Identify Implementation Strategies Research Articles

ECOLOGICAL MOMENTARY ASSESSMENT TO MEASURE SOCIAL CONNECTEDNESS IN OLDER ADULTS: AN INTEGRATIVE REVIEW

Abstract While the importance of social connectedness in the lives of older adults is well-established, more comprehensive evidence is needed regarding its real-world operation. This study utilizes Ecological Momentary Assessment (EMA), increasingly employed in social and health sciences, to capture real-time social interactions in everyday environments, aiming to conduct an integrative review to understand multifactorial components of social connectedness and identify implementation strategies for older adults. Five databases (PubMed, Embase, Web of Science, CINAHL, and PsycINFO) were searched to retrieve studies published up to the year 2023. Of the 2,208 studies identified, 21 were selected for final analysis. Our analysis focused on identifying the multifactorial components of social connectedness (structural, functional, and quality) and assessment of EMA methods and participant adherence to the EMA. The components of social connectedness using EMA included the following: structural components such as social contacts or interactions (n=18), loneliness (n=9) as a functional component, and quality components, such as quality of social interactions (n=3). Additionally, as a context for understanding social connectedness, location at the time of assessment, and physical (e.g., pain, fatigue) and psychological states (e.g., anxiety, depression) were evaluated. Data were mostly collected using an app on digital devices (e.g., smartphone), with assessments conducted 5-6 times per day for 5 to 21 days, achieving an adherence rate of over 70%. Findings of this review highlight the current state of science in measuring social connectedness in older adults through EMA, focusing on its structural, functional, and quality components, and indicating its feasibility in real-world contexts.

Implementation of nasal high flow therapy for infants with bronchiolitis: An integrative review

Objective: Identify factors relevant to the implementation of nasal high flow for infants with bronchiolitis in rural and remote contexts. Background: Healthcare services in rural and remote Australia must be resilient in responding to paediatric respiratory illness and provide equitable access of care to the tertiary contexts. Retrievals cannot be the only option to provide equitable care, particularly in examples of cyclones reducing aeromedical retrieval services. Nasal high flow (NHF) therapy is available for use in tertiary contexts for treating infants with respiratory illness. However, its use in rural and remote services is inconsistent and implementations to support routine implementation into this context are unknown. Study Design and methods: An integrative review was completed using an adapted implementation science framework. The COM-B (Capability, Opportunity, Motivation - Behaviour) framework was used to structure and analyse the results in alignment with translatable clinical care setting implementations. Seven databases were searched using specified search terms such as nasal high flow therapy, bronchiolitis, and implementation. Results: The original search terms ‘rural’ and/or ‘remote’ yielded zero results and were therefore removed from the search criteria. Sixteen publications were included in the final analysis that yielded 73 implementation factors. Eight related to capability, 61 were opportunity factors and four were motivation factors. Many of the factors were relating to the local context level, such as using observation regimes. One study (two publications) explicitly reported using an implementation framework where context was considered as an important component in identifying implementation strategies. Discussion: Implementation strategies included staff training (capability). The opportunity for staff to use NHF was the most common factor with using guidelines. The least represented motivation strategies focused on the clinician’s confidence to use NHF therapy. Conclusion: The lack of reported NHF studies in rural and remote hospitals highlights a knowledge gap. Implementation science is recommended for use in contexts such as the rural/remote setting where the context is unique and requires targeted implementation strategies. Implications for research, policy, and practice: Research exploring the use of NHF therapy should consider the unique rural and remote context using appropriate implementation strategies. Implementation science has shown that factors such as local champions, guidelines, use of observational data, and having locally tailored training and supportive approaches does improve the implementation of NHF therapy. The authors recommend these strategies be applied in rural and remote contexts to inform future research, policies, procedures, and practices that will promote and support clinicians’ confidence and ability to implement NHF therapy. What is already known on the subject NHF therapy is used for infants with bronchiolitis within the tertiary environment. NHF is used outside of paediatric intensive care units. Implementation science frameworks hasten evidence-based clinical practice routine uptake. What this paper adds Identifies a gap in the literature reporting implementation factors relevant for NHF therapy. Identifies no published literature reporting NHF use in rural and remote contexts. Describes, using an implementation framework, relevant factors for the use of NHF therapy in rural and remote hospitals.

Specialty Tobacco Treatment Implementation in Oncology: A Qualitative Study.

