paper examines Philadelphia's efforts to work toward an evidence-based and recovery-oriented behavioral health system, and uses the policy ecology framework to illustrate how multifaceted, multilevel implementation strategies can facilitate the widespread implementation of evidence-based practices. Ongoing challenges and implications for research and practice are discussed.

A Multi-Level Examination of Stakeholder Perspectives of Implementation of Evidence-Based Practices in a Large Urban Publicly-Funded Mental Health System.

Our goal was to identify barriers and facilitators to the implementation of evidence-based practices from the perspectives of multiple stakeholders in a large publicly funded mental health system. We completed 56 interviews with three stakeholder groups: treatment developers (n = 7), agency administrators (n = 33), and system leadership (n = 16). The three stakeholder groups converged on the importance of inner (e.g., agency competing resources and demands, therapist educational background) and outer context (e.g., funding) factors as barriers to implementation. Potential threats to implementation and sustainability included the fiscal landscape of community mental health clinics and an evolving workforce. Intervention characteristics were rarely endorsed as barriers. Inner context, outer context, and intervention characteristics were all seen as important facilitators. All stakeholders endorsed the importance of coordinated collaboration across stakeholder groups within the system to successfully implement evidence-based practices.

Barriers and Facilitators to Implementing an Evidence-Based Community Health Worker Model.

Importance: Community health worker (CHW) programs may improve health outcomes, increase quality of life, and reduce hospitalizations and cost of care. However, knowledge is limited on the barriers and facilitators associated with scaling evidence-based CHW programs to maximize their public health outcomes. Objective: To identify barriers and facilitators to implementing an evidence-based CHW model. Design, Setting, and Participants: This qualitative study examined perspectives of Individualized Management of Person-Centered Targets (IMPaCT) program staff (health system leaders, program managers, and community health workers) and patients receiving the intervention between March 9, 2020, and July 22, 2021, at 5 institutionally and geographically diverse health systems across the US. The collected data were analyzed between December 1, 2021, and April 27, 2022. Program staff were recruited via purposive sampling, and patients were recruited via convenience sampling. Intervention: The disease-agnostic IMPaCT CHW model includes a standardized implementation approach and a structured set of theory-informed intervention components to create and achieve individualized action plans. Main Outcomes and Measures: Interview guides were informed by the Consolidated Framework for Implementation Research. A rapid qualitative analytic technique was used to identify key themes, which were categorized into barriers and facilitators associated with framework ecological domains. Results: Of a total 41 individuals invited, 39 agreed to participate (95% response rate; mean [SD] age, 45.0 [12.6] years; 30 women). General barriers included economic and policy constraints, including insufficient funding for CHW programs, clinical integration challenges, and CHW difficulty with maintaining boundaries. Program-specific barriers included insufficiently tailored materials for certain populations and upfront and ongoing program costs. General facilitators included CHWs' interpersonal skills and life experiences. Program-specific facilitators included the model's strong evidence base, supportive implementation team, and program design that enabled relationship building and engagement. Additional themes were cited as both barriers and facilitators, including the COVID-19 pandemic, organizational leadership, IMPaCT training, and program fidelity. Conclusions and Relevance: These findings suggest growing recognition of the importance of CHWs to improving health equity and population health. Barriers identified point to important policy and practice implications for CHW programs more broadly, including the need for continued attention to improving clinical integration and the need for sustainable program financing to preserve the longevity of this workforce.

Addressing social needs in oncology care: another research-to-practice gap.

Social determinants of health and unmet social needs are directly related to cancer outcomes, from diagnosis to survivorship. If identified, unmet social needs can be addressed in oncology care by changing care plans in collaboration with patients' preferences and accounting for clinical practice guidelines (eg, reducing the frequency of appointments, switching treatment modalities) and connecting patients to resources within healthcare organizations (eg, social work support, patient navigation) and with community organizations (eg, food banks, housing assistance programs). Screening for social needs is the first step to identifying those who need additional support and is increasingly recognized as a necessary component of high-quality cancer care delivery. Despite evidence about the relationship between social needs and cancer outcomes and the abundance of screening tools, the implementation of social needs screening remains a challenge, and little is known regarding the adoption, reach, and sustainability of social needs screening in routine clinical practice. We present data on the adoption and implementation of social needs screening at two large academic cancer centers and discuss three challenges associated with implementing evidence-based social needs screening in clinical practice: (1) identifying an optimal approach for administering social needs screening in oncology care, (2) adequately addressing identified unmet needs with resources and support, and (3) coordinating social needs screening between oncology and primary care.

Navigating grey areas in HIV and mental health implementation science.

INTRODUCTION: Implementation science (IS) offers methods to systematically achieve the Ending the HIV Epidemic goals in the United States, as well as the global UNAIDS targets. Federal funders such as the National Institutes of Mental Health (NIMH) have invested in implementation research to achieve these goals, including supporting the AIDS Research Centres (ARCs), which focus on high-impact science in HIV and mental health (MH). To facilitate capacity building for the HIV/MH research workforce in IS, "grey areas," or areas of IS that are confusing, particularly for new investigators, should be addressed in the context of HIV/MH research. DISCUSSION: A group of IS experts affiliated with NIMH-funded ARCs convened to identify common and challenging grey areas. The group generated a preliminary list of 19 grey areas in HIV/MH-related IS. From the list, the authors developed a survey which was distributed to all ARCs to prioritize grey areas to address in this paper. ARC members across the United States (N = 60) identified priority grey areas requiring clarification. This commentary discusses topics with 40% or more endorsement. The top grey areas that ARC members identified were: (1) Differentiating implementation strategies from interventions; (2) Determining when an intervention has sufficient evidence for adaptation; (3) Integrating recipient perspectives into HIV/MH implementation research; (4) Evaluating whether an implementation strategy is evidence-based; (5) Identifying rigorous approaches for evaluating the impact of implementation strategies in the absence of a control group or randomization; and (6) Addressing innovation in HIV/MH IS grants. The commentary addresses each grey area by drawing from the existing literature (when available), providing expert guidance on addressing each in the context of HIV/MH research, and providing domestic and global HIV and HIV/MH case examples that address these grey areas. CONCLUSIONS: HIV/MH IS is key to achieving domestic and international goals for ending HIV transmission and mitigating its impact. Guidance offered in this paper can help to overcome challenges to rigorous and high-impact HIV/MH implementation research.

Population mental health science: Guiding principles and initial agenda.

A recent American Psychological Association Summit provided an urgent call to transform psychological science and practice away from a solely individual-level focus to become accountable for population-level impact on health and mental health. A population focus ensures the mental health of all children, adolescents, and adults and the elimination of inequities across groups. Science must guide three components of this transformation. First, effective individual-level interventions must be scaled up to the population level using principles from implementation science, investing in novel intervention delivery systems (e.g., online, mobile application, text, interactive voice response, and machine learning-based), harnessing the strength of diverse providers, and forging culturally informed adaptations. Second, policy-driven community-level interventions must be innovated and tested, such as public efforts to promote physical activity, public policies to support families in early life, and regulation of corporal punishment in schools. Third, transformation is needed to create a new system of universal primary care for mental health, based on models such as Family Connects, Triple P, PROmoting School-community-university Partnerships to Enhance Resilience, Communities That Care, and the Early Childhood Collaborative of the Pittsburgh Study. This new system must incorporate valid measurement, universal screening, and a community-based infrastructure for service delivery. Addressing tasks ahead, including scientific creativity and discovery, rigorous evaluation, and community accountability, will lead to a comprehensive strategic plan to shape the emergent field of public mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Consultation as an implementation strategy for evidence-based practices across multiple contexts: unpacking the black box.

There is great interest in the dissemination and implementation of evidence-based treatments and practices for children across schools and community mental health settings. A growing body of literature suggests that the use of one-time workshops as a training tool is ineffective in influencing therapist behavior and patient outcomes and that ongoing expert consultation and coaching is critical to actual uptake and quality implementation. Yet, we have very limited understanding of how expert consultation fits into the larger implementation support system, or the most effective consultation strategies. This commentary reviews the literature on consultation in child mental health, and proposes a set of core consultation functions, processes, and outcomes that should be further studied in the implementation of evidence-based practices for children.

