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Background: Scalable PTSD screening strategies must be brief, accurate and capable of administration by a non-specialized workforce. Methods: We used PTSD as determined by the structured clinical interview as our gold standard and considered predictors sets of (a) Posttraumatic Stress Checklist-5 (PCL-5), (b) Primary Care PTSD Screen for the DSM-5 (PC-PTSD) and, (c) PCL-5 and PC-PTSD questions to identify the optimal items for PTSD screening for public sector settings in Kenya. A logistic regression model using LASSO was fit by minimizing the average squared error in the validation data. Area under the receiver operating characteristic curve (AUROC) measured discrimination performance. Results: Penalized regression analysis suggested a screening tool that sums the Likert scale values of two PCL-5 questions-intrusive thoughts of the stressful experience (#1) and insomnia (#21). This had an AUROC of 0.85 (using hold-out test data) for predicting PTSD as evaluated by the MINI, which outperformed the PC-PTSD. The AUROC was similar in subgroups defined by age, sex, and number of categories of trauma experienced (all AUROCs>0.83) except those with no trauma history- AUROC was 0.78. Conclusion: In some East African settings, a 2-item PTSD screening tool may outperform longer screeners and is easily scaled by a non-specialist workforce.
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Tamizaje Masivo , Trastornos por Estrés Postraumático , Humanos , Trastornos por Estrés Postraumático/diagnóstico , Femenino , Masculino , Adulto , Kenia , Persona de Mediana Edad , Análisis de Regresión , Adulto Joven , Adolescente , Encuestas y CuestionariosRESUMEN
BACKGROUND: Implementation of new practices in team-based settings requires teams to work together to respond to new demands and changing expectations. However, team constructs and team-based implementation approaches have received little attention in the implementation science literature. This systematic review summarizes empirical research examining associations between teamwork and implementation outcomes when evidence-based practices and other innovations are implemented in healthcare and human service settings. METHODS: We searched MEDLINE, CINAHL, APA PsycINFO and ERIC for peer-reviewed empirical articles published from January 2000 to March 2022. Additional articles were identified by searches of reference lists and a cited reference search for included articles (completed in February 2023). We selected studies using quantitative, qualitative, or mixed methods to examine associations between team constructs and implementation outcomes in healthcare and human service settings. We used the Mixed Methods Appraisal Tool to assess methodological quality/risk of bias and conducted a narrative synthesis of included studies. GRADE and GRADE-CERQual were used to assess the strength of the body of evidence. RESULTS: Searches identified 10,489 results. After review, 58 articles representing 55 studies were included. Relevant studies increased over time; 71% of articles were published after 2016. We were unable to generate estimates of effects for any quantitative associations because of very limited overlap in the reported associations between team variables and implementation outcomes. Qualitative findings with high confidence were: 1) Staffing shortages and turnover hinder implementation; 2) Adaptive team functioning (i.e., positive affective states, effective behavior processes, shared cognitive states) facilitates implementation and is associated with better implementation outcomes; Problems in team functioning (i.e., negative affective states, problematic behavioral processes, lack of shared cognitive states) act as barriers to implementation and are associated with poor implementation outcomes; and 3) Open, ongoing, and effective communication within teams facilitates implementation of new practices; poor communication is a barrier. CONCLUSIONS: Teamwork matters for implementation. However, both team constructs and implementation outcomes were often poorly specified, and there was little overlap of team constructs and implementation outcomes studied in quantitative studies. Greater specificity and rigor are needed to understand how teamwork influences implementation processes and outcomes. We provide recommendations for improving the conceptualization, description, assessment, analysis, and interpretation of research on teams implementing innovations. TRIAL REGISTRATION: This systematic review was registered in PROSPERO, the international prospective register of systematic reviews. REGISTRATION NUMBER: CRD42020220168.
