An Emergent Network for the Diffusion of Innovations Among Local Health Departments at the Onset of the COVID-19 Pandemic.

INTRODUCTION: Communication networks among professionals can be pathways for accelerating the diffusion of innovations if some local health departments (LHDs) drive the spread of knowledge. Such a network could prove valuable during public health emergencies such as the novel coronavirus disease 2019 (COVID-19) pandemic. Our objective was to determine whether LHDs in the United States were tied together in an informal network to share information and advice about innovative community health practices, programs, and policies. METHODS: In January and February 2020, we conducted an online survey of 2,303 senior LHD leaders to ask several questions about their sources of advice. We asked respondents to rank up to 3 other LHDs whose practices informed their work on new public health programs, evidence-based practices, and policies intended to improve community health. We used a social network analysis program to assess answers. RESULTS: A total of 329 LHDs responded. An emergent network appeared to operate nationally among 740 LHDs. Eleven LHDs were repeatedly nominated by peers as sources of advice or examples (ie, opinion leaders), and 24 acted as relational bridges to hold these emergent networks together (ie, boundary spanners). Although 2 LHDs played both roles, most LHDs we surveyed performed neither of these roles. CONCLUSION: Opinion leading and boundary spanning health departments can be accessed to increase the likelihood of affecting the rate of interest in and adoption of innovations. Decision makers involved in disseminating new public health practices, programs, or policies may find our results useful both for emergencies and for practice-as-usual.

Environmental Stigma: Resident Responses to Living in a Contaminated Area.

This article examined the extent to which residents living in the Midland-Saginaw-Bay City area in Eastern Michigan felt stigmatized due to industrial contamination. Seventy in-depth interviews were conducted with local residents, focusing on the extent to which they experienced three aspects of stigma-affective, cognitive, and behavioral. Results indicated that although some participants were not concerned with living in a contaminated community, local residents largely perceived dioxin as a risk to individual health and the local environment. Concern, shock, and irritation were typical affective responses at the time participants learned of the contamination. Several participants indicated a feeling of embarrassment and fear of being rejected by others because of the stigma associated with industrial contamination. Instead of actively seeking information about dioxin contamination and remediation, participants often relied on information provided to them by government officials. Behaviorally, participants avoided eating locally caught fish and prepared fish more carefully in order to avoid exposure to contaminants. As a whole, this study provided insight to understand affective, cognitive, and behavioral responses to environmental stigma.

Facilitators and Barriers to Implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Primary Care in Integrated Health Care Settings.

BACKGROUND: Substance abuse in the United States is a serious public health concern impacting morbidity and mortality. However, systematic screening and intervention has not been widely adopted into routine practice by health care organizations and routine screening and intervention is not currently in place for primary care at Kaiser Permanente Colorado. Therefore, a formative evaluation was conducted to explore and enhance implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) screening, brief intervention, and referral to treatment (SBIRT) approach in the organization. METHODS: Key clinical stakeholders, including internal and family medicine physicians, primary care nurses, mental health therapists, chemical dependency clinicians, and clinic-based psychologists provided feedback. Two focus groups were also conducted with patient stakeholders: one in English and one in Spanish. RESULTS: All clinical stakeholders promoted clinic-based psychologists to conduct brief intervention and determine referral to treatment as the optimal implementation program. Inclusion of the patient perspective also highlighted the importance of considering this perspective in implementation. Both patient groups were generally supportive of SBIRT, especially the educational value of screening questions defining healthy drinking limits; however, English-speaking patients noted privacy concerns and Spanish-speaking patients noted frequently being asked about drug or alcohol use. Organizationally, systems exist to facilitate drug and alcohol use screening, intervention, and referral to treatment. However, physician time, alignment with other priorities, and lack of consistent communication were noted potential barriers to SBIRT implementation. CONCLUSIONS: Clinicians expressed concerns about competing priorities and the need for organizational leadership involvement for successful SBIRT implementation. A unique suggestion for successful implementation is to utilize existing primary care clinic-based psychologists to conduct brief intervention and facilitate referral to treatment. Patient stakeholders supported universal screening, but cultural differences in opinions and current experience were noted, indicating the importance of including this perspective when evaluating implementation potential.

Share of Adult Suicides After Recent Jail Release.

Importance: Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. Objective: To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. Design, Setting, and Participants: This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. Main Outcomes and Measures: The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Results: Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. Conclusions and Relevance: This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.

The Evolve to Next-Gen ACT Network: An evolving open-access, real-world data resource primed for real-world evidence research across the Clinical and Translational Science Award Consortium.

