Applying Implementation Science Research Articles

Systematic Process Framework for Conducting Implementation Science Research in Food Fortification Programs.

Food fortification has proven to be an effective approach for preventing micronutrient deficiencies in many settings. Factors that lead to successful fortification programs are well established. However, due to the multisectoral nature of fortification and the added complexities present in many settings, the barriers to success are not always evident and the strategies to address them are not always obvious. We developed a systematic process for identifying and addressing gaps in the implementation of a food fortification program. The framework is composed of 4 phases: (1) connect program theory of change to program implementation; (2) develop an implementation research agenda; (3) conduct implementation research; and (4) analyze findings and develop/disseminate recommendations for next steps. We detail steps in each phase to help guide teams through the process. To our knowledge, this is the first attempt to outline a systematic process for applying implementation science research to food fortification. The development of this framework is intended to promote implementation research in the field of food fortification, thus improving access to and effectiveness of this key public health intervention.

Commentary on “Building capable environments using practice leadership”

PurposeThis paper aims to present a conceptual viewpoint highlighting the utility of active support in implementing capable environments and to extend this by presenting a three-tiered preventative model of positive behavioural support (PBS) in UK health and social care.Design/methodology/approachProvision of a commentary on “Building capable environments using practice leadership” by Linda Hume, Nadia Khan and Martin Reilly.FindingsCapable environments and active support should be key, universal and essential PBS tier one supports in UK health and social care. Training staff in Active Support and developing practice leadership help implement capable environments.Originality/valueThe three-tiered PBS model was recently proposed by Leitch et al. (2020) and is worthy of further debate and refinement with the involvement of stakeholders. It has several practical implications including refocussing efforts on early intervention to get tier one supports implemented effectively in recognition that PBS is much wider than intense tier three supports. It could reinforce and motivate existing providers of quality support and indicate where and how other providers can commence the process of implementing PBS. Future research could consider the effectiveness of applying implementation science to the field of learning disabilities and PBS in particular.

Implementation of clinical practice changes in the PICU: a qualitative study using and refining the iPARIHS framework

BackgroundLike in many settings, implementation of evidence-based practices often fall short in pediatric intensive care units (PICU). Very few prior studies have applied implementation science frameworks to understand how best to improve practices in this unique environment. We used the relatively new integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to assess practice improvement in the PICU and to explore the utility of the framework itself for that purpose.MethodsWe used the iPARIHS framework to guide development of a semi-structured interview tool to examine barriers, facilitators, and the process of change in the PICU. A framework approach to qualitative analysis, developed around iPARIHS constructs and subconstructs, helped identify patterns and themes in provider interviews. We assessed the utility of iPARIHS to inform PICU practice change.ResultsFifty multi-professional providers working in 8 U.S. PICUs completed interviews. iPARIHS constructs shaped the development of a process model for change that consisted of phases that include planning, a decision to adopt change, implementation and facilitation, and sustainability; the PICU environment shaped each phase. Large, complex multi-professional teams, and high-stakes work at near-capacity impaired receptivity to change. While the unit leaders made decisions to pursue change, providers’ willingness to accept change was based on the evidence for the change, and provider’s experiences, beliefs, and capacity to integrate change into a demanding workflow. Limited analytic structures and resources frustrated attempts to monitor changes’ impacts. Variable provider engagement, time allocated to work on changes, and limited collaboration impacted facilitation. iPARIHS constructs were useful in exploring implementation; however, we identified inter-relation of subconstructs, unique concepts not captured by the framework, and a need for subconstructs to further describe facilitation.ConclusionsThe PICU environment significantly shaped the implementation. The described process model for implementation may be useful to guide efforts to integrate changes and select implementation strategies. iPARIHS was adequate to identify barriers and facilitators of change; however, further elaboration of subconstructs for facilitation would be helpful to operationalize the framework.Trial registrationNot applicable, as no health care intervention was performed.

Creating Dementia-Friendly Communities for Social Inclusion: A Scoping Review.