In 2017, the National Cancer Institute (NCI) funded the Cancer Center Cessation Initiative (C3I) to implement and expand tobacco treatment programs in routine oncology care. Many C3I programs developed specialty care programs staffed by tobacco treatment specialists (TTSs) to deliver evidence-based treatment to adult patients who smoke. People involved in specialty tobacco treatment programs can help to identify implementation strategies and adaptations that may enhance tobacco treatment reach and effectiveness in cancer care and help more patients with cancer quit using tobacco. We conducted semistructured interviews with TTSs from 21 C3I-funded cancer centers and applied content analysis to interview transcripts from 37 TTSs and 17 respondents in other program roles. We used the Consolidated Framework for Implementation Research to code interview data. We identified final themes and implementation strategies and adaptations recommended by respondents on the basis of these codes. Respondents shared that implementation of specialty tobacco treatment programs in cancer care settings could be facilitated by training staff to provide patient connection to services, incorporating prescription of no- or low-cost cessation medications, hiring additional staff to deliver tobacco treatment, allocating space to the program, and automating electronic health record workflows. TTSs and others involved in specialty tobacco treatment in NCI-designated cancer centers identified ways to improve tobacco treatment access, use, and effectiveness by (1) adapting specialty tobacco treatment delivery to meet patient needs; (2) facilitating referrals and pharmacotherapy coordination; and (3) committing staffing, space, and support resources to tobacco treatment programs. Key program participants suggested that these approaches would help more oncology patients connect with evidence-based tobacco treatment and quit smoking.

Multiple Stakeholder Perspectives of Implementing Work-Related Cognitive Behavioral Therapy (WCBT) in Vocational Service Settings: A Qualitative Exploration of Intervention Acceptability and Sustainability.

Growing mental health treatment access disparities elevate the urgency for identifying and implementing innovative approaches for delivering evidence-supported interventions. Work-related cognitive behavioral therapy (WCBT), a technology-assisted CBT (t-CBT) designed to address social anxiety and employment outcomes among job seekers at vocational service centers and for delivery by vocational service professionals, offers a promising way to increase access to needed mental health care. This qualitative study, guided by the Organizational Transformation Model (OTM), explored factors related to WCBT's implementation at two Jewish Vocational Services (JVS) Human Service sites in Detroit, MI and Los Angeles County, CA. Twenty-seven staff-stakeholders across the two JVS sites completed in-depth, semi-structured interviews focused on their experiences with WCBT over the four-year study period. Thematic analysis identified five core codes that most broadly captured participants' perceptions of WCBT implementation and the factors influencing implementation, including: (1) Need, (2) Buy-in and engagement, (3) Communication, (4) Sustainability concerns, and (5) Implementation facilitators. Core codes aligned with OTM factors related to impetus to transform, improvement initiatives, integration across boundaries, alignment from top to bottom, and leadership. Findings identify implementation strategies likely to optimize uptake and sustainability of WCBT within JVS sites that can be tested in a larger, multi-site implementation trial.

Implementation of collaborative care for depression in VA HIV clinics: Translating Initiatives for Depression into Effective Solutions (HITIDES): protocol for a cluster-randomized type 3 hybrid effectiveness-implementation trial

BackgroundDepression is the most diagnosed mental health condition among people living with HIV. Collaborative care is an effective intervention for depression, typically delivered in primary care settings. The HIV Translating Initiatives for Depression into Effective Solutions (HITIDES) clinical intervention involves a depression care team housed off-site that supports depression care delivery by HIV care providers. In a randomized controlled trial, HITIDES significantly improved depression symptoms for veterans living with HIV and delivered cost savings. However, no HIV clinics in the Veterans Health Administration (VHA) have implemented HITIDES; as such, it is unclear what implementation strategies are necessary to launch and sustain this intervention.MethodsThis hybrid type-3 effectiveness-implementation trial examines the implementation and effectiveness of HITIDES in 8 VHA HIV clinics randomly assigned to one of two implementation arms. Each arm uses a different implementation strategy package. Arm 1 includes an intervention operations guide; an on-site clinical champion who, with the help of a peer community of practice, will work with local clinicians and leadership to implement HITIDES at their site; and patient engagement in implementation tools. Arm 2 includes all strategies from Arm 1 with assistance from an external facilitator. The primary implementation outcomes is reach; secondary outcomes include adoption, implementation dose, depressive symptoms, and suicidal ideation. We will conduct a budget impact analysis of the implementation strategy packages. We hypothesize that Arm 2 will be associated with greater reach and adoption and that Arm 1 will be less costly.DiscussionPreliminary work identified implementation strategies acceptable to veterans living with HIV and HIV care providers; however, the effectiveness and cost of these strategies are unknown. While the depression care team can deliver services consistently with high quality, the ability of the depression care team to engage with HIV care providers at sites is unknown. Findings from this study will be used to inform selection of implementation strategies for a broad rollout to enhance depression and suicide care for people living with HIV.Trial registrationClinicalTrials.gov ID: NCT05901272, Registered 10 May 2023, https://clinicaltrials.gov/study/NCT05901272

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

BackgroundMississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.PurposeThe study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.MethodsSemi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.ResultsData suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.ConclusionsThough patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

Implementation Strategies for Quality Improvement in Palliative Care: A Scoping Review.