The ACT Network was funded by NIH to provide investigators from across the Clinical and Translational Science Award (CTSA) Consortium the ability to directly query national federated electronic health record (EHR) data for cohort discovery and feasibility assessment of multi-site studies. NIH refunded the program for expanded research application to become "Evolve to Next-Gen ACT" (ENACT). In parallel, the US Food and Drug Administration has been evaluating the use of real-world data (RWD), including EHR data, as sources of real-world evidence (RWE) for its regulatory decisions involving drug and biological products. Using insights from implementation science, six lessons learned from ACT for developing and sustaining RWD/RWE infrastructures and networks across the CTSA Consortium are presented in order to inform ENACT's development from the outset. Lessons include intentional institutional relationship management, end-user engagement, beta-testing, and customer-driven adaptation. The ENACT team is also conducting customer discovery interviews with CTSA hub and investigators using Innovation-Corps@NCATS (I-Corps™) methodology for biomedical entrepreneurs to uncover unmet RWD needs. Possible ENACT value proposition hypotheses are presented by stage of research. Developing evidence about methods for sustaining academically derived data infrastructures and support can advance the science of translation and support our nation's RWD/RWE research capacity.

Perception of direct-to-consumer genetic testing and direct-to-consumer advertising of genetic tests among members of a large managed care organization.

This small qualitative study was designed to determine possible attitudes toward and understanding of direct-to-consumer (DTC) genetic testing among members of a large managed care organization, and whether differences might exist between population groups. Ten focus groups were conducted by population type (high risk, White, African American, Hispanic/Latino) to determine knowledge, attitudes and beliefs about DTC genetics. Focus group transcripts were coded for attitudes toward and framing of the issue. Study results found participants were negative towards DTC genetic testing but they also found some aspects useful. Participants framed the issue mainly in terms of disease prevention and uncertainty of reaction to results, with some variation between population types. The concept of an "Informed Consumer," or process to seek information when the issue becomes personally relevant, emerged. This concept suggests that individuals may seek additional assistance to make personally-appropriate choices when faced with a DTC advertisement or genetic test.

A Framework for Introducing Global Health Innovations to the US.

Background: Across the globe, there are successful health innovations that could help improve public health in US communities at lower cost and with higher effectiveness than standard practice. However, which factors should be considered to heighten the likelihood of successful transfer of global health ideas to the US still warrants more empirical investigation. Objective: This study aimed to develop a conceptual framework delineating important factors to be considered for successful introduction of global health innovations to US communities, based on diffusion of innovations literature and case studies of global health innovations that have been adopted in US communities. Methods: Five global health innovations adopted in US communities were selected based on expert panel recommendations and a review of academic and gray literatures. These innovations had diverse origins (Columbia, Mexico, South Africa, Sweden, and Wales) and exhibited various means of achieving desired health outcomes. We conducted archival research and 27 interviews (42 interviewees) with leaders and stakeholders of the five innovations to identify important factors for the transfer of global health innovations to the US. Findings: Six factors were determined to be important for global health innovation adoption in the US: (1) innovation attributes, (2) linking agents, (3) inter-organizational partnerships, (4) scale up strategies, (5) implementation processes and outcomes in US communities, and (6) policy and social context. These factors correspond well to factors emphasized in the diffusion of innovation literature, although the importance of some sub-factors (e.g., stigma regarding the origin of innovations) diverged from the literature. Conclusions: Based on our findings, we developed the Designing for Diffusion Framework for Global Health Innovations. The framework provides a comprehensive picture of factors that can be facilitators or hindrances for moving a global health innovation to the US to help smooth the diffusion process for better adoption and implementation in US communities.

Translating research into practice-implementation recommendations for pediatric rheumatology; Proceedings of the childhood arthritis and rheumatology research alliance 2020 implementation science retreat.

The translation of research findings into clinical practice is challenging, especially fields like in pediatric rheumatology, where the evidence base is limited, there are few clinical trials, and the conditions are rare and heterogeneous. Implementation science methodologies have been shown to reduce the research- to- practice gap in other clinical settings may have similar utility in pediatric rheumatology. This paper describes the key discussion points from the inaugural Childhood Arthritis and Rheumatology Research Alliance Implementation Science retreat held in February 2020. The aim of this report is to synthesize those findings into an Implementation Science Roadmap for pediatric rheumatology research. This roadmap is based on three foundational principles: fostering curiosity and ensuring discovery, integration of research and quality improvement, and patient-centeredness. We include six key steps anchored in the principles of implementation science. Applying this roadmap will enable researchers to evaluate the full range of research activities, from the initial clinical design and evidence acquisition to the application of those findings in pediatric rheumatology clinics and direct patient care.

