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BACKGROUND: For youth receiving care in community mental health centers, comorbidities are the rule rather than the exception. Using measurement-based care (MBC), or the routine evaluation of symptoms to inform care decisions, as the foundation of treatment for youth with comorbid problems significantly improves the impact of psychotherapy by focusing care and building engagement and alliance. MBC increases the rate of symptom improvement, detects clients who would otherwise deteriorate, and alerts clinicians to non-responders. Despite its demonstrated utility, MBC is rarely implemented with fidelity; less than 15% of providers report using MBC per recommendations. Previous efforts to support MBC implementation have yielded suboptimal outcomes, in part, due to organizations' challenges with identifying and prioritizing barriers and selecting and developing strategies to overcome them. New methods are needed for identifying and prioritizing barriers, and matching strategies to barriers to optimize MBC implementation and treatment quality to improve youth mental health outcomes in community settings. METHODS: Pragmatic implementation methods will be piloted in four diverse community mental health centers. Methods include (a) rapid evidence synthesis; (b) rapid ethnography; (c) design kits (e.g., kits with disposable cameras, journals, maps); (d) barrier prioritization, and (e) causal pathway diagramming. These activities will generate actionable barriers; subsequently, we will use facilitated group processes to prioritize barriers and develop causal pathway diagrams to match strategies to barriers to create implementation plans that optimize MBC fidelity (Aim 1). We will track strategy deployment for 6 months, then compare MBC fidelity for another 6 months post-implementation with data from 2 years of historical controls (Aim 2). Finally, we will co-design a toolkit for design kit methods with youth and the practice and scientific communities (Aim 3). DISCUSSION: Optimizing MBC implementation in community mental health centers could transform youth mental health care by ensuring the most pressing symptoms are targeted early in treatment. The discussion section highlights expected challenges and limits to using the five methods, including recruitment and engagement given the high pressure on community mental health settings. TRIAL REGISTRATION: Clinicaltrials.gov. NCT05644756 . Registered on 18 November 2022. This trial was retrospectively registered.
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Objectives: Theory of planned of behavior (TPB) constructs have been linked to health behavior intentions. Intentions to try mindfulness-based stress reduction (MBSR), a first-line therapy for chronic low back pain (cLBP), have been less studied. This study aimed to identify which TPB constructs could inform strategies to improve adoption of MBSR. Methods: People with cLBP (n = 457) read a description of MBSR then completed survey items assessing TPB constructs: attitudes, norms, self-efficacy, perceived control, and intentions to try MBSR training. Results: Structural equation modeling showed self-efficacy/control (coefficient: 0.564), norms (0.245), and attitudes (0.131) were all positively associated with intentions to try mindfulness trainings. Conclusions: Results suggest self-efficacy/control may be the most strongly related TPB construct with intentions to try MBSR. Dissemination of MBSR for cLBP could focus on adapting the intervention to increase accessibility and improving available resources to overcome logistical barriers (online formats, drop-in classes). Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-022-02022-2.
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BACKGROUND: Chronic low back pain is a common and sometimes disabling condition, and mindfulness-based stress reduction is recommended as a first line of therapy. This study tested whether different descriptions of mindfulness training altered based on influential intervention characteristics increased adoption intentions. METHODS: People with chronic low back pain (n = 452) were randomized to review one of four mindfulness training descriptions in an online survey using a 2 × 2 factorial design. The first factor was evidence strength and quality with relative advantage (ER). The second factor was adaptability, trialability, complexity, and design quality and packaging (AD). Each factor had two levels: a description of standardized mindfulness training that described each intervention characteristic and a patient-centered description emphasizing flexibility and patient testimonials. The primary outcomes were intentions to try mindfulness training and practice mindfulness at home. Using structural equation modeling with a bootstrapped distribution, we tested six mediators, three of which are Theory of Planned Behavior predictors of intention-self-efficacy, norms, and attitudes- and the other three are predictors of adoption-feasibility, appropriateness, and acceptability. RESULTS: Overall, the mindfulness training descriptions were not associated with an increase in intentions compared to the classic vignette (11/12 p's > 0.05). Most descriptions were unrelated to mediators except the classic ER with patient-centered AD was associated with higher self-efficacy/control and feasibility (p's ≤ 0.05; standardized effect range: 0.111-0.125). Self-efficacy/control (training standardized coefficient: 0.531, home: 0.686), norms (training: 0.303, home: 0.256), and attitudes (training: 0.316, home: 0.293) were all positively associated with intentions to adopt mindfulness training and home practice. Feasibility (training: 0.185; home: 0.293) and acceptability (training: 0.639; home: 0.554) were positively related to intentions to adopt mindfulness training. Appropriateness was related to intentions to adopt home practice (0.187) but not mindfulness training (0.100). None of the indirect effects from experimental group to intentions was significant (all p's > 0.05). CONCLUSIONS: Self-efficacy/control and acceptability may be key mediators for increasing patient adoption of mindfulness. Because experimental manipulation did not substantially change intentions to adopt mindfulness, the presentation and delivery of MBSR may need to be tailored to the individual patient's needs rather than a specific format for chronic low back pain.
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Background: Clinician champions are front-line clinicians who advocate for and influence practice change in their local context. The strategies they use when leading efforts to reduce the use of low-value care have not been well described. The purpose of this study is to identify and describe strategies used by six clinician champions who led a low-value care initiative in their clinical setting. Methods: Qualitative data collected during an overuse reduction initiative led by clinician champions were used to identify strategies, guided by the Expert Recommendations for Implementing Change compilation of strategies. Clinician champions were asked to rank the importance of these activities and indicate which one of the six most important activities they would be willing to discuss in an interview. A 30-min semi-structured interview was conducted with each clinician about the activity they selected and thematically analyzed. Results: Twelve Expert Recommendations for Implementing Change strategies were identified. The top six strategies discussed during interviews were: build a coalition, conduct a local needs assessment, develop a formal implementation blueprint, conduct educational meetings, use facilitation, and develop clinical reminders. Common themes that emerged across all interviews were the use of data to engage clinicians in conversations, including the patient's perspective in designing the interventions, and investing the time upfront to plan and launch the initiative because of the inherent challenges of relinquishing a service. Conclusions: Clinician champions identified multiple strategies as important when de-implementing a low-value service. Many were used to engage in conversations with stakeholders, including leadership, providers, and patients, to increase buy-in and support, challenge beliefs, promote behavior change, and gather insights about next steps in their effort. Future work is needed to better understand how prepare clinicians for this role and to understand the mechanisms through which these strategies might be effective.
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Background: Tailoring implementation strategies and adapting treatments to better fit the local context may improve their effectiveness. However, there is a dearth of valid, reliable, pragmatic measures that allow for the prospective tracking of strategies and adaptations according to reporting recommendations. This study describes the development and pilot testing of three tools to be designed to serve this purpose. Methods: Measure development was informed by two systematic reviews of the literature (implementation strategies and treatment adaptation). The three resulting tools vary with respect to the degree of structure (brainstorming log = low, activity log = moderate, detailed tracking log = high). To prospectively track treatment adaptations and implementation strategies, three stakeholder groups (treatment developer, implementation practitioners, and mental health providers) were randomly assigned one tool per week through an anonymous web-based survey for 12 weeks and incentivized to participate. Three established implementation outcome measures, the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure, were used to assess the tools. Semi-structured interviews were conducted to gather more nuanced information from stakeholders regarding their perceptions of the tools and the tracking process. Results: The three tracking tools demonstrated moderate to good acceptability, appropriateness, and feasibility; the activity log was deemed the most feasible of the three tools. Implementation practitioners rated the tools the highest of the three stakeholder groups. The tools took an average of 15 min or less to complete. Conclusion: This study sought to fill methodological gaps that prevent stakeholders and researchers from discerning which strategies are most important to deploy for promoting implementation and sustainment of evidence-based practices. These tools would allow researchers and practitioners to track whether activities were treatment adaptations or implementation strategies and what barrier(s) each targets. These tools could inform prospective tailoring of implementation strategies and treatment adaptations, which would promote scale out and spread. Plain Language Summary: Strategies to support the implementation of evidence-based practices may be more successful if they are carefully customized based on local factors. Evidence-based practices themselves may be thoughtfully changed to better meet the needs of the settings and recipients. This study reports on a pilot study that aimed to create various types of tools to help individuals involved in implementation efforts track the actions they take to modify and implement interventions. These tools allow individuals to track the types of activities they are involved in, when the activities occurred, who was involved in the implementation efforts, and the reasons or rationale for the actions. The three tools in this study used a combination of open-ended and forced-response questions to test how the type of data recorded changed. Participants generally found the tools quick and easy to use and helpful in planning the delivery of an evidence-based practice. Most participants wanted more training in implementation science terminology and how to complete the tracking tools. Participating mental health providers would have liked more opportunities to review the data collected from the tools with their supervisors to use the data to improve the delivery of the evidence-based practice. These tools can help researchers, providers, and staff involved in implementation efforts to better understand what actions are needed to improve implementation success. Future research should address gaps identified in this study, such as the need to involve more participants in the tool development process.