Quality improvement (QI) programs based on person-centred outcome measures (PCOMs) play an important role in promoting optimal palliative care. However, routine use of PCOMs has been slow and difficult to implement, including within QI programs. This study aimed to identify implementation strategies that support the implementation of PCOMs as routine practice in hospital-based palliative care, as well as the implementation theories, models and frameworks (TMFs) guiding the design of these implementation strategies. A scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) Scoping Review framework. Four databases (Medline, CINAHL, Scopus and PubMed) were systematically searched for literature published between 1 January 1990 and 8 March 2024. One hundred and fifteen unique implementation strategies, identified from 11 included studies, were mapped onto the 73 Expert Recommendations for Implementing Change (ERIC) discrete implementation strategies, covering 52% of the ERIC strategies. The most commonly used categories were train and educate stakeholders, and support clinicians, followed by develop stakeholder interrelationships and use evaluation and iterative strategies. Three key themes emerged: what to do; how to do it; and who to do it with. Only four studies employed TMFs to guide the design of the implementation strategies in this review. To promote the implementation of PCOM-based QI programs, strategies should be developed based on identified/potential barriers and facilitators by using rigorous TMFs. The components of the implementation strategies must be reported transparently and consistently to enable replication and measurement in future research and practice. This scoping review does not directly involve patients or the general public in its design or execution. However, it is part of an implementation study aimed at integrating the Palliative Care Outcome Collaboration (PCOC) model into routine clinical practice at a cancer hospital in China. Before the formal implementation, palliative care professionals from this hospital highlighted the need for a comprehensive analysis of existing evidence to support the effective adoption of the PCOC model in their specific clinical setting.

Using the consolidated framework for implementation research to identify church leaders’ perspectives on contextual determinants of community-based colorectal cancer screening for Black Kentuckians

BackgroundBlack Kentuckians experience more deleterious colorectal cancer (CRC) outcomes than their White counterparts, a disparity that could be reduced by increased screening in Black communities. Previous research has shown that Black Kentuckians may not be equitably informed of different CRC screening options by health care providers, making community-based screening a potentially effective option among this disparate population. We used the Consolidated Framework for Implementation Research (CFIR) to identify church leaders’ perspectives of contextual factors that might influence community-based screening and explore the feasibility of using church-based screening outreach.MethodsSix participants were selected, based on leadership roles and interest in CRC screening, from five established Louisville-area church partners that had previously participated in community health initiatives. Data were collected, both virtually and in-person, in Summer 2021 using semi-structured interview guides developed with guidance from the CFIR Guide that focused on domains most relevant to community-based interventions. Data were transcribed verbatim, coded by two independent researchers, and member checked for accuracy.ResultsData were aligned primarily with six CFIR constructs: key stakeholders, champions, opinion leaders, tension for change, compatibility, and culture. Participants noted a strong tension for change in their community due to perceptions of inadequacy with clinical approaches to CRC screening. Additionally, they stressed the importance of identifying individuals both within the church who could champion CRC screening and help implement program activities, as well as those outside the church who could collaborate with other local organizations to increase participant reach. Finally, participants agreed that faith-based CRC screening aligned with church culture and would also likely be compatible with overall community values.ConclusionsOverall, our church partners strongly endorsed the need for, and importance of, community-based CRC screening. Given a history of successful implementation of health promotion programs within our partner churches, it is highly likely that a CRC screening intervention would also be effective. Findings from this study will be used to identify implementation strategies that might positively impact a future faith-based CRC screening intervention, as well as CFIR constructs that are most positively associated with CRC screening completion.

Overcoming Barriers: Strategies for Implementing Pharmacist-Led Pharmacogenetic Services in Swiss Clinical Practice.

