Barriers to and facilitators of implementing colorectal cancer screening evidence-based interventions in federally qualified health centers: a qualitative study.

BACKGROUND: There is an urgent need to increase colorectal cancer screening (CRCS) uptake in Texas federally qualified health centers (FQHCs), which serve a predominantly vulnerable population with high demands. Empirical support exists for evidence-based interventions (EBIs) that are proven to increase CRCS; however, as with screening, their use remains low in FQHCs. This study aimed to identify barriers to and facilitators of implementing colorectal cancer screening (CRCS) evidence-based interventions (EBIs) in federally qualified health centers (FQHCs), guided by the Consolidated Framework for Implementation Research (CFIR). METHODS: We recruited employees involved in implementing CRCS EBIs (e.g., physicians) using data from a CDC-funded program to increase the CRCS in Texas FQHCs. Through 23 group interviews, we explored experiences with practice change, CRCS promotion and quality improvement initiatives, organizational readiness, the impact of COVID-19, and the use of CRCS EBIs (e.g., provider reminders). We used directed content analysis with CFIR constructs to identify the critical facilitators and barriers. RESULTS: The analysis revealed six primary CFIR constructs that influence implementation: information technology infrastructure, innovation design, work infrastructure, performance measurement pressure, assessing needs, and available resources. Based on experiences with four recommended EBIs, participants described barriers, including data limitations of electronic health records and the design of reminder alerts targeted at deliverers and recipients of patient or provider reminders. Implementation facilitators include incentivized processes to increase provider assessment and feedback, existing clinic processes (e.g., screening referrals), and available resources to address patient needs (e.g., transportation). Staff buy-in emerged as an implementation facilitator, fostering a conducive environment for change within clinics. CONCLUSIONS: Using CFIR, we identified barriers, such as the burden of technology infrastructure, and facilitators, such as staff buy-in. The results, which enhance our understanding of CRCS EBI implementation in FQHCs, provide insights into designing nuanced, practical implementation strategies to improve cancer control in a critical setting.

From study plans to capacity building: a journey towards health equity in cancer survivorship.

This article highlights the importance of pausing and reflecting on one's motivation, capacity, and positionality when engaging in health equity research and encourages researchers to engage in critical self-reflection and contribute to the ongoing dialogue on the ethical conduct of health equity-focused cancer research. In response to the urgent need to address health disparities and improve health equity in cancer survivorship care, the Cancer Prevention and Control Research Network (CPCRN) Survivorship workgroup discussed developing a study focused on understanding how racism impacts patient engagement in cancer survivorship care. However, during the study's development, the workgroup recognized limitations in research team composition and infrastructure. The workgroup engaged in critical self-reflections, individually and collectively, leading to the halting of the research study. Consequently, they redirected their efforts towards strengthening the necessary infrastructure for conducting such research, including diverse investigator representation and equitable partnerships with cancer survivors. The description of this process, along with suggestions for reflection, may be helpful and informative to other researchers and research networks seeking to center marginalized voices and work in partnership to address healthcare and health equity.

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

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

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

BACKGROUND: Organizational readiness is a key factor for successful implementation of evidence-based interventions (EBIs), but a valid and reliable measure to assess readiness across contexts and settings is needed. The R = MC2 heuristic posits that organizational readiness stems from an organization's motivation, capacity to implement a specific innovation, and its general capacity. This paper describes a process used to examine the face and content validity of items in a readiness survey developed to assess organizational readiness (based on R = MC2) among federally qualified health centers (FQHC) implementing colorectal cancer screening (CRCS) EBIs. METHODS: We conducted 20 cognitive interviews with FQHC staff (clinical and non-clinical) in South Carolina and Texas. Participants were provided a subset of items from the readiness survey to review. A semi-structured interview guide was developed to elicit feedback from participants using "think aloud" and probing techniques. Participants were recruited using a purposive sampling approach and interviews were conducted virtually using Zoom and WebEx. Participants were asked 1) about the relevancy of items, 2) how they interpreted the meaning of items or specific terms, 3) to identify items that were difficult to understand, and 4) how items could be improved. Interviews were transcribed verbatim and coded in ATLAS.ti. Findings were used to revise the readiness survey. RESULTS: Key recommendations included reducing the survey length and removing redundant or difficult to understand items. Additionally, participants recommended using consistent terms throughout (e.g., other units/teams vs. departments) the survey and changing pronouns (e.g., people, we) to be more specific (e.g., leadership, staff). Moreover, participants recommended specifying ambiguous terms (e.g., define what "better" means). CONCLUSION: Use of cognitive interviews allowed for an engaged process to refine an existing measure of readiness. The improved and finalized readiness survey can be used to support and improve implementation of CRCS EBIs in the clinic setting and thus reduce the cancer burden and cancer-related health disparities.

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

BACKGROUND: Organizational readiness is important for the implementation of evidence-based interventions. Currently, there is a critical need for a comprehensive, valid, reliable, and pragmatic measure of organizational readiness that can be used throughout the implementation process. This study aims to develop a readiness measure that can be used to support implementation in two critical public health settings: federally qualified health centers (FQHCs) and schools. The measure is informed by the Interactive Systems Framework for Dissemination and Implementation and R = MC2 heuristic (readiness = motivation × innovation-specific capacity × general capacity). The study aims are to adapt and further develop the readiness measure in FQHCs implementing evidence-based interventions for colorectal cancer screening, to test the validity and reliability of the developed readiness measure in FQHCs, and to adapt and assess the usability and validity of the readiness measure in schools implementing a nutrition-based program. METHODS: For aim 1, we will conduct a series of qualitative interviews to adapt the readiness measure for use in FQHCs. We will then distribute the readiness measure to a developmental sample of 100 health center sites (up to 10 staff members per site). We will use a multilevel factor analysis approach to refine the readiness measure. For aim 2, we will distribute the measure to a different sample of 100 health center sites. We will use multilevel confirmatory factor analysis models to examine the structural validity. We will also conduct tests for scale reliability, test-retest reliability, and inter-rater reliability. For aim 3, we will use a qualitative approach to adapt the measure for use in schools and conduct reliability and validity tests similar to what is described in aim 2. DISCUSSION: This study will rigorously develop a readiness measure that will be applicable across two settings: FQHCs and schools. Information gained from the readiness measure can inform planning and implementation efforts by identifying priority areas. These priority areas can inform the selection and tailoring of support strategies that can be used throughout the implementation process to further improve implementation efforts and, in turn, program effectiveness.