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Ciencia de la Implementación , Grupo de Atención al Paciente , Humanos , Grupo de Atención al Paciente/organización & administración , Conducta Cooperativa , Atención a la Salud/organización & administración , Práctica Clínica Basada en la Evidencia/organización & administraciónRESUMEN
INTRODUCTION: Government agencies have identified evidence-based practice (EBP) dissemination as a pathway to high-quality behavioral health care for youth. However, gaps remain about how to best sustain EBPs in treatment organizations in the U.S., especially in resource-constrained settings like publicly-funded youth substance use services. One important, but understudied, determinant of EBP sustainment is alignment: the extent to which multi-level factors that influence sustainment processes and outcomes are congruent, consistent, and/or coordinated. This study examined the role of alignment in U.S. states' efforts to sustain the Adolescent Community Reinforcement Approach (A-CRA), an EBP for youth substance use disorders, during the COVID-19 pandemic. METHODS: In this mixed methods study, the qualitative investigation preceded and informed the quantitative investigation. We interviewed state administrators and providers (i.e., supervisors and clinicians) from 15 states that had completed a federal A-CRA implementation grant; providers also completed surveys. The sample included 50 providers from 35 treatment organizations that reported sustaining A-CRA when the COVID-19 pandemic began, and 20 state administrators. In qualitative thematic analyses, we applied the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to characterize alignment processes that interviewees described as influential on sustainment. We then used survey items to quantitatively explore the associations described in qualitative themes, using bivariate linear regressions. RESULTS: At the time of interview, staff from 80 % of the treatment organizations (n = 28), reported sustaining A-CRA. Providers from both sustainer and non-sustainer organizations, as well as state administrators, described major sources of misalignment when state agencies ceased technical assistance post-grant, and because limited staff capacity conflicted with A-CRA's training model, which was perceived as time-intensive. Participants described the pandemic as exacerbating preexisting challenges, including capacity issues. Sustainer organizations reported seeking new funding to help sustain A-CRA. Quantitative associations between self-rated extent of sustainment and other survey items mostly followed the pattern predicted from the qualitative findings. CONCLUSIONS: The COVID-19 pandemic amplified longstanding A-CRA sustainment challenges, but treatment organizations already successfully sustaining A-CRA pre-pandemic largely continued. There are missed opportunities for state-level actors to coordinate with providers on the shared goal of EBP sustainment. A greater focus on alignment processes in research and practice could help states and providers strengthen sustainability planning.
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INTRODUCTION: Evidence-based practice (EBP) implementation represents a strategic change that requires alignment of leadership and support throughout organizations. Leadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy that aims to improve implementation leadership and climate within organizations through iterative cycles of leadership and climate assessment and feedback, leadership training and coaching, and strategic planning with upper-level leaders. This study tested the effects of LOCI on transformational and implementation leadership, implementation climate, implementation citizenship behavior, and EBP reach. METHODS: A multiple cohort, cluster randomized trial tests the effect of LOCI in 60 clinics across nine behavioral health organizations in California and Arizona, USA. The study randomized clinics within organizations to either LOCI or a leadership training webinar control condition in three consecutive cohorts. Repeated web-based surveys of direct service providers (nLOCI = 201, nControl = 179) assessed leadership, implementation climate, and implementation citizenship over time. Multilevel autoregressive modeling was the primary statistical analysis such that providers (level-1) were nested within clinics (level-2). The study predicted between-condition differences at 4-, 8-, and 12-month follow-up assessments. Provider engagement in a fidelity monitoring process assessed reach of motivational interviewing (i.e., number of sessions recorded/submitted for fidelity coding). An independent sample t-test explored between condition differences in motivational interviewing reach. RESULTS: Results indicated between condition differences at 4 months for implementation leadership, implementation climate, and implementation citizenship behavior such that greater improvements were evidenced in the LOCI condition compared to the control condition. Reach of MI was significantly greater in the LOCI vs control condition such that LOCI providers were significantly more likely to engage in the fidelity monitoring process (chi-square (1, n = 370) = 5.59, p = .018). CONCLUSIONS: LOCI was developed based on organizational theories of strategic leadership and climate to affect organizational change processes that communicate that innovation implementation is expected, supported, and recognized as a value of the organization. The LOCI implementation strategy resulted in more positive hypothesized outcomes compared to the control condition. Organizational change strategies have utility for implementing health innovations in complex, multilevel contexts and for greater sustainment of facilitative leader behaviors, strategic implementation climate, and improved implementation outcomes. TRIAL REGISTRATION: This study is registered with Clinicaltrials.gov gov (NCT03042832, 2 February 2017; retrospectively registered).