There is growing evidence that pharmacogenetic analysis can improve drug therapy for individual patients. In Switzerland, pharmacists are legally authorized to initiate pharmacogenetic tests. However, pharmacogenetic tests are rarely conducted in Swiss pharmacies. Therefore, we aimed to identify implementation strategies that facilitate the integration of a pharmacist-led pharmacogenetic service into clinical practice. To achieve this, we conducted semi-structured interviews with pharmacists and physicians regarding the implementation process of a pharmacist-led pharmacogenetic service. We utilized the Consolidated Framework for Implementation Research (CFIR) to identify potential facilitators and barriers in the implementation process. Additionally, we employed Expert Recommendations for Implementing Change (ERIC) to identify strategies mentioned in the interviews and used the CFIR-ERIC matching tool to identify additional strategies. We obtained interview responses from nine pharmacists and nine physicians. From these responses, we identified 7 CFIR constructs as facilitators and 12 as barriers. Some of the most commonly mentioned barriers included unclear procedures, lack of cost coverage by health care insurance, insufficient pharmacogenetics knowledge, lack of interprofessional collaboration, communication with the patient, and inadequate e-health technologies. Additionally, we identified 23 implementation strategies mentioned by interviewees using ERIC and 45 potential strategies using the CFIR-ERIC matching tool. In summary, we found that significant barriers hinder the implementation process of this new service. We hope that by highlighting potential implementation strategies, we can advance the integration of a pharmacist-led pharmacogenetic service in Switzerland.

S70 - Identifying Implementation Strategies to Inform Implementation of a Hospital-Based Opioid Use Disorder (OUD) Treatment Intervention Across Twelve Hospitals in Colorado

S70 - Identifying Implementation Strategies to Inform Implementation of a Hospital-Based Opioid Use Disorder (OUD) Treatment Intervention Across Twelve Hospitals in Colorado

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review.

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity. To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system. This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies). This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format. Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems. Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally. DalSpace dalspace.library.dal.ca/handle/10222/80835.

Community-Identified Implementation Strategies for Promoting the Adoption of HIV Self-Testing in a Southern California American Indian community: A Rapid Qualitative Analysis

HIV incidence increased by 18% between 2015 and 2019 among American Indians (AIs) despite declining rates in other racial/ethnic groups. Culturally-appropriate implementation of prevention programs is needed to address the intersectional conditions contributing to HIV vulnerabilities experienced by AIs. The objectives of this study were to understand factors influencing HIV testing decisions and identify implementation strategies to promote the acceptability of HIV self-testing (HIVST) in a southern California AI community. A total of 15 semi-structured interviews were completed with adult community members of a southern California AI reservation. Analysis used a rapid analytic approach that was guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework and expert recommendations for implementing change (ERIC) compilation. Two team members applied a standardized summary template to elucidate implementation determinants and implementation strategies for adopting HIVST. Barriers to HIV testing identified by community members included HIV-related stigma and privacy concerns within their community. Community members expressed positive perceptions of the acceptability of HIVST, with many identifying ease of use and privacy as appealing attributes. Several implementation strategies were suggested for facilitating the adoption of HIVST, including increasing access to tests by mailing kits to community members and increasing demand for kits through media campaigns (e.g., local flyers, social media posts, and booths at tribal events). Community members also recommended discreet packaging of kits and cultural adaptation of accompanying materials (e.g., educational videos featuring community members). The qualitative input from AI community members facilitated identification of implementation strategies that may promote the acceptability and culturally-appropriateness of HIVST.

Preventing venous thromboembolism for ambulatory patients with cancer: Developing the form and content of implementation strategies

BackgroundFor ambulatory cancer patients receiving systemic chemotherapy, adherence is low to recommended venous thromboembolism (VTE) prevention interventions. Previously, we identified implementation strategies to address barriers to adherence, including (1) conducting clinician education and training; (2) developing and distributing educational materials for clinicians; (3) adapting electronic health records to provide interactive assistance; and (4) developing and distributing educational materials for patients. The objective of this study was to develop these implementation strategies’ form (i.e., how and when) and content (i.e., information conveyed) as a critical step for implementation and dissemination. MethodsTo design and develop the form and content of the implementation strategies, we conducted multidisciplinary stakeholder panels with oncology clinicians, pharmacists, and hematologists. Over several panel discussions, we developed a low fidelity prototype. Participants performed preliminary usability testing, simulating patient care encounters. We also conducted interviews with three patients who provided additional feedback. ResultsThe form and content for each strategy, respectively, included (1) concise training with a slide deck; (2) succinct summary of evidence for the interventions and support for anticoagulation management; (3) automated VTE risk-assessment and clinical decision support, including bleeding risk assessment and anticoagulation options; and (4) patient education resources. During development, audit and feedback was identified as an additional strategy, for which we created report cards to implement. ConclusionWith stakeholder input, we successfully developed the form and content needed to put the implementation strategies into practice. The next step is to study the effect on the uptake of ambulatory VTE prevention recommendations in oncology clinics.

