Abstract
BackgroundAdvancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. This study will test the generalizability of a conceptual model that integrates organizational constructs and behavioral theory to predict clinician use of cognitive-behavioral therapy (CBT) techniques in community mental health centers. CBT is a leading psychosocial EBP for psychiatric disorders that remains underused despite substantial efforts to increase its implementation.MethodsWe will leverage ongoing CBT implementation efforts in two large public health systems (Philadelphia and Texas) to recruit 300 mental health clinicians and 600 of their clients across 40 organizations. Our primary implementation outcomes of interest are clinician intentions to use CBT and direct observation of clinician use of CBT. As CBT comprises discrete components that vary in complexity and acceptability, we will measure clinician use of six discrete components of CBT. After finishing their CBT training, participating clinicians will complete measures of organizational and behavior change constructs delineated in the model. Clinicians also will be observed twice via audio recording delivering CBT with a client. Within 48 h of each observation, theorized moderators of the intention-behavior gap will be collected via survey. A subset of clinicians who report high intentions to use CBT but demonstrate low use will be purposively recruited to complete semi-structured interviews assessing reasons for the intention-behavior gap. Multilevel path analysis will test the extent to which intentions and determinants of intention predict the use of each discrete CBT component. We also will test the extent to which theorized determinants of intention that include psychological, organizational, and contextual factors explain variation in intention and moderate the association between intentions and CBT use.DiscussionProject ACTIVE will advance implementation theory, currently in its infancy, by testing the generalizability of a promising causal model of implementation. These results will inform the development of implementation strategies targeting modifiable factors that explain substantial variance in intention and implementation that can be applied broadly across EBPs.
Highlights
Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use
Tailored implementation strategies, which target specific mechanisms associated with the use of specific EBP components, may be more successful and efficient than general implementation strategies in facilitating clinician behavior change [6, 7]
Research demonstrates that clinicians may not use a given EBP for one of two reasons: (1) either a clinician does not intend to use the component or (2) a clinician has strong intentions, but something interferes with their ability to act on those intentions
Summary
Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. Recent research documents the high cost of many implementation strategies [1] and their relatively modest effects on increasing clinician use of evidence-based practices (EBPs) to improve mental health [2,3,4,5]. Tailored implementation strategies, which target specific mechanisms associated with the use of specific EBP components, may be more successful and efficient than general implementation strategies in facilitating clinician behavior change [6, 7]. Elucidating the mutable causal processes underlying EBP implementation using prospective data collection and objective measurement of implementation outcomes is a critical step for advancing implementation theory and practice
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