An agenda for research on the sustainability of public health programs.

Funders of programs in public health and community health are increasingly concerned about the sustainability of changes they initiate. Despite a recent increase in sustainability research and evaluation, this literature has not developed a widely used paradigm for conducting research that can accumulate into generalizable findings. We provide guidance for research and evaluation of health program sustainability, including definitions and types of sustainability, specifications and measurements of dependent variables, definitions of independent variables or factors that influence sustainability, and suggestions for designs for research and data collection. We suggest viewing sustainability research as a further stage in the translation or dissemination of research-based interventions into practice. This perspective emphasizes ongoing relationships with earlier stages of a broader diffusion framework, including adoption and implementation processes.

Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization.

BACKGROUND: In 2006, recognizing variations in performance in quality, safety, service, and efficiency, Kaiser Permanente leaders initiated the development of a performance improvement (PI) system. Kaiser Permanente has implemented a strategy for creating the systemic capacity for continuous improvement that characterizes a learning organization. Six "building blocks" were identified to enable Kaiser Permanente to make the transition to becoming a learning organization: real-time sharing of meaningful performance data; formal training in problem-solving methodology; workforce engagement and informal knowledge sharing; leadership structures, beliefs, and behaviors; internal and external benchmarking; and technical knowledge sharing. Putting each building block into place required multiple complex strategies combining top-down and bottom-up approaches. SUCCESSES AND CHALLENGES: Although the strategies have largely been successful, challenges remain. The demand for real-time meaningful performance data can conflict with prioritized changes to health information systems. It is an ongoing challenge to teach PI, change management, innovation, and project management to all managers and staff without consuming too much training time. Challenges with workforce engagement include low initial use of tools intended to disseminate information through virtual social networking. Uptake of knowledge-sharing technologies is still primarily by innovators and early adopters. Leaders adopt new behaviors at varying speeds and have a range of abilities to foster an environment that is psychologically safe and stimulates inquiry. CONCLUSIONS: A learning organization has the capability to improve, and it develops structures and processes that facilitate the acquisition and sharing of knowledge.

Implementation of Physical Activity Programs for Rural Cancer Survivors: Challenges and Opportunities.

Physical activity after cancer diagnosis has been consistently associated with improvements in quality of life and prognosis. However, few cancer survivors meet physical activity recommendations, and adherence is even lower among those living in rural settings. The purpose of this quasi-experimental study was to evaluate the implementation of a clinic-based physical activity program for cancer survivors at a rural community oncology setting. We also examined changes in quality-of-life measures among 24 cancer survivors participating in the physical activity program and described challenges and opportunities to optimize future implementation efforts in rural settings. Significant pre- to post-program improvements in fatigue (5.5 to 6.8; p = 0.03), constipation (7.7 to 9.0; p = 0.02), pain (6.7 to 8.0; p = 0.007), and sleep quality (p = 0.008) were observed. Participants also reported improved nausea, stamina, depression, stress, and overall physical health after participation in the physical activity program, although the differences were not statistically significant (all p-values > 0.13). However, the reach of the physical activity program was limited, with only 0.59% of cancer survivors participating. Fidelity to the physical activity program was relatively high, with 72.7% of survivors participating in at least five classes. Our findings suggest that physical activity programs in oncological settings may need tailoring to effectively reach rural cancer survivors.

"I didn't know you could do that": A Pilot Assessment of EHR Optimization Training.

BACKGROUND: Informatics tools within electronic health records (EHRs)-for example, data rosters and clinical reminders-can help disseminate care guidelines into clinical practice. Such tools' adoption varies widely, however, possibly because many primary care providers receive minimal training in even basic EHR functions. OBJECTIVES: This mixed-methods evaluation of a pilot training program sought to identify factors to consider when providing EHR use optimization training in community health centers (CHCs) as a step toward supporting CHC providers' adoption of EHR tools. METHODS: In spring 2018, we offered 10 CHCs a 2-day, 16-hour training in EHR use optimization, provided by clinician trainers, and customized to each CHC's needs. We surveyed trainees pre- and immediately post-training and again 3 months later. We conducted post-training interviews with selected clinic staff, and conducted a focus group with the trainers, to assess satisfaction with the training, and perceptions of how it impacted subsequent EHR use. RESULTS: Six CHCs accepted and received the training; 122 clinic staff members registered to attend, and most who completed the post-training survey reported high satisfaction. Three months post-training, 80% of survey respondents said the training had changed their daily EHR use somewhat or significantly. CONCLUSION: Factors to consider when planning EHR use optimization training in CHCs include: CHCs may face barriers to taking part in such training; it may be necessary to customize training to a given clinic's needs and to different trainees' clinic roles; identifying trainees' skill level a priori would help but is challenging; in-person training may be preferable; and inclusion of a practice coach may be helpful. Additional research is needed to identify how to provide such training most effectively.

Sustained effects of the INFORM cluster randomized trial: an observational post-intervention study.

BACKGROUND: Numerous studies have examined the efficacy and effectiveness of health services interventions. However, much less research is available on the sustainability of study outcomes. The purpose of this study was to assess the lasting benefits of INFORM (Improving Nursing Home Care Through Feedback On perfoRMance data) and associated factors 2.5 years after removal of study supports. INFORM was a complex, theory-based, three-arm, parallel cluster-randomized trial. In 2015-2016, we successfully implemented two theory-based feedback strategies (compared to a simple feedback approach) to increase nursing home (NH) care aides' involvement in formal communications about resident care. METHODS: Sustainability analyses included 51 Western Canadian NHs that had been randomly allocated to a simple and two assisted feedback interventions in INFORM. We measured care aide involvement in formal interactions (e.g., resident rounds, family conferences) and other study outcomes at baseline (T1, 09/2014-05/2015), post-intervention (T2, 01/2017-12/2017), and long-term follow-up (T3, 06/2019-03/2020). Using repeated measures, hierarchical mixed models, adjusted for care aide, care unit, and facility variables, we assess sustainability and associated factors: organizational context (leadership, culture, evaluation) and fidelity of the original INFORM intervention. RESULTS: We analyzed data from 18 NHs (46 units, 529 care aides) in simple feedback, 19 NHs (60 units, 731 care aides) in basic assisted feedback, and 14 homes (41 units, 537 care aides) in enhanced assisted feedback. T2 (post-intervention) scores remained stable at T3 in the two enhanced feedback arms, indicating sustainability. In the simple feedback group, where scores were had remained lower than in the enhanced groups during the intervention, T3 scores rose to the level of the two enhanced feedback groups. Better culture (ß = 0.099, 95% confidence interval [CI] 0.005; 0.192), evaluation (ß = 0.273, 95% CI 0.196; 0.351), and fidelity enactment (ß = 0.290, 95% CI 0.196; 0.384) increased care aide involvement in formal interactions at T3. CONCLUSIONS: Theory-informed feedback provides long-lasting improvement in care aides' involvement in formal communications about resident care. Greater intervention intensity neither implies greater effectiveness nor sustainability. Modifiable context elements and fidelity enactment during the intervention period may facilitate sustained improvement, warranting further study-as does possible post-intervention spread of our intervention to simple feedback homes.

Multisolving Innovations For Climate And Health: Message Framing To Achieve Broad Public Support.

Rapid diffusion of solutions to a changing climate is paramount if the US is to mitigate carbon emissions. A timely response depends on how people perceive and understand innovations such as new practices, programs, policies, and technologies that promise to reduce emissions. This article explores multisolving innovations in the context of interventions that can be targeted to community leaders and decision makers. We focus on examples led by policy staff; directors of municipal offices and departments of transportation, housing, sustainability, urban planning, and public health; and elected county and city officials where there may be mixed support for efforts to reduce carbon emissions, to show that some innovations can be accurately framed solely in terms of community health benefits. When communicating with stakeholders who are dismissive or skeptical of climate change, we suggest using messages that describe the benefits of mitigation innovations in terms of human health, rather than climate, to achieve broader acceptability.

Applying Diffusion of Innovation Theory to Intervention Development.

Few social science theories have a history of conceptual and empirical study as long as does the diffusion of innovations. The robustness of this theory derives from the many disciplines and fields of study in which diffusion has been studied, from the international richness of these studies, and from the variety of new ideas, practices, programs, and technologies that have been the objects of diffusion research. Early theorizing from the beginning of the 20th century was gradually displaced by post hoc empirical research that described and explained diffusion processes. By the 1950s, diffusion researchers had begun to apply the collective knowledge learned about naturalistic diffusion in tests of process interventions to affect the spread of innovations. Now, this purposive objective has given form to a science of dissemination in which evidence-based practices are designed a priori not just to result in internal validity but to increase the likelihood that external validity and diffusion both are more likely to result. Here, I review diffusion theory and focus on seven concepts-intervention attributes, intervention clusters, demonstration projects, societal sectors, reinforcing contextual conditions, opinion leadership, and intervention adaptation-with potential for accelerating the spread of evidence-based practices, programs, and policies in the field of social work.