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INTRODUCTION: Multi-level and cross-context implementation strategies are needed to support health systems, healthcare delivery organizations, and providers to adopt evidence-based practice (EBP) for substance use disorder (SUD) treatment. However, misalignment between state oversight agencies and healthcare organizations about which services to prioritize and which outcomes are reasonable to expect can hinder implementation success and widespread access to high-quality care. This study investigated the utility of the Leadership and Organizational Change for Implementation-System Level (LOCI-SL) strategy for supporting statewide EBP implementation for SUD treatment. METHODS: Nine community mental health centers (CMHCs) contracted by a state agency participated in a combined motivational-enhancement therapy and cognitive behavioral therapy (MET/CBT) implementation effort. Five of the CMHCs also received the LOCI-SL strategy to obtain ongoing implementation support. We conducted 21 individual interviews and three small group interviews with 30 participants across CMHCs and state health agencies to investigate the utility of LOCI-SL in supporting their EBP implementation efforts. Deductive thematic analysis was guided by the Exploration, Preparation, Implementation, Sustainment Framework. RESULTS: Five themes described CMHCs' LOCI-SL and broader contextual experiences implementing EBPs: (1) LOCI-SL supported executives in Preparation phase activities that holistically considered organizational needs and capacity to implement and sustain EBPs; (2) LOCI-SL facilitated trust and communication processes across Preparation, Implementation, and Sustainment phases to improve EBP uptake; (3) LOCI-SL increased CMHCs' use of implementation climate strengthening activities throughout the Implementation phase; (4) state contracts did not emphasize quality and thus were not sufficient bridging factors to enforce EBP fidelity during Implementation; and, (5) limited funding and low Medicaid reimbursement rates hindered EBP use throughout the Implementation and Sustainment phases. CONCLUSIONS: LOCI-SL was viewed as a favorable and useful implementation strategy for supporting statewide adoption of EBPs. However, outer context barriers, including limited financial investments in the treatment system, impeded implementation and sustainment efforts. While previous research suggests that contracts are viable alignment-promoting bridging factors, this study demonstrates the importance of articulating implementation outcome expectations to aid state-contracted organizations in achieving EBP implementation success. This study also highlights the need for multi-level implementation strategies to effectively align implementation expectations between outer- and inner-context entities.
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Práctica Clínica Basada en la Evidencia , Liderazgo , Innovación Organizacional , Trastornos Relacionados con Sustancias , Humanos , Trastornos Relacionados con Sustancias/terapia , Práctica Clínica Basada en la Evidencia/organización & administración , Terapia Cognitivo-Conductual/organización & administración , Servicios Comunitarios de Salud Mental/organización & administraciónRESUMEN
BACKGROUND: Policymaking is quickly gaining focus in the field of implementation science as a potential opportunity for aligning cross-sector systems and introducing incentives to promote population health, including substance use disorders (SUD) and their prevention in adolescents. Policymakers are seen as holding the necessary levers for realigning service infrastructure to more rapidly and effectively address adolescent behavioral health across the continuum of need (prevention through crisis care, mental health, and SUD) and in multiple locations (schools, primary care, community settings). The difficulty of aligning policy intent, policy design, and successful policy implementation is a well-known challenge in the broader public policy and public administration literature that also affects local behavioral health policymaking. This study will examine a blended approach of coproduction and codesign (i.e., Policy Codesign), iteratively developed over multiple years to address problems in policy formation that often lead to poor implementation outcomes. The current study evaluates this scalable approach using reproducible measures to grow the knowledge base in this field of study. METHODS: This is a single-arm, longitudinal, staggered implementation study to examine the acceptability and short-term impacts of Policy Codesign in resolving critical challenges in behavioral health policy formation. The aims are to (1) examine the acceptability, feasibility, and reach of Policy Codesign within two geographically distinct counties in Washington state, USA; (2) examine the impact of Policy Codesign on multisector policy development within these counties using social network analysis; and (3) assess the perceived replicability of Policy Codesign among leaders and other staff of policy-oriented state behavioral health intermediary organizations across the USA. DISCUSSION: This study will assess the feasibility of a specific approach to collaborative policy development, Policy Codesign, in two diverse regions. Results will inform a subsequent multi-state study measuring the impact and effectiveness of this approach for achieving multi-sector and evidence informed policy development in adolescent SUD prevention and treatment.
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Background: This study's aims are to: (1) Compare the acceptability and feasibility of five types of implementation strategies that could be deployed to increase the reach of evidence-based practices (EBPs) with revenue from policies that earmark taxes for behavioral health services, and (2) Illustrate how definitions of implementation strategies and measures of acceptability and feasibility can be used in policy-focused implementation science research. Methods: Web-based surveys of public agency and community organization professionals involved with earmarked tax policy implementation were completed in 2022-2023 (N = 211, response rate = 24.9%). Respondents rated the acceptability and feasibility of five types of implementation strategies (dissemination, implementation process, integration, capacity-building, and scale-up). Aggregate acceptability and feasibility scores were calculated for each type of strategy (scoring range 4-20). Analyses of variance compared scores across strategies and between organizational actor types. Findings: For acceptability, capacity-building strategies had the highest rating (M = 16.3, SD = 3.0), significantly higher than each of the four other strategies, p ≤ . 004), and scale-up strategies had the lowest rating (M = 15.6). For feasibility, dissemination strategies had the highest rating (M = 15.3, significantly higher than three of the other strategies, p ≤ .002) and scale-up strategies had the lowest rating (M = 14.4). Conclusions: Capacity-building and dissemination strategies may be well-received and readily deployed by policy implementers to support EBPs implementation with revenue from taxes earmarked for behavioral health services. Adapting definitions of implementation strategies for policy-focused topics, and applying established measures of acceptability and feasibility to these strategies, demonstrates utility as an approach to advance research on policy-focused implementation strategies.