Aims: This scoping review explores key strategies of creating inclusive dementia-friendly communities that support people with dementia and their informal caregiver. Background: Social exclusion is commonly reported by people with dementia. Dementia-friendly community has emerged as an idea with potential to contribute to cultivating social inclusion. Methods: This scoping review follows the Joanna Briggs Institute scoping review methodology and took place between April and September 2020. The review included a three-step search strategy: (1) identifying keywords from CINAHL and AgeLine; (2) conducting a second search using all identified keywords and index terms across selected databases (CINAHL, AgeLine, MEDLINE, PsycINFO, Web of Science, ProQuest, and Google); and (3) hand-searching the reference lists of all included articles and reports for additional studies. Results: Twenty-nine papers were included in the review. Content analysis identified strategies for creating dementia-friendly communities: (a) active involvement of people with dementia and caregivers (b) inclusive environmental design; (c) public education to reduce stigma and raise awareness; and (d) customized strategies informed by theory. Conclusion: This scoping review provides an overview of current evidence on strategies supporting dementia-friendly communities for social inclusion. Future efforts should apply implementation science theories to inform strategies for education, practice, policy and future research.

An Implementation Science Approach to Promote Optimal Implementation, Adoption, Use, and Spread of Continuous Clinical Monitoring System Technology.

This study aimed to apply implementation science tenets to guide the deployment and use of in-hospital Clinical Monitoring System Technology (CMST) and to develop a toolkit to promote optimal implementation, adoption, use, and spread of CMST. Six steps were carried out to (1) establish leadership support; (2) identify, educate, and sustain champions; (3) enlist clinical staff users to learn barriers and facilitators; (4) examine initial qualitative data from 11 clinician group interviews; (5) validate barriers/facilitators to CMST use and toolkit content; and (6) propose a toolkit to promote utilization. Clinical Monitoring System Technology output before and after implementation were compared. The top 3 barriers to effective CMST use were as follows: (1) inadequate education/training/support, (2) clinical workflow challenges, and (3) lack of communication. Facilitators to CMST implementation and adoption included the following: (1) providing comprehensive and consistent CMST education, (2) presenting evidence early and often, (3) tailoring device and usage expectations to individual environments, and (4) providing regular feedback about progress. Empirical data drove the development of a CMST implementation toolkit covering 6 areas: (1) why, (2) readiness, (3) readiness and implementation, (4) patient/family introduction, (5) champions, (6) care team saves, and (7) troubleshooting. Clinical Monitoring System Technology positively impacted failure to rescue events. Monthly median cardiac alert responses decreased from 30 to 3.64 minutes (87.9%), and respiratory alert responses decreased from 26 to 4.85 minutes (81.4%). Using implementation science tenets to concurrently guide deployment and study performance of 2 CMST devices and impact on workload was effective for both learning CMST efficacy at 2 hospital systems and developing a toolkit to promote optimal implementation, adoption, use, and spread.

Use of implementation science in tobacco control intervention studies in the USA between 2000 and 2020: a scoping review protocol

IntroductionDespite continuing efforts to reduce tobacco use in the USA, decline in smoking rates have stalled and smoking remains a major contributor to preventable death. Implementation science could potentially improve...

Implementation Science to Advance Practice and Curricular Transformation: Report of the 2019-2020 AACP Research and Graduate Affairs Committee

The 2019-2020 AACP Research and Graduate Affairs Committee (RGAC) was charged with articulating the case for and evaluating the state of implementation science in academic pharmacy, given the potential for implementation science to act as a driver of practice and curricular transformation. Based on the current state of pharmacy research in this area, the RGAC was further charged with outlining a plan to raise the profile of implementation science with pharmacy leadership and defining strategies for AACP to facilitate schools in applying its methods to their practice and education missions. For this work, the RGAC considered implementation science to be the scientific study of methods and strategies to promote adoption of evidence-based practices and interventions into real world settings and routine practice, to improve the quality and effectiveness of services. The RGAC identified three components of an effective strategy for AACP to assist schools in applying implementation science in practice and education: 1) raising awareness of implementation science as an opportunity for academic pharmacy, 2) connecting pharmacy researchers with the larger implementation science community, and 3) developing pharmacy researchers in the competencies and methods associated with implementation science. Specific recommendations for this strategy were informed by searches of the literature and funding landscape related to implementation science and pharmacy. The RGAC also identified stakeholder groups that AACP could target in a campaign to raise awareness of implementation science and connectivity to the existing research community in this space, including academic leadership, faculty with expertise in relevant research methodologies (eg, the Social and Administrative Science (SAS) section of AACP), and the academic pharmacy community as a whole.

Powering Swiss health care for the future: implementation science to bridge "the valley of death".

A 2019 Swiss Academy of Medical Science bulletin addressed the challenge of translational research: the enormous rift between basic scientific discoveries and their use in clinical therapies. The report termed this distance “the valley of death”. Strategies to apply implementation science methods to Swiss health research offer an excellent return on investment. Designing studies specifically to overcome translation barriers promises to remove years from the current research process.

Addressing Common Mental Health Disorders Among Incarcerated People Living with HIV: Insights from Implementation Science for Service Integration and Delivery.

Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA. Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators. Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.

Development of an implementation-focused network to improve healthcare delivery as informed by the experiences of the SCI knowledge mobilization network

Context: Implementing research findings into clinical practice is challenging. This manuscript outlines the experiences and key learnings from a network that operated as a community of practice across seven Canadian Spinal Cord Injury (SCI) rehabilitation centers. These learnings are being used to inform a new implementation-focused network involving SCI rehabilitation programs based in Ontario, Canada.Methods: The SCI KMN adapted and applied implementation science principles based on the National Implementation Research Network’s (NIRN) Active Implementation Frameworks in the implementation of best practices in pressure injury and pain prevention and management.Results: The SCI KMN was successful in implementing best practices in both pressure ulcer and pain prevention and management across the various participating sites. Other key objectives met were building capacity in implementation methods in site personnel so that project scaling could occur with these skills and expertise applied to numerous other initiatives. Additionally, various papers, abstracts and conference presentation as well as an implementation guide were disseminated to inform the field of implementation science.Conclusion: The key lessons learned from this experience are being used to develop a new implementation-focused network. Features felt to be especially important for the SCI KMN includes a highly representative governance structure, the use of indicators within an overall evaluation framework and the systematic application of implementation processes with shared learnings supporting each site.

Approaching change in a challenging environment: Applying implementation science to academic administration.

Approaching change in a challenging environment: Applying implementation science to academic administration.

Building capacity for Public Health 3.0: introducing implementation science into an MPH curriculum

BackgroundMany public health programs fail because of an inability to implement tested interventions in diverse, complex settings. The field of implementation science is engaged in developing strategies for successful implementation, but current training is primarily researcher-focused. To tackle the challenges of the twenty-first century, public health leaders are promoting a new model titled Public Health 3.0 where public health practitioners become “chief health strategists” and develop interdisciplinary skills for multisector engagement to achieve impact. This requires broad training for public health practitioners in implementation science that includes the allied fields of systems and design thinking, quality improvement, and innovative evaluation methods. At UNC Chapel Hill’s Gillings School of Global Public Health, we created an interdisciplinary set of courses in applied implementation science for Master of Public Health (MPH) students and public health practitioners. We describe our rationale, conceptual approach, pedagogy, courses, and initial results to assist other schools contemplating similar programs.MethodsOur conceptual approach recognized the vital relationship between implementation research and practice. We conducted a literature review of thought leaders in public health to identify skill areas related to implementation science that are priorities for the future workforce. We also reviewed currently available training programs in implementation science to understand their scope and objectives and to assess whether any of these would be a fit for these priorities. We used a design focused implementation framework to create four linked courses drawing from multiple fields such as engineering, management, and the social sciences and emphasizing application through case studies. We validated the course content by mapping them to implementation science competencies in the literature.ResultsTo date, there is no other program that provides comprehensive interdisciplinary skills in applied implementation science for MPH students. As of April 2018, we have offered a total of eleven sections of the four courses, with a total enrollment of 142, of whom 127 have been master’s-level students in the school of public health. Using Kirkpatrick’s Model, we found positive student reaction, learning, and behavior. Many students have completed applied implementation science focused practicums, master’s papers, and special studies.ConclusionsA systematically designed interdisciplinary curriculum in applied implementation science for MPH students has been found by students to be a useful set of skills. Students have demonstrated the capability to master this material and incorporate it into their practicums and master’s papers.

Barriers and solutions to conducting patient-reported outcomes (PRO) research in patients with pain.

227 Background: Cancer pain prevalence ranges from 52-77%. Poorly controlled pain contributes to patient suffering and increased health care utilization. Shared decision making (SDM), where patient preferences, goals, and concerns are discussed, can foster earlier identification and improved pain management. A study was proposed to determine if incorporating SDM into a pain care plan is feasible and effective. Methods: Patients with metastatic cancer reported their pain and symptom experiences on an electronic patient-reported outcome (ePRO) platform. A drill down pain assessment included questions on chronic and breakthrough pain and end of dose failure. The patient and provider jointly discussed ePROs; an individualized care plan was printed for each patient. One academic and two community sites planned to recruit 105 patients over 6 months. Accrual quickly fell behind predicted rates (1 vs 15 patients per month). Study teams met to identify and mitigate accrual barriers. Results: Using an implementation science framework, barriers were identified in study design, and patient, provider, and environmental issues. Literature reports challenges in accruing/ retaining patients with metastatic disease, such as uncontrolled symptoms, inability to complete measures, missed visits, hospice admission, and death. Researchers broadened eligibility requirements to include all cancer stages; study team members were re-educated to clarify the operational definition of pain (experiencing pain or controlled on opioids). Some patient-related barriers were solved with workflow modifications (pre-visit survey completion). Environmental issues such as privacy to complete ePRO measures and internet connection reliability were solved with clinical staff. Conclusions: Study accrual improved 500% (from 6 to 36 in 3 months) following design and process changes. While examining patients with metastatic disease is important, expanding eligibility allows researchers to still include these patients and yet answer research questions timelier with the expanded population. Applying implementation science principles during study design is relevant to broader studies of pain and symptom ePROs and SDM in cancer care. Clinical trial information: NCT03304145.

The Family Check-Up 4 Health (FCU4Health): Applying Implementation Science Frameworks to the Process of Adapting an Evidence-Based Parenting Program for Prevention of Pediatric Obesity and Excess Weight Gain in Primary Care.

Implementation experts have recently argued for a process of “scaling out” evidence-based interventions, programs, and practices (EBPs) to improve reach to new populations and new service delivery systems. A process of planned adaptation is typically required to integrate EBPs into new service delivery systems and address the needs of targeted populations while simultaneously maintaining fidelity to core components. This process-oriented paper describes the application of an implementation science framework and coding system to the adaptation of the Family Check-Up (FCU), for a new clinical target and service delivery system—prevention of obesity and excess weight game in primary care. The original FCU has demonstrated both short- and long-term effects on obesity with underserved families across a wide age range. The advantage of adapting such a program is the existing empirical evidence that the intervention improves the primary mediator of effects on the new target outcome. We offer a guide for determining the levels of evidence to undertake the adaptation of an existing EBP for a new clinical target. In this paper, adaptation included shifting the frame of the intervention from one of risk reduction to health promotion; adding health-specific assessments in the areas of nutrition, physical activity, sleep, and media parenting behaviors; family interaction tasks related to goals for health and health behaviors; and coordinating with community resources for physical health. We discuss the multi-year process of adaptation that began by engaging the FCU developer, community stakeholders, and families, which was then followed by a pilot feasibility study, and continues in an ongoing randomized effectiveness-implementation hybrid trial. The adapted program is called the Family Check-Up 4 Health (FCU4Health). We apply a comprehensive coding system for the adaptation of EBPs to our process and also provide a side-by-side comparison of behavior change techniques for obesity prevention and management used in the original FCU and in the FCU4Health. These provide a rigorous means of classification as well as a common language that can be used when adapting other EBPs for context, content, population, or clinical target. Limitations of such an approach to adaptation and future directions of this work are discussed.

Longitudinal evaluation of a course to build core competencies in implementation practice

BackgroundFew training opportunities are available for implementation practitioners; we designed the Practicing Knowledge Translation (PKT) to address this gap. The goal of PKT is to train practitioners to use evidence and apply implementation science in healthcare settings. The aim of this study was to describe PKT and evaluate participant use of implementation science theories, models, and frameworks (TMFs), knowledge, self-efficacy, and satisfaction and feedback on the course.MethodsPKT was delivered to implementation practitioners between September 2015 and February 2016 through a 3-day workshop, 11 webinars. We assessed PKT using an uncontrolled before and after study design, using convergent parallel mixed methods. The primary outcome was use of TMFs in implementation projects. Secondary outcomes were knowledge and self-efficacy across six core competencies, factors related to each of the outcomes, and satisfaction with the course. Participants completed online surveys and semi-structured interviews at baseline, 3, 6, and 12 months.ResultsParticipants (n = 15) reported an increase in their use of implementation TMFs (mean = 2.11; estimate = 2.11; standard error (SE) = 0.4; p = 0.03). There was a significant increase in participants’ knowledge of developing an evidence-informed, theory-driven program (ETP) (estimate = 4.10; SE = 0.37; p = 0.002); evidence implementation (estimate = 2.68; SE = 0.42; p < 0.001); evaluation (estimate = 4.43; SE = 0.36; p < 0.001); sustainability, scale, and spread (estimate = 2.55; SE = 0.34; p < 0.001); and context assessment (estimate = 3.86; SE = 0.32; p < 0.001). There was a significant increase in participants’ self-efficacy in developing an ETP (estimate = 3.81; SE = 0.34; p < 0.001); implementation (estimate = 3.01; SE = 0.36; p < 0.001); evaluation (estimate = 3.83; SE = 0.39; p = 0.002); sustainability, scale, and spread (estimate = 3.06; SE = 0.46; p = 0.003); and context assessment (estimate = 4.05; SE = 0.38; p = 0.016).ConclusionProcess and outcome measures collected indicated that PKT participants increased use of, knowledge of, self-efficacy in KT. Our findings highlight the importance of longitudinal evaluations of training initiatives to inform how to build capacity for implementers.

Implementation of evidence based treatment into clinical practice for older people – A negative trial

This project took the strong evidence that vitamin D supplements reduce falls in older people living in residential aged care facilities and applied implementation science principles to investigate whether the prevalence of vitamin D supplement use could be increased. A multifaceted implementation program was developed that included education and targeted all stakeholders, use of audits and feedback, and addressing stakeholder beliefs and attitudes. Its effectiveness was assessed using a stepped wedge design. In the first group of 17 facilities (1466 residents) the prevalence of vitamin D supplement use was stable at 58% over the six month intervention period. Comparison data from control group facilities confirmed that the intervention was not effective in increasing supplement use. Despite a carefully designed implementation program the goal of increasing use of an evidence based treatment was not achieved. It is likely that this occurred due to a complex interplay of factors that meant behaviour did not change in key players (general practitioners, facility managers and staff, and family caregivers and older people). This project has shown that an evidence based treatment recommendation and a best practice implementation program is not sufficient. In this case a direct action approach through general practitioners may have been more effective.

Applying implementation science in a clinical setting: A reflective discussion

This paper provides a description of our experience in applying implementation science to service development. We describe the process of assessing the needs of a specialist care setting in the implementation of psychological interventions in dementia, specifically but not exclusively, the Newcastle Clinical Model (NCM; James, 1999) for distressed behaviours. The assessment highlighted the specialist settings present stage of implementation with a number of barriers addressed to progress implementation of the model. Furthermore, specific recommendations were suggested that would enable the maintenance of systemic changes to support the NCM in the settings routine practice. The paper reflects on the overall process ofapplying implementation science as a clinical framework with potential recommendations for services highlighted.

Successes and challenges in developing trauma-informed child welfare systems: A real-world case study of exploration and initial implementation

Trauma and behavioral health problems among children in foster care are significant and prevalent, affecting their well-being and permanency. Despite the wide scope and magnitude of social and emotional problems among youth in out-of-home care, few child welfare systems have an integrated service response into their routine procedures and practices. This paper describes three federally-funded statewide demonstration sites, which represent northeast, south, and Midwest regions of the U.S., and that aimed to implement trauma and evidence-informed initiatives. Applying implementation science frameworks, we share our experiences with three key stages of implementation: exploration, installation, and initial implementation. During the exploration stage, each state engaged community stakeholders in a comprehensive data mining process to define the needs of children in care and relevant gaps in the evidence-informed service array. To respond to trauma and behavioral health needs of children, these states' initiatives established implementation plans for screening, functional assessment, data-driven case planning, ongoing progress monitoring, and service array reconfiguration. Each state's distinct installation and initial implementation experiences are described as well their shared successes and challenges. While vast differences existed within the administrative and policy context of these three states, the study demonstrates both unique and common experiences of successes and setbacks. Across the exploration, installation, and initial implementation, these analyses revealed six themes of common successes to include collaboration, building consensus, conducting trainings, teaming, optimizing opportunity, and establishing data systems. Additionally, nine themes of common challenges were workforce, turf, client voice, data sharing, coaching and support for fidelity, time, competing priorities, momentum, and policies and leadership. Implications for practice, policy, and future research are discussed.

Harnessing Implementation Science to Increase the Impact of Health Equity Research.

Health disparities are differences in health or health care between groups based on social, economic, and/or environmental disadvantage. Disparity research often follows 3 steps: detecting (phase 1), understanding (phase 2), and reducing (phase 3), disparities. Although disparities have narrowed over time, many remain. We argue that implementation science could enhance disparities research by broadening the scope of phase 2 studies and offering rigorous methods to test disparity-reducing implementation strategies in phase 3 studies. We briefly review the focus of phase 2 and phase 3 disparities research. We then provide a decision tree and case examples to illustrate how implementation science frameworks and research designs could further enhance disparity research. Most health disparities research emphasizes patient and provider factors as predominant mechanisms underlying disparities. Applying implementation science frameworks like the Consolidated Framework for Implementation Research could help disparities research widen its scope in phase 2 studies and, in turn, develop broader disparities-reducing implementation strategies in phase 3 studies. Many phase 3 studies of disparity-reducing implementation strategies are similar to case studies, whose designs are not able to fully test causality. Implementation science research designs offer rigorous methods that could accelerate the pace at which equity is achieved in real-world practice. Disparities can be considered a "special case" of implementation challenges-when evidence-based clinical interventions are delivered to, and received by, vulnerable populations at lower rates. Bringing together health disparities research and implementation science could advance equity more than either could achieve on their own.

The current state of implementation science in genomic medicine: opportunities for improvement.

The objective of this study was to identify trends and gaps in the field of implementation science in genomic medicine. We conducted a literature review using the Centers for Disease Control and Prevention's Public Health Genomics Knowledge Base to examine the current literature in the field of implementation science in genomic medicine. We selected original research articles based on specific inclusion criteria and then abstracted information about study design, genomic medicine, and implementation outcomes. Data were aggregated, and trends and gaps in the literature were discussed. Our final review encompassed 283 articles published in 2014, the majority of which described uptake (35.7%, n = 101) and preferences (36.4%, n = 103) regarding genomic technologies, particularly oncology (35%, n = 99). Key study design elements, such as racial/ethnic composition of study populations, were underreported in studies. Few studies incorporated implementation science theoretical frameworks, sustainability measures, or capacity building. Although genomic discovery provides the potential for population health benefit, the current knowledge base around implementation to turn this promise into a reality is severely limited. Current gaps in the literature demonstrate a need to apply implementation science principles to genomic medicine in order to deliver on the promise of precision medicine.Genet Med advance online publication 12 January 2017.