Understanding rapid implementation from discovery to scale: Rwanda’s implementation of rotavirus vaccines and PMTCT in the quest to reduce under-5 mortality

BackgroundOver the last eight decades, many evidence-based interventions (EBIs) have been developed to reduce amenable under-5 mortality (U5M). Implementation research can help reduce the lag between discovery and delivery, including as new EBIs emerge, or as existing ones are adapted based on new research. Rwanda was the first low-income African country to implement the rotavirus vaccine (RTV) and also adopted Option B+ for effective prevention of mother-to-child transmission (PMTCT) before the World Health Organization’s (WHO) recommendation. We use implementation research to identify contextual factors and strategies associated with Rwanda’s rapid uptake of these two EBIs developed or adapted during the study period.MethodsWe conducted a mixed methods case study informed by a hybrid implementation research framework to understand how Rwanda outperformed regional and economic peers in reducing U5M, focusing on the implementation of health system-delivered EBIs. The research included review of existing literature and data, and key informant interviews to identify implementation strategies and contextual factors that influenced implementation outcomes. We extracted relevant results from the broader case study and used convergent methods to understand successes and challenges of implementation of RTV, a newly introduced EBI, and PMTCT, an adapted EBI reflecting new research.ResultsWe found several cross-cutting strategies that supported the rapid uptake and implementation of PMTCT, RTV, and leveraging facilitating contextual factors and identifying and addressing challenging ones. Key implementation strategies included community and stakeholder involvement and education, leveraging of in-country research capacity to drive adoption and adaptation, coordination of donors and implementing partners, data audit and feedback of coverage, a focus on equity, and integration into pre-existing systems, including community health workers and primary care. The availability of donor funding, culture of evidence-based decision-making, preexisting accountability systems, and rapid adoption of innovation were facilitating contextual factors.ConclusionImplementation strategies which are generalizable to other settings were key to success in rapidly achieving high acceptability and coverage of both a new and an evolving EBI. Choosing strategies which leverage their facilitating factors and address barriers are important for other countries working to accelerate uptake of new EBIs and implement needed adaptations based on emerging evidence.

Identifying Implementation Strategies for Integrating Drones into STEM and Career Technology Education CTE Programs

As drone technology is rapidly becoming accessible to school children in terms of both low cost and ease-of-use, primary and secondary school teachers are beginning to consider where modern drones can play an important role in schooling. To date, there is little empirical education research printed in the education research literature guiding innovative curriculum developers in the incipient domain of drone education. As a result, teachers interested in including emerging technologies in their classrooms are often at a loss of where to begin. Through clinical interviews with schoolteachers in the United States, our study identified five readily accessible “departure points” to include drones in contemporary STEM and vocational technology (CTE) school classrooms that help teachers address common curricular goals. Taken together, these interviews reveal that teachers using drones follow one of several distinct pathways as a first step toward achieving a widespread goal of teaching students to use modern technologies to construct, pursue, and communicate findings of fruitful research inquiries—the prevalence of which is not reflected in a comprehensive review of the literature. The five dominant pathways for starting a successful drone education emerging from the interview data were as follows: timed racing trials; precision flight obstacle courses; computer coding; videography; and domain-specific knowledge of drone operation laws and ethics.

Stakeholder Engagement to Identify Implementation Strategies to Overcome Barriers to Delivering Chronic Pain Treatments: A NIDILRR and VA TBI Model Systems Collaborative Project.

The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI). Community. Healthcare providers (n = 63) with 2 or more years' experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach. Participatory-based research design, using descriptive and intervention mapping approaches. Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change. Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice.

A use case of ChatGPT: summary of an expert panel discussion on electronic health records and implementation science.

