Implementation and modification of an organizational-level intervention: a prospective analysis.

BACKGROUND: Modifications to interventions can jeopardize intervention outcomes. Pre-existing perceived barriers and facilitators to the intervention arising in the implementation preparation phase may help explain why modifications to the intervention may occur during the implementation phase. This two-site comparative case study describes modifications made to a complex organizational-level intervention and examines how known implementation science factors may have enabled such changes to occur. METHODS: Northwestern Medicine'sTM Hispanic Kidney Transplant Program (HKTP) is a culturally competent transplant center-based intervention designed to reduce disparities in living donor kidney transplantation among Hispanics. In-depth qualitative interviews and discussions were longitudinally conducted with transplant stakeholders (i.e., physicians, administrators, clinicians) at two kidney transplant programs with large Hispanic populations during implementation preparation and implementation phases. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis, and Stirman's Framework for Reporting Adaptations and Modifications-Expanded (FRAME) guided modification classification. RESULTS: Across sites, 57 stakeholders participated in an interview, group discussion, and/or learning collaborative discussion. Site-B made more modifications than Site-A (n = 29 versus n = 18). Sites differed in the proportions of delaying/skipping (Site-A 50% versus Site-B 28%) and adding (Site-A 11% versus Site-B 28%) but had comparable substituting (Site-A 17% versus Site-B 17%) and tweaking (Site-A 17% versus Site-B 14%) modification types. Across sites, the transplant team consistently initiated the most modifications (Site-A 66%; Site-B 62%). While individuals initiated slightly more modifications at Site-B (21% versus Site-A 17%), institutions instigated proportionately slightly more modifications at Site-A (17% versus Site-B 10%). CFIR inner setting factors (i.e., structural characteristics, culture, available resources, implementation climate) that prominently emerged during the implementation preparation phase explained similarities and differences in sites' modification numbers, types, and agents in the implementation phase. CONCLUSION: Organizations implementing a culturally competent care intervention made modifications. CFIR inner setting factors emerging in the implementation preparation phase largely explained similarities and differences in study sites' modifications. Identifying factors contributing to modifications may help institutions become better prepared to implement an intervention by addressing known factors in advance, which may foster greater fidelity leading to desired outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03276390 . We registered the study retrospectively on 9-7-17.

Sustainment of a complex culturally competent care intervention for Hispanic living donor kidney transplantation: A longitudinal analysis of adaptations.

Introduction: Sustainment refers to continued intervention delivery over time, while continuing to produce intended outcomes, often with ongoing adaptations, which are purposeful changes to the design or delivery of an intervention to improve its fit or effectiveness. The Hispanic Kidney Transplant Program (HKTP), a complex, culturally competent intervention, was implemented in two transplant programs to reduce disparities in Hispanic/Latinx living donor kidney transplant rates. This study longitudinally examined the influence of adaptations on HKTP sustainment. Methods: Qualitative interviews, learning collaborative calls, and telephone meetings with physicians, administrators, and staff (n = 55) were conducted over three years of implementation to identify HKTP adaptations. The Framework for Reporting Adaptations and Modifications-Expanded was used to classify adaptation types and frequency, which were compared across sites over time. Results: Across sites, more adaptations were made in the first year (n = 47), then fell and plateaued in the two remaining years (n = 35). Adaptations at Site-A were consistent across years (2017: n = 18, 2018: n = 17, 2019: n = 14), while Site-B made considerably fewer adaptations after the first year (2017: n = 29, 2018: n = 18, 2019: n = 21). Both sites proportionally made mostly skipping (32%), adding (20%), tweaking (20%), and substituting (16%) adaptation types. Skipping- and substituting-type adaptations were made due to institutional structural characteristics and lack of available resources, respectively. However, Site-A's greater proportion of skipping-type adaptations was attributed to greater system complexity, and Site-B's greater proportion of adding-type adaptation was attributed to the egalitarian team-based culture. Conclusion: Our findings can help prepare implementers to expect certain context-specific adaptations and preemptively avoid those that hinder sustainment.

Effectiveness of a culturally competent care intervention in reducing disparities in Hispanic live donor kidney transplantation: A hybrid trial.

Hispanic patients receive disproportionately fewer living donor kidney transplants (LDKTs) than non-Hispanic Whites (NHWs). The Northwestern Medicine Hispanic Kidney Transplant Program (HKTP), designed to increase Hispanic LDKTs, was evaluated as a nonrandomized, implementation-effectiveness hybrid trial of patients initiating transplant evaluation at two intervention and two similar control sites. Using a mixed method, observational design, we evaluated the fidelity of the HKTP implementation at the two intervention sites. We tested the impact of the HKTP intervention by evaluating the likelihood of receiving LDKT comparing pre-intervention (January 2011-December 2016) and postintervention (January 2017-March 2020), across ethnicity and centers. The HKTP study included 2063 recipients. Intervention Site A exhibited greater implementation fidelity than intervention Site B. For Hispanic recipients at Site A, the likelihood of receiving LDKTs was significantly higher at postintervention compared with pre-intervention (odds ratio [OR] = 3.17 95% confidence interval [1.04, 9.63]), but not at the paired control Site C (OR = 1.02 [0.61, 1.71]). For Hispanic recipients at Site B, the likelihood of receiving an LDKT did not differ between pre- and postintervention (OR = 0.88 [0.40, 1.94]). The LDKT rate was significantly lower for Hispanics at paired control Site D (OR = 0.45 [0.28, 0.90]). The intervention significantly improved LDKT rates for Hispanic patients at the intervention site that implemented the intervention with greater fidelity. Registration: ClinicalTrials.gov registered (retrospectively) on September 7, 2017 (NCT03276390).

Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study.

BACKGROUND: Despite available evidence-based interventions that decrease health disparities, these interventions are often not implemented. Northwestern Medicine's® Hispanic Kidney Transplant Program (HKTP) is a culturally and linguistically competent intervention designed to reduce disparities in living donor kidney transplantation (LDKT) among Hispanics/Latinos. The HKTP was introduced in two transplant programs in 2016 to evaluate its effectiveness. OBJECTIVE: This study assessed barriers and facilitators to HKTP implementation preparation. METHODS: Interviews and group discussions were conducted with transplant stakeholders (ie administrators, nurses, physicians) during implementation preparation. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis. RESULTS: Forty-four stakeholders participated in 24 interviews and/or 27 group discussions. New factors, not found in previous implementation preparation research in health-care settings, emerged as facilitators and barriers to the implementation of culturally competent care. Implementation facilitators included: stakeholders' focus on a moral imperative to implement the HKTP, personal motivations related to their Hispanic heritage, and perceptions of Hispanic patients' transplant education needs. Implementation barriers included: stakeholders' perceptions that Hispanics' health insurance payer mix would negatively impact revenue, a lack of knowledge about LDKT disparities and patient data disaggregated by ethnicity/race, and a perception that the family discussion component was immoral because of the possibility of coercion. DISCUSSION AND CONCLUSIONS: Our study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations' implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.

A complex culturally targeted intervention to reduce Hispanic disparities in living kidney donor transplantation: an effectiveness-implementation hybrid study protocol.

BACKGROUND: The shortage of organs for kidney transplantation for patients with end-stage renal disease (ESRD) is magnified in Hispanics/Latin Americans in the United States. Living donor kidney transplantation (LDKT) is the treatment of choice for ESRD. However, compared to their representation on the transplant waitlist, fewer Hispanics receive a LDKT than non-Hispanic whites. Barriers to LDKT for Hispanics include: lack of knowledge, cultural concerns, and language barriers. Few interventions have been designed to reduce LDKT disparities. This study aims to reduce Hispanic disparities in LDKT through a culturally targeted intervention. METHODS/DESIGN: Using a prospective effectiveness-implementation hybrid design involving pre-post intervention evaluation with matched controls, we will implement a complex culturally targeted intervention at two transplant centers in Dallas, TX and Phoenix, AZ. The goal of the study is to evaluate the effect of Northwestern Medicine's® Hispanic Kidney Transplant Program's (HKTP) key culturally targeted components (outreach, communication, education) on Hispanic LDKT rates over five years. The main hypothesis is that exposure to the HKTP will reduce disparities by increasing the ratio of Hispanic to non-Hispanic white LDKTs and the number of Hispanic LDKTs. We will also examine other process and outcome measures including: dialysis patient outreach, education session attendance, marketing efforts, Hispanic patients added to the waitlist, Hispanic potential donors per potential recipient, and satisfaction with culturally competent care. We will use mixed methods based on the Promoting Action on Research Implementation in Health Services (revised PARIHS) and the Consolidated Framework for Implementation Research (CFIR) frameworks to formatively evaluate the fidelity and innovative adaptations to HKTP's components at both study sites, to identify moderating factors that most affect implementation fidelity, and to identify adaptations that positively and negatively affect outcomes for patients. DISCUSSION: Our study will provide new knowledge about implementing culturally targeted interventions and their impact on reducing health disparities. Moreover, the study of a complex organizational-level intervention's implementation over five years is rare in implementation science; as such, this study is poised to contribute new knowledge to the factors influencing how organizational-level interventions are sustained over time. TRIAL REGISTRATION: (ClinicalTrials.gov registration # NCT03276390 , date of registration: 9-7-17, retrospectively registered).

Proscriptive models and evidence in antismoking advertising.

This study assessed the proscriptive models and evidence used in antismoking campaigns. A content analysis of 399 television advertisements cataloged in the Media Campaign Resource Center database was conducted. Findings reveal that the analyzed advertisements fail to use evidence and often reinforce proscriptive models of smoking. In advertisements with images of a smoker (N = 111), 40% showed no graphic visual consequences from smoking, and 2% portrayed the smoker as someone engaged in vigorous activities. In 20% of the advertisements, smoking was portrayed as a rite of passage to adulthood. Most of the advertisements did not provide any evidence to support the claims made, and advertisements aimed at teenagers were significantly less likely to use evidence than were advertisements aimed at adults (p < .01). The research identifies several areas of improvement for antismoking campaigns.

Original: anti-smoking media campaign messages: theory and practice.

This study examined televised anti-smoking advertisements that were designed to discourage adult and teen smoking. A content analysis of 399 television advertisements catalogued in the Media Campaign Resource Center (MCRC) database were evaluated to determine (a) whether the advertising content reflected core health communication theories used in the design of health campaign messages to change behavior and (b) the affective presentation of tobacco-control advertisements aimed to decrease smoking. The results revealed that anti-smoking advertising relied overwhelmingly on appeals to attitudes. Although the benefits of not smoking were mentioned in 61% of advertisements, barriers were mentioned in only 17% of advertisements. Advertisements emphasized the consequences of smoking more than the viewer's self-efficacy. Finally, advertisements were more likely to use informational and humor appeals, rather than sadness, fear, or anger appeals. The research identifies the types of advertisements that are most likely to be utilized and underutilized in national and statewide anti-smoking advertising campaigns catalogued in the MCRC database.