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BACKGROUND: Theory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested LOCI's hypothesized mechanisms of change, namely: (1) LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI's effect on implementation climate, which in turn will (3) mediate LOCI's effect on MBC fidelity. METHODS: Twenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders' implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses. RESULTS: LOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps < .01), producing large effects (range of ds = 0.76 to 1.34). LOCI's effects on transformational leadership were small at 4 months (d = 0.31, p = .019) and nonsignificant thereafter (ps > .05). LOCI's improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p = .004). Transformational leadership did not mediate LOCI's effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI's effect on MBC fidelity during the same period (pm = 0.71, p = .045). CONCLUSIONS: LOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019.
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Servicios de Salud Mental , Salud Mental , Humanos , Atención a la Salud , Práctica Clínica Basada en la Evidencia , LiderazgoRESUMEN
Background: Although studies have demonstrated that implementation leadership and climate are important constructs in predicting evidence-based practice (EBP) implementation, concrete descriptions of how they operate during organizational implementation efforts are lacking. This case study fills that gap through an in-depth description of an organization with effective implementation leadership that successfully built a strong implementation climate. This case study provides an illustration of implementation leadership and climate in tangible, replicable terms to assist managers, practitioners, and researchers in addressing the organizational context in their own implementation projects. Method: A single organization, intrinsic case study was employed to paint a multifaceted picture of how one organization leveraged implementation leadership to strengthen a climate for the successful implementation of digital measurement-based care. The case was drawn from a cluster-randomized trial designed to test the effects of a leadership-focused implementation strategy on youth-level fidelity and clinical outcomes of digital measurement-based care. Following the completion of the trial, case study activities commenced. Descriptive summaries of multiple data sources (including quantitative data on implementation leadership and climate, coaching call and organizational alignment meeting recordings and notes, and development plans) were produced and revised iteratively until consensus was reached. Leadership actions were analyzed for corresponding dimensions of implementation leadership and climate. Results: Specific actions organizational leaders took, as well as the timing specific strategies were enacted, to create a climate for implementation are presented, along with lessons learned from this experience. Conclusion: This case study offers concrete steps organizational leaders took to create a consistent and aligned message that the implementation of a specific EBP was a top priority in the agency. The general approach taken to create an implementation climate provides several lessons for leaders, especially for EBPs that have broad implications across an organization.
Using treatments with known positive impact in community-based mental health programs is challenging. Many studies suggest leaders of these programs can help. Similarly, certain features of community-based programs can also be helpful. This case study of an outpatient mental health clinic provides rich descriptions of actions leaders took that shaped the environment in their program and helped improve the use of a treatment with known positive impact. This case study can serve as a practical guide for leaders to reference when aiming to improve the use of treatments with known impact in their own programs.
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BACKGROUND: Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria. METHODS: Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions. DISCUSSION: The assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV. TRIAL REGISTRATION: Prospectively registered on November 7, 2023, at ClinicalTrials.gov no. NCT06128304. https://classic. CLINICALTRIALS: gov/ct2/show/study/NCT06128304.
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Infecciones por VIH , Neoplasias del Cuello Uterino , Humanos , Femenino , Nigeria , Neoplasias del Cuello Uterino/diagnóstico , Neoplasias del Cuello Uterino/prevención & control , Autoeficacia , Infecciones por VIH/diagnóstico , Infecciones por VIH/prevención & control , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: A myriad of federal, state, and organizational policies are designed to improve access to evidence-based healthcare, but the impact of these policies likely varies due to contextual determinants of, reinterpretations of, and poor compliance with policy requirements throughout implementation. Strategies enhancing implementation and compliance with policy intent can improve population health. Critically assessing the multi-level environments where health policies and their related health services are implemented is essential to designing effective policy-level implementation strategies. California passed a 2019 health insurance benefit mandate requiring coverage of fertility preservation services for individuals at risk of infertility due to medical treatments, in order to improve access to services that are otherwise cost prohibitive. Our objective was to document and understand the multi-level environment, relationships, and activities involved in using state benefit mandates to facilitate patient access to fertility preservation services. METHODS: We conducted a mixed-methods study and used the policy-optimized exploration, preparation, implementation, and sustainment (EPIS) framework to analyze the implementation of California's fertility preservation benefit mandate (SB 600) at and between the state insurance regulator, insurer, and clinic levels. RESULTS: Seventeen publicly available fertility preservation benefit mandate-relevant documents were reviewed. Interviews were conducted with four insurers; 25 financial, administrative, and provider participants from 16 oncology and fertility clinics; three fertility pharmaceutical representatives; and two patient advocates. The mandate and insurance regulator guidance represented two "Big P" (system level) policies that gave rise to a host of "little p" (organizational) policies by and between the regulator, insurers, clinics, and patients. Many little p policies were bridging factors to support implementation across levels and fertility preservation service access. Characterizing the mandate's functions (i.e., policy goals) and forms (i.e., ways that policies were enacted) led to identification of (1) intended and unintended implementation, service, and patient outcomes, (2) implementation processes by level and EPIS phase, (3) actor-delineated key processes and heterogeneity among them, and (4) inner and outer context determinants that drove adaptations. CONCLUSIONS: Following the midstream and downstream implementation of a state health insurance benefit mandate, data generated will enable development of policy-level implementation strategies, evaluation of determinants and important outcomes of effective implementation, and design of future mandates to improve fit and fidelity.
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Preservación de la Fertilidad , Neoplasias , Humanos , Beneficios del Seguro , Política de Salud , Política Organizacional , Neoplasias/terapia , Seguro de SaludRESUMEN
BACKGROUND: Cross-system interventions that integrate health, behavioral health, and social services can improve client outcomes and expand community impact. Successful implementation of these interventions depends on the extent to which service partners can align frontline services and organizational operations. However, collaboration strategies linking multiple implementation contexts have received limited empirical attention. This study identifies, describes, and specifies multi-level collaboration strategies used during the implementation of Ohio Sobriety Treatment and Reducing Trauma (Ohio START), a cross-system intervention that integrates services across two systems (child welfare and evidence-based behavioral health services) for families that are affected by co-occurring child maltreatment and parental substance use disorders. METHODS: In phase 1, we used a multi-site qualitative design with 17 counties that implemented Ohio START. Qualitative data were gathered from 104 staff from child welfare agencies, behavioral health treatment organizations, and regional behavioral health boards involved in implementation via 48 small group interviews about collaborative approaches to implementation. To examine cross-system collaboration strategies, qualitative data were analyzed using an iterative template approach and content analysis. In phase 2, a 16-member expert panel met to validate and specify the cross-system collaboration strategies identified in the interviews. The panel was comprised of key child welfare and behavioral health partners and scholars. RESULTS: In phase 1, we identified seven cross-system collaboration strategies used for implementation. Three strategies were used to staff the program: (1) contract for expertise, (2) provide joint supervision, and (3) co-locate staff. Two strategies were used to promote service access: (4) referral protocols and (5) expedited access agreements. Two strategies were used to align case plans: (6) shared decision-making meetings, and (7) sharing data. In phase 2, expert panelists specified operational details of the cross-system collaboration strategies, and explained the processes by which strategies were perceived to improve implementation and service system outcomes. CONCLUSIONS: We identified a range of cross-system collaboration strategies that show promise for improving staffing, service access, and case planning. Leaders, supervisors, and frontline staff used these strategies during all phases of implementation. These findings lay the foundation for future experimental and quasi-experimental studies that test the effectiveness of cross-system collaboration strategies.
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Maltrato a los Niños , Trastornos Relacionados con Sustancias , Niño , Humanos , Protección a la Infancia , Investigación Cualitativa , Trastornos Relacionados con Sustancias/terapia , Servicios de Protección InfantilRESUMEN
OBJECTIVE: Measurement-based care (MBC), which collects session-by-session symptom data from patients and provides clinicians with feedback on treatment response, is a highly generalizable evidence-based practice with significant potential to improve the outcomes of mental health treatment in youth when implemented with fidelity; however, it is rarely used in community settings. This study tested whether an implementation strategy targeting organizational leadership and organizational implementation climate could improve MBC fidelity and clinical outcomes for youth in outpatient mental health clinics. METHOD: In a cluster randomized trial, 21 clinics were assigned to the Leadership and Organizational Change for Implementation strategy plus training and technical assistance in MBC (k = 11, n = 117) or training and technical assistance only (k = 10, n = 117). Primary outcomes of MBC fidelity (assessed via electronic metadata) and youth symptom improvement (assessed via caregiver-reported change on the Shortform Assessment for Children Total Problem Score) were collected for consecutively enrolled youths (ages 4-18 years) who initiated treatment in the 12 months following MBC training. Outcomes of each youth were assessed for 6 months following baseline. RESULTS: A total of 234 youths were enrolled and included in intent-to-treat analyses. At baseline, there were no significant differences by condition in clinic, clinician, or youth characteristics. Youths in clinics using the Leadership and Organizational Change for Implementation strategy experienced significantly higher MBC fidelity compared with youths in control clinics (23.1% vs 3.4%, p = .014), and exhibited significantly greater reductions in symptoms from baseline to 6 months (d = 0.31, 95% CI: 0.04-0.58, p = .023). CONCLUSION: Implementation strategies targeting organizational leadership and focused implementation climate can improve fidelity to evidence-based practices and clinical outcomes of youth mental health services. CLINICAL TRIAL REGISTRATION INFORMATION: Working to Implement and Sustain Digital Outcome Measures (WISDOM); https://clinicaltrials.gov/; NCT04096274.
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Background: Adherence to intervention training implementation strategies is at the foundation of fidelity; however, few studies have linked training adherence to trainee attitudes and leadership behaviors to identify what practically matters for the adoption and dissemination of evidence-based practices. Through the conduct of this hybrid type 3 effectiveness-implementation cluster randomized controlled trial, we collected Exploration, Preparation, Implementation, and Sustainment (EPIS) data and merged it with tailored motivational interviewing training adherence data, to elucidate the relationship between provider attitudes toward evidence-based practices, leadership behaviors, and training implementation strategy (e.g., workshop attendance and participation in one-on-one coaching) adherence. Method: Our sample included data from providers who completed baseline (pre-intervention) surveys that captured inner and outer contexts affecting implementation and participated in tailored motivational interviewing training, producing a dataset that included training implementation strategies adherence and barriers and facilitators to implementation (N = 77). Leadership was assessed by two scales: the director leadership scale and implementation leadership scale. Attitudes were measured with the evidence-based practice attitude scale (EBPAS-50). Adherence to training implementation strategies was modeled as a continuous outcome with a Gaussian distribution. Analyses were conducted in SPSS. Results: Of the nine general attitudes toward evidence-based practice, openness was associated with training adherence (estimate [EST] = 0.096, p < .001; 95% CI = [0.040, 0.151]). Provider general (EST = 0.054, 95% CI = [0.007, 0.102]) and motivational interviewing-specific (EST = 0.044, 95% CI = [0.002, 0.086]) leadership behaviors were positively associated with training adherence (p < .05). Of the four motivational interviewing-specific leadership domains, knowledge and perseverant were associated with training adherence (p < .05). As these leadership behaviors increased, knowledge (EST = 0.042, 95% CI = [0.001, 0.083]) and perseverant (EST = 0.039, 95% CI = [0.004, 0.075]), so did provider adherence to training implementation strategies. Conclusions: As implementation science places more emphasis on assessing readiness prior to delivering evidence-based practices by evaluating organizational climate, funding streams, and change culture, consideration should also be given to metrics of leadership. A potential mechanism to overcome resistance is via the implementation of training strategies focused on addressing leadership prior to conducting training for the evidence-based practice of interest.
Researchers and practitioners, who aim to improve the uptake of evidence-based practices, continue to seek ways in which to improve provider participation in training implementation strategies. The persistent challenge in addressing provider disengagement, while linking this disinterest to poor patient outcomes, has been ascertaining how to quantify relevant delivery considerations, for example, provider attitudes and leadership behaviors that may influence commitment to learning or apathy to behavior change, concurrently with training adherence. Through the conduct of this study, we collected both types of data: (1) provider attitudes and leadership behaviors and (2) training adherence outcomes. We found that provider openness, general leadership behaviors, and motivational interviewing-specific leadership behaviors were associated with adherence to training implementation strategies. As more emphasis is placed on assessing clinic readiness prior to adopting new evidence-based practices, a discussion on including metrics of provider attitudes to evidence-based practice, innovation, and the specific intervention is warranted, alongside consideration for how implementation training strategies focused on addressing leadership can bolster change-supportive behaviors prior to delivery of innovations.
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OBJECTIVE: The authors sought to characterize perceptions of the impacts, attributes, and support for taxes earmarked for behavioral health services and to compare perceptions of the taxes among professionals in California and Washington, two states differing in earmarked tax designs. METHODS: Surveys were completed by 155 public agency and community organization professionals involved in tax implementation in California (N=87) and Washington State (N=68) during 2022-2023 (29% response rate). Respondents indicated their perceptions of the taxes' impacts, attributes, and support. Responses were summed as aggregate scores and were also analyzed as individual items. Bivariate analyses were used to compare responses of professionals in California versus Washington State. RESULTS: Earmarked taxes were generally regarded positively. Of the respondents, >80% strongly agreed that the taxes increased funding for services and were helpful, and only 10% strongly agreed that the taxes decreased behavioral health funding from other sources. Substantially more respondents in California than in Washington State strongly agreed that taxes' reporting requirements were complicated (45% vs. 5%, p<0.001) and that the taxes increased unjustified scrutiny of services or systems (33% vs. 2%, p<0.001). However, more respondents in California than in Washington State also strongly agreed that the taxes increased public awareness about behavioral health (56% vs. 15%, p<0.001) and decreased behavioral health stigma (47% vs. 14%, p<0.001). CONCLUSIONS: Perceptions of the strengths and weaknesses of taxes earmarked for behavioral health services may vary by design features of the tax. Such features include stigma-reduction initiatives and tax spending and reporting requirements.
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Background: A myriad of federal, state, and organizational policies are designed to improve access to evidence-based healthcare, but the impact of these policies likely varies due to contextual determinants, re-interpretations of and poor compliance with policy requirements throughout implementation. Strategies enhancing implementation and compliance with policy intent can improve population health. Critically assessing the multi-level environments where health policies and their related health services are implemented is essential to designing effective policy-level implementation strategies. California passed a 2019 health insurance benefit mandate requiring coverage of fertility preservation (FP) services for individuals at risk of infertility due to medical treatments to improve access to services that are otherwise cost-prohibitive. Our objective was to document and understand multi-level environment, relationships, and activities involved in using state benefit mandates to facilitate patient access to FP services. Methods: We conducted a mixed-methods study and used the policy-optimized Exploration, Preparation, Implementation, Sustainment (EPIS) framework to analyze implementation of California's fertility preservation benefit mandate (SB 600) at and between the state insurance regulator, insurer and clinic levels. Results: Seventeen publicly available FP benefit mandate-relevant documents were reviewed, and four insurers, 25 financial, administrative and provider participants from 16 oncology and fertility clinics, three fertility pharmaceutical representatives, and two patient advocates were interviewed. The mandate and insurance regulator guidance represented two "Big P" (system level) policies that gave rise to a host of "little p" (organizational) policies by and between the regulator, insurers, clinics, and patients. Many little p policies were bridging factors to support implementation across levels and FP service access. Characterizing the mandate's functions (i.e., policy goals) and forms (i.e., ways that policies were enacted) led to identification of (1) intended and unintended implementation, service, and patient outcomes; (2) implementation processes by level, EPIS phase; (3) actor-delineated key processes and heterogeneity among them; and (4) inner and outer context determinants that drove adaptations. Conclusions: Following the mid- and down-stream implementation of a state health insurance benefit mandate, data generated will enable development of policy level implementation strategies, evaluation of determinants and important outcomes of effective implementation, and design of future mandates to improve fit and fidelity.
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The UC San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center (DISC) launched in 2020 to provide dissemination and implementation science (DIS) training, technical assistance, community engagement, and research advancement. DISC developed a program-wide logic model to inform a process evaluation of member engagement and impact related to DISC services. The DISC Logic Model (DLM) served as the framework for a process evaluation capturing quantitative and qualitative information about scientific activities, outputs, and outcomes. The evaluation involved a multimethod approach with surveys, attendance tracking, feedback forms, documentation of grant outcomes, and promotions metrics (e.g., Twitter engagement). There were 540 DISC Members at the end of year 2 of the DISC. Engagement in the DISC was high with nearly all members endorsing at least one scientific activity. Technical assistance offerings such as DISC Journal Club and consultation were most frequently used. The most common scientific outputs were grant submission (65, 39%), formal mentoring for career award (40, 24%), and paper submission (34, 21%). The DLM facilitated a comprehensive process evaluation of our center. Actionable steps include prioritizing technical assistance, strengthening networking opportunities, identifying streamlined approaches to facilitate DIS grant writing through writing workshops, as well as "office hours" or organized writing leagues.
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Background: Effective teams are essential to high-quality healthcare. However, teams, team-level constructs, and team effectiveness strategies are poorly delineated in implementation science theories, models, and frameworks (TMFs), hindering our understanding of how teams may influence implementation. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework is a flexible and accommodating framework that can facilitate the application of team effectiveness approaches in implementation science. Main Text: We define teams and provide an overview of key constructs in team effectiveness research. We describe ways to conceptualize different types of teams and team constructs relevant to implementation within the EPIS framework. Three case examples illustrate the application of EPIS to implementation studies involving teams. Within each study, we describe the structure of the team and how team constructs influenced implementation processes and outcomes. Conclusions: Integrating teams and team constructs into the EPIS framework demonstrates how TMFs can be applied to advance our understanding of teams and implementation. Implementation strategies that target team effectiveness may improve implementation outcomes in team-based settings. Incorporation of teams into implementation TMFs is necessary to facilitate application of team effectiveness research in implementation science.
Teams and team-level constructs are neglected in implementation theories, models, and frameworks (TMFs). This paper calls attention to the importance of teams in implementation research and practice and provides an overview of team effectiveness research for implementation science. We illustrate how the EPIS framework can be applied to advance our understanding of how teams influence implementation processes and outcomes. We identify future directions for research on teams and implementation, including developing and testing implementation strategies that focus on team effectiveness.
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BACKGROUND: Although healthcare is delivered in inherently multilevel contexts, implementation science has no widely endorsed methodological standards defining the characteristics of rigorous, multilevel implementation research. We identify and describe eight characteristics of high-quality, multilevel implementation research to encourage discussion, spur debate, and guide decision-making around study design and methodological issues. RECOMMENDATIONS: Implementation researchers who conduct rigorous multilevel implementation research demonstrate the following eight characteristics. First, they map and operationalize the specific multilevel context for defined populations and settings. Second, they define and state the level of each construct under study. Third, they describe how constructs relate to each other within and across levels. Fourth, they specify the temporal scope of each phenomenon at each relevant level. Fifth, they align measurement choices and construction of analytic variables with the levels of theories selected (and hypotheses generated, if applicable). Sixth, they use a sampling strategy consistent with the selected theories or research objectives and sufficiently large and variable to examine relationships at requisite levels. Seventh, they align analytic approaches with the chosen theories (and hypotheses, if applicable), ensuring that they account for measurement dependencies and nested data structures. Eighth, they ensure inferences are made at the appropriate level. To guide implementation researchers and encourage debate, we present the rationale for each characteristic, actionable recommendations for operationalizing the characteristics in implementation research, a range of examples, and references to make the characteristics more usable. Our recommendations apply to all types of multilevel implementation study designs and approaches, including randomized trials, quantitative and qualitative observational studies, and mixed methods. CONCLUSION: These eight characteristics provide benchmarks for evaluating the quality and replicability of multilevel implementation research and promote a common language and reference points. This, in turn, facilitates knowledge generation across diverse multilevel settings and ensures that implementation research is consistent with (and appropriately leverages) what has already been learned in allied multilevel sciences. When a shared and integrated description of what constitutes rigor is defined and broadly communicated, implementation science is better positioned to innovate both methodologically and theoretically.
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Atención a la Salud , Ciencia de la Implementación , HumanosRESUMEN
BACKGROUND: Financial barriers in substance use disorder service systems have limited the widespread adoption-i.e., provider-level reach-of evidence-based practices (EBPs) for youth substance use disorders. Reach is essential to maximizing the population-level impact of EBPs. One promising, but rarely studied, type of implementation strategy for overcoming barriers to EBP reach is financing strategies, which direct financial resources in various ways to support implementation. We evaluated financing strategies for the Adolescent Community Reinforcement Approach (A-CRA) EBP by comparing two US federal grant mechanisms, organization-focused and state-focused grants, on organization-level A-CRA reach outcomes. METHOD: A-CRA implementation took place through organization-focused and state-focused grantee cohorts from 2006 to 2021. We used a quasi-experimental, mixed-method design to compare reach between treatment organizations funded by organization-focused versus state-focused grants (164 organizations, 35 states). Using administrative training records, we calculated reach as the per-organization proportion of trained individuals who received certification in A-CRA clinical delivery and/or supervision by the end of grant funding. We tested differences in certification rate by grant type using multivariable linear regression models that controlled for key covariates (e.g., time), and tested threats to internal validity from our quasi-experimental design through a series of sensitivity analyses. We also drew on interviews and surveys collected from the treatment organizations and (when relevant) interviews with state administrators to identify factors that influenced reach. RESULTS: The overall certification rates were 27 percentage points lower in state-focused versus organization-focused grants (p = .01). Sensitivity analyses suggested these findings were not explained by confounding temporal trends nor by organizational or state characteristics. We did not identify significant quantitative moderators of reach outcomes, but qualitative findings suggested certain facilitating factors were more influential for organization-focused grants (e.g., strategic planning) and certain barrier factors were more impactful for state-focused grants (e.g., states finding it difficult to execute grant activities). DISCUSSION: As the first published comparison of EBP reach outcomes between financing strategies, our findings can help guide state and federal policy related to financing strategies for implementing EBPs that reduce youth substance use. Future work should explore contextual conditions under which different financing strategies can support the widespread implementation of EBPs for substance use disorder treatment.