Artificial intelligence (AI) is revolutionizing healthcare, but less is known about how it may facilitate methodological innovations in research settings. In this manuscript, we describe a novel use of AI in summarizing and reporting qualitative data generated from an expert panel discussion about the role of electronic health records (EHRs) in implementation science. 15 implementation scientists participated in an hour-long expert panel discussion addressing how EHRs can support implementation strategies, measure implementation outcomes, and influence implementation science. Notes from the discussion were synthesized by ChatGPT (a large language model-LLM) to generate a manuscript summarizing the discussion, which was later revised by participants. We also surveyed participants on their experience with the process. Panelists identified implementation strategies and outcome measures that can be readily supported by EHRs and noted that implementation science will need to evolve to assess future EHR advancements. The ChatGPT-generated summary of the panel discussion was generally regarded as an efficient means to offer a high-level overview of the discussion, although participants felt it lacked nuance and context. Extensive editing was required to contextualize the LLM-generated text and situate it in relevant literature. Our qualitative findings highlight the central role EHRs can play in supporting implementation science, which may require additional informatics and implementation expertise and a different way to think about the combined fields. Our experience using ChatGPT as a research methods innovation was mixed and underscores the need for close supervision and attentive human involvement.

Integrated care for children in rural Australia: Barriers and enablers during early implementation

Introduction: Children and young people (CYP) with medical complexity, have high levels of healthcare needs and utilisation, representing 10% of patients attending children’s hospitals, and accounting for 60% of healthcare expenditure in the state of New South Wales (NSW), Australia. Furthermore, 30% of children in NSW live outside major cities and require enhanced local health solutions to manage healthcare needs, reduce travel and family disruptions and limit out-of-pocket expenses. The Rural Kids Guided Personalised Service (RuralKidsGPS) is a co-designed innovative integrated model of care coordination for CYP living with medical complexity, modelled on the successfully implemented and sustained KidsGPS program in tertiary children’s hospitals in Sydney. RuralKidsGPS is being implemented into four rural local health districts (LHDs) across NSW. This study explores early implementation barriers and enablers to inform contextual adaption and ensure scalability across diverse health settings.
 Methods: The implementation evaluation is informed by qualitative methods using semi-structured interviews and focus groups, with children and families, healthcare providers embedded researchers, and health service managers. Adopting an inductive approach underpinned by the Consolidated Framework for Implementation Research (CFIR), we identify implementation strategies, barriers and enablers influencing adoption, delivery, and sustainability of RuralKidsGPS. In this early phase of implementation evaluation (6-12 month after commencement) we have focused on implementation outcomes based on Proctor’s framework, including acceptability, appropriateness, adaptability, fidelity, and feasibility. 
 Results: The interviews demonstrated the variations in setting and context across the LHDs and the adaption of RuralKidsGPS to meet local needs. Different levels of service demand, the time required for engagement with families from diverse socio-economic and cultural backgrounds and different levels of pre-existing service, and staff changes, contribute to the complexity of service implementation and delivery. All four LHDs share borders with jurisdictions outside of NSW, resulting in some children traveling across state or territory borders to access specialist health services. The complexities of sharing and gaining access to healthcare information across jurisdictions has impacted the timely delivery of care coordination and shared care plan development. RuralKidsGPS builds local healthcare capacity to manage CYP living with medical complexity but requires commitment and effort to build relationships with established local services and understanding of processes, and values, whilst conserving local resources. The perceived value and commitment to RuralKidsGPS by nurse care coordinators who leverage local knowledge and networks to deliver family-centred care, is a key enabler. Importantly, reciprocal support from health managers and health care professionals, and access to resources and networks is providing nurse coordinators the power to adapt and implement RuralKidsGPS. During this period, all LHDs were impacted by natural disasters (floods, bushfires) and COVID-19 creating barriers that required those implementing the RuralKidsGPS to flex and adapt.
 Conclusion: Early findings highlight the importance of adaptation to local contexts, the challenges and barriers and the resilience of the care coordinators implementing RuralKidsGPS. Care coordination enables families to navigate fragmented, complex health care systems, more efficiently and effectively. This research will inform the development of an implementation guide to support scaling and sustaining similar models of paediatric integrated care. 

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BackgroundUnwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.MethodsRealist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.ResultsThe program’s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.ConclusionsAudit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Abstract C109: Identifying implementation strategies to support cervical cancer screening programs in resource-limited countries through participatory action research

Abstract Background: Improving the adoption and integration of cervical cancer screening programs in resource-limited countries requires engaging with many local health system actors. We hypothesize that participatory design workshops co-developed by researchers, health system practitioners, and policy makers, facilitate rapid engagement to identify context-specific priorities and tailor strategies to improve implementation processes. Methods: With the Peruvian Ministry of Health (MOH), we co-designed a week-long workshop with health system actors (planners, providers, lab technicians) from the North District of Lima city. Through facilitated dialogue, participants engaged in self-reflