Implementation Science's Role in Community Engagement for Substance Use Prevention.

Until recently, the field of implementation science has provided limited insight and guidance on the use of community engagement and partnership to support implementation of evidence-based practices. Listing community engagement as a barrier to optimal implementation is often the extent of the discussion. An article recently published by Perry et al. (PS 24:61-76, 2023) details what community engagement can entail and documents how this engagement can shape opioid use prevention research. The article also describes benefits of engaging community partners in prevention interventions, particularly for opioid use disorder, and the feasibility of employing multiple levels of engagement to do so. The article concludes by emphasizing areas for future research including examining the role community engagement has on the success of prevention interventions and the impact on long-term intervention outcomes. To respond to the Perry et al. (PS 24:61-76, 2023) article, our team conducted a literature scan of recently published implementation science and community engagement manuscripts, which demonstrated a growing body of research on the subject. We summarize these findings by offering suggested approaches for integrating implementation science and community engagement for substance use prevention programs and suggestions for advancing this intersection.

Toward an Effective Innovation Framework for Federal Grant-Making: an Exploration into OPA's Teen Pregnancy Prevention Program.

States, local, tribal, and territorial governments received almost 20% of all federal spending in fiscal year 2022, about $1.2 trillion dollars (US Office of Management and Budget, 2023a). For a strong, well-functioning democracy, the federal government must be able to disperse grant funds efficiently and effectively. Rates of teen pregnancy in the USA, while decreasing in recent years, are still consistently higher than that of other western industrialized nations (Centers for Disease Control and Prevention, 2023). The Office of Population Affairs' (OPA) Teen Pregnancy Prevention program combines cutting edge research with innovative grant distribution to creatively tackle this issue. In this commentary, we explore some of the strengths of OPA's grant distribution program in the hope that others may emulate best practices from this program. Specifically, the special issue highlights how OPA's grant program took a customer-centered focus by prioritizing work with end users and community. This evidence-based focus enabled the testing of ideas, which in turn could be iterated and scaled up. Through grantee innovation networks, they created space for external expertise, creative thinking, and diversity of thought. Other programs, policymakers, and their partners may learn from OPA's success, which arises from three core characteristics: (1) their funding stature allows long-term and flexible allocation of funding toward innovation; (2) OPA focuses on creating and supporting local communities and networks of innovation; (3) OPA emphasizes evidence-based decision-making and rigorous evaluation throughout the grant process. With a fifth of the federal budget being dispersed through grant-making and teen pregnancy still at high rates, OPA offers an exciting avenue for innovation and success in both of these areas. This commentary concludes with some recommendations for future practice.

Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a cluster-randomized type 3 hybrid trial.

Background: Substance use disorders (SUDs) have a serious adverse impact on people living with HIV. Previously, using a 39-site dual-randomized type 2 hybrid trial design, findings from the Substance Abuse Treatment to HIV Care Project supported the Implementation and Sustainment Facilitation (ISF) strategy to improve implementation and effectiveness of a motivational interviewing brief intervention (MIBI) for SUD within HIV service settings across the United States (US). Building on this trial, this cluster-randomized type 3 hybrid trial aimed to test the incremental effectiveness of a pay-for-performance (P4P), a form of the "alter incentive/allowance structures" strategy. Methods: Twenty-six HIV service organizations, their staff participants (N=87), and their client participants (N=341) were cluster-randomized to one of two implementation conditions. The control condition included staff-focused training, feedback, and consultation (TFC) and team-focused implementation and sustainment (ISF). The experimental condition included TFC+ISF as well as P4P (TFC+ISF+P4P). P4P used financial incentives to reward MIBI implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined. Results: The addition of P4P had a large and significant effect on the number of MIBIs implemented (d=1.30, p<.05) and reduction in anxiety (d=-1.54), but there was no impact on days of substance use. P4P had large effects on MIBI quality (d=1.24) and MIBI implementation effectiveness (d=1.28), but these were not significant (p<.10). Conclusions: P4P is a form of the "alter incentive/allowance structures" strategy Its function is to reward the implementation of a clinical innovation. Rewarding implementation is consistent with the theory of implementation effectiveness, which suggests implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded) is a key antecedent of implementation effectiveness (i.e., the consistency and quality of implementation). We found that P4P had a significant, positive impact on MIBI implementation in HIV service settings, but client-level outcomes were mixed. Future research should examine the cost-effectiveness of this strategy, as well as to examine the effectiveness of P4P to improve the implementation of other evidence-based innovations. Trial registration: ClinicalTrials.gov: NCT04687917. Registered 12/18/2020.

A Roadmap for conducting psychosocial research in epidemiological studies: perspectives of cohort study principal investigators.

BACKGROUND: Psychosocial adversity disproportionately affects racial/ethnic and socioeconomic minorities in the USA, and therefore understanding the mechanisms through which psychosocial stress and resilience influence human health can provide meaningful insights into addressing US health disparities. Despite this promise, psychosocial factors are infrequently and unsystematically collected in the US prospective cohort studies. METHODS: We sought to understand prospective cohort principal investigators' (PIs') attitudes regarding the importance of psychosocial influences on disease aetiology, in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research. One-hour, semi-structured qualitative interviews were conducted with 20 PIs representing 24 US prospective cohort studies funded by the National Institutes of Health (NIH), collectively capturing health data on 1.25 of every 100 American adults. A hypothesis-free, grounded theory approach was used to analyse and interpret interview data. RESULTS: Most cohort PIs view psychosocial factors as an important research area to further our understanding of disease aetiology and agree that this research will be crucial for future public health innovations. Virtually all PIs emphasised that future psychosocial research will need to elucidate biological and behavioural mechanisms in order to be taken seriously by the epidemiological community more broadly. A lack of pertinent funding mechanisms and a lack of consensus on optimal scales and measures of psychosocial factors were identified as additional barriers to advancing psychosocial research. CONCLUSIONS: Our interviews emphasised the need for: (1) high-quality, longitudinal studies that investigate biological mechanisms and pathways through which psychosocial factors influence health, (2) effort among epidemiological cohorts to broaden and harmonise the measures they use across cohorts, to facilitate replication of results and (3) the need for targeted funding opportunities from NIH and other grant-making institutions to study these domains.

Patterns of symptom control and palliative care-focused original research articles in the International Journal of Radiation Oncology *Biology* Physics and the Radiotherapy and Oncology Journal, 2005-2014.

BACKGROUND: A significant portion of radiation treatment (30-40%) is delivered with palliative intent. Given the frequency of palliative care (PC) in radiation oncology, we determined the patterns of research focusing on symptom control and palliative care (SCPC) in two prominent radiation oncology journals from 2005-2014. METHODS: Original research manuscripts published from 2005-2014 in the International Journal of Radiation Oncology *Biology* Physics (Red Journal) and the Radiotherapy and Oncology Journal (Green Journal) were reviewed to categorize articles as PC and/or SCPC. Articles were categorized as PC if it pertained to any aspect of treatment of metastatic cancer, and as SCPC if symptom control in the metastatic cancer setting was the goal of the research inquiry and/or any domain of palliative clinical practice guidelines was the goal of research inquiry. RESULTS: From 2005-2014, 4.9% (312/6,386) of original research articles published in the Red Journal and 3.5% (84/2,406) published in the Green Journal pertained to metastatic cancer, and were categorized as PC. In the Red Journal, 1.3% (84/6,386) of original research articles were categorized as SCPC; 1.3% (32/2,406) of articles in the Green Journal were categorized as SCPC. There was no trend observed in the proportion of SCPC articles published over time in the Red Journal (P=0.76), the Green Journal (P=0.48), or both journals in aggregate (P=0.38). CONCLUSIONS: Despite the fact that palliative radiotherapy is a critical part of radiation oncology practice, PC and SCPC-focused original research is poorly represented in the Red Journal and the Green Journal.