Scaling Up Solutions to Toxic Contamination in Communities.

In this special issue of IJERPH, we feature studies conducted by research translation and community engagement teams that are funded through the Superfund Research Program in the United States. These and other teams funded by this program demonstrate how environmental and health communication research can contribute to generalizable lessons about helping and empowering contaminated communities. These types of applied behavioral, social and communication projects are important because while much about our communities is unique and must be addressed on a case by case basis, other aspects of research translation and community engagement processes are potentially generalizable across sites and can thus be used to scale up solutions to toxic contamination to other communities and countries more rapidly than would otherwise occur.

The Effect of Dioxin Contamination and Remediation on Property Values.

Loss of property value is a major concern in communities faced with the toxic byproducts of industrial practices. Even after site remediation, stigma may persist and negatively affect market values of residential properties. To study the effects of contamination and of remediation on property values in Midland, Michigan, where dioxins have been released into the environment through the incineration of contaminated waste and the discharge of contaminated water for many years, records of assessed value were obtained for 229 homes within the same neighborhood for the previous 18 years. A multilevel, longitudinal analysis was conducted to determine if there was a relationship between level of dioxin and assessed value after controlling for housing characteristics. Remediated and un-remediated properties saw increases in value at a similar rate over time. However, a property's level of dioxin was found to have a small, significant, and negative relationship with assessed value, and this negative effect was present regardless if a home had been remediated or not. These results suggest that while environmental remediation may be effective at removing the contamination, its economic effects may persist for a longer period of time.

Working with Institutional Stakeholders: Propositions for Alternative Approaches to Community Engagement.

Community engagement is a vital aspect of addressing environmental contamination and remediation. In the United States, the Superfund Research Program (SRP) forms groups of academic researchers from the social and physical sciences into Community Engagement Cores (CECs) and Research Translation Cores (RTCs), which focus on various aspects of informing and working with communities during and through the resolution of environmental crises. While this work typically involves engaging directly with members of affected communities, no two situations are the same. In some cases, alternative approaches to community engagement can be more appropriate for community improvement than traditional approaches. In particular, when research teams become involved in contamination crises at a late point in the process, their contributions can be better directed at supporting and reinforcing the work of institutional stakeholders charged with remediating pollution. Relevant factors include issue fatigue among a local population, and contamination that is due to a major employer. Supported by literature and experience, we offer several propositions that we believe lay out conditions that warrant such an approach by academic teams, rather than their direct engagement with unaffiliated individuals in communities.

Understanding professional advice networks in long-term care: an outside-inside view of best practice pathways for diffusion.

BACKGROUND: Interpersonal relationships among professionals drive both the adoption and rejection of consequential innovations. Through relationships, decision-makers learn which colleagues are choosing to adopt innovations, and why. The purpose of our study was to understand how and why long-term care (LTC) leaders in a pan-Canadian interpersonal network provide and seek advice about care improvement innovations, for the eventual dissemination and implementation of these innovations. METHODS: We used a mixed methods approach. An online survey was sent to senior leaders in 958 LTC facilities in 11 Canadian provinces and territories. Participants were asked to name up to three individuals whose advice they most value when considering care improvement and practice innovations. Sociometric analysis revealed the structure of provincial-level advice networks and how those networks were linked. Using sociometric indicators, we purposively selected 39 key network actors to interview to explore the nature of advice relationships. Data were analyzed thematically. RESULTS: In this paper, we report our qualitative findings. We identified four themes from the data. One theme related to characteristics of particular network roles: opinion leaders, advice seekers, and boundary spanners. Opinion leaders and boundary spanners have long tenures in LTC, a broad knowledge of the network, and share an interest in advancing the sector. Advice seekers were similarly committed to LTC; they initially seek and then, over time, exchange advice with opinion leaders and become an important source of information for them. A second theme related to characterizing advice seeking relationships as formal, peer-to-peer, mentoring, or reciprocal. The third and fourth themes described motivations for providing and seeking advice, and the nature of advice given and sought. Advice seekers initially sought information to resolve clinical care problems; however, over time, the nature of advice sought expanded to include operational and strategic queries. Opinion leaders sought to expand their networks and to solicit information from their more established advice seekers that might benefit the network and advance LTC. CONCLUSIONS: New knowledge about the distinct roles that different network actors play vis-a-vis one another offers healthcare professionals, researchers, and decision- and policy-makers insights that are useful when formulating best practice dissemination strategies.

Does increased implementation support improve community clinics' guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial.

BACKGROUND: Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs). METHODS: This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs' EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes. RESULTS: Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes. CONCLUSIONS: Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics' ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.