Provider perspectives on clinical decision support to improve HIV prevention in pediatric primary care: a multiple methods study.

BACKGROUND: Clinical decision support (CDS) is a promising intervention for improving uptake of HIV testing and pre-exposure prophylaxis (PrEP). However, little is known regarding provider perspectives on acceptability, appropriateness, and feasibility of CDS for HIV prevention in pediatric primary care, a key implementation setting. METHODS: This was a cross-sectional multiple methods study utilizing surveys and in-depth interviews with pediatricians to assess acceptability, appropriateness, and feasibility of CDS for HIV prevention, as well as to identify contextual barriers and facilitators to CDS. Qualitative analysis utilized work domain analysis and a deductive coding approach grounded in the Consolidated Framework of Implementation Research. Quantitative and qualitative data were merged to develop an Implementation Research Logic Model to conceptualize implementation determinants, strategies, mechanisms, and outcomes of potential CDS use. RESULTS: Participants (n = 26) were primarily white (92%), female (88%), and physicians (73%). Using CDS to improve HIV testing and PrEP delivery was perceived as highly acceptable (median score 5), IQR [4-5]), appropriate (5, IQR [4-5]), and feasible (4, IQR [3.75-4.75]) using a 5-point Likert scale. Providers identified confidentiality and time constraints as two key barriers to HIV prevention care spanning every workflow step. With respect to desired CDS features, providers sought interventions that were integrated into the primary care workflow, standardized to promote universal testing yet adaptable to the level of a patient's HIV risk, and addressed providers' knowledge gaps and bolstered self-efficacy in providing HIV prevention services. CONCLUSIONS: This multiple methods study indicates that clinical decision support in the pediatric primary care setting may be an acceptable, feasible, and appropriate intervention for improving the reach and equitable delivery of HIV screening and PrEP services. Design considerations for CDS in this setting should include deploying CDS interventions early in the visit workflow and prioritizing standardized but flexible designs.

Evaluation of a brief virtual implementation science training program: the Penn Implementation Science Institute.

BACKGROUND: To meet the growing demand for implementation science expertise, building capacity is a priority. Various training opportunities have emerged to meet this need. To ensure rigor and achievement of specific implementation science competencies, it is critical to systematically evaluate training programs. METHODS: The Penn Implementation Science Institute (PennISI) offers 4 days (20 h) of virtual synchronous training on foundational and advanced topics in implementation science. Through a pre-post design, this study evaluated the sixth PennISI, delivered in 2022. Surveys measures included 43 implementation science training evaluation competencies grouped into four thematic domains (e.g., items related to implementation science study design grouped into the "design, background, and rationale" competency category), course-specific evaluation criteria, and open-ended questions to evaluate change in knowledge and suggestions for improving future institutes. Mean composite scores were created for each of the competency themes. Descriptive statistics and thematic analysis were completed. RESULTS: One hundred four (95.41% response rate) and 55 (50.46% response rate) participants completed the pre-survey and post-survey, respectively. Participants included a diverse cohort of individuals primarily affiliated with US-based academic institutions and self-reported as having novice or beginner-level knowledge of implementation science at baseline (81.73%). In the pre-survey, all mean composite scores for implementation science competencies were below one (i.e., beginner-level). Participants reported high value from the PennISI across standard course evaluation criteria (e.g., mean score of 3.77/4.00 for overall quality of course). Scores for all competency domains increased to a score between beginner-level and intermediate-level following training. In both the pre-survey and post-survey, competencies related to "definition, background, and rationale" had the highest mean composite score, whereas competencies related to "design and analysis" received the lowest score. Qualitative themes offered impressions of the PennISI, didactic content, PennISI structure, and suggestions for improvement. Prior experience with or knowledge of implementation science influenced many themes. CONCLUSIONS: This evaluation highlights the strengths of an established implementation science institute, which can serve as a model for brief, virtual training programs. Findings provide insight for improving future program efforts to meet the needs of the heterogenous implementation science community (e.g., different disciplines and levels of implementation science knowledge). This study contributes to ensuring rigorous implementation science capacity building through the evaluation of programs.