Impact of a dedicated palliative radiation oncology service on the use of single fraction and hypofractionated radiation therapy among patients with bone metastases.

BACKGROUND: Radiation therapy (RT) is frequently used to palliate symptomatic bone metastases. While high quality literature has shown that for uncomplicated bone metastases, shorter radiotherapy courses are just as effective as longer courses for the treatment of pain, shorter courses remain under-utilized. We aimed to assess the impact of a dedicated palliative radiation oncology service on the frequency of single fraction RT (SF-RT) and hypofractionated radiation (hypo-RT) (≤5 fractions) among patients with bone metastases. METHODS: We identified 2,086 instances of palliative radiation (RT) for complicated and uncomplicated bone metastases between April 10, 2008 and September 17, 2014. We used multivariable logistic regression analysis (MVA) to estimate the association of the Supportive and Palliative Radiation Oncology (SPRO) service with the likelihood of receiving SF-RT or hypo-RT after controlling for age, sex, tumor type, and treatment site. RESULTS: Prior to SPRO's implementation on July 1, 2011, the proportion of SF-RT and hypo-RT for bone metastases was 6.4% and 27.6% respectively. After SPRO's implementation, the proportion of SF-RT and hypo-RT increased to 22.3% (P<0.001) and 53.5% (P<0.001) respectively. In MVA, patients were more likely to receive SF-RT [odds ratio (OR) =3.3, 95% confidence interval (CI) =2.4-4.7, P<0.001], and hypo-RT (OR =2.5, 95% CI =2.0-3.1, P<0.001) after SPRO's implementation. Compared to sites without a dedicated palliative service, patients receiving care at the SPRO affiliated department were more likely to receive SF-RT (OR =1.9, 95% CI =1.1-3.2, P=0.02) and hypo-RT (OR =1.5, 95% CI =1.1-2.0, P=0.004) for bone metastases. After SPRO's implementation, the average number of RT courses delivered for bone metastases increased from 17.4 to 25.6 per month, (+8.3, 95% CI =4.99-11.55, P<0.001). Despite greater SF-RT and hypo-RT, the average total fractions per month of palliative RT for bone metastases increased from 163.5 pre-SPRO to 166.8 post-SPRO, though not significantly (+3.22, P=NS). CONCLUSIONS: Implementation of a dedicated palliative radiation oncology service was associated with increased use of SF and hypo-RT and with greater courses of RT delivered for bone metastases.

Seeking and Accepting: U.S. Clergy Theological and Moral Perspectives Informing Decision Making at the End of Life.

BACKGROUND: People with serious illness frequently rely on religion/spirituality to cope with their diagnosis, with potentially positive and negative consequences. Clergy are uniquely positioned to help patients consider medical decisions at or near the end of life within a religious/spiritual framework. OBJECTIVE: We aimed to examine clergy knowledge of end-of-life (EOL) care and beliefs about the role of faith in EOL decision making for patients with serious illness. DESIGN: Key informant interviews, focus groups, and survey. SETTING/SUBJECTS: A purposive sample of 35 active clergy in five U.S. states as part of the National Clergy End-of-Life Project. MEASUREMENT: We assessed participant knowledge of and desire for further education about EOL care. We transcribed interviews and focus groups for the purpose of qualitative analysis. RESULTS: Clergy had poor knowledge of EOL care; 75% desired more EOL training. Qualitative analysis revealed a theological framework for decision making in serious illness that balances seeking life and accepting death. Clergy viewed comfort-focused treatments as consistent with their faith traditions' views of a good death. They employed a moral framework to determine the appropriateness of EOL decisions, which weighs the impact of multiple factors and upholds the importance of God-given free will. They viewed EOL care choices to be the primary prerogative of patients and families. Clergy described ambivalence about and a passive approach to counseling congregants about decision making despite having defined beliefs regarding EOL care. CONCLUSIONS: Poor knowledge of EOL care may lead clergy to passively enable congregants with serious illness to pursue potentially nonbeneficial treatments that are associated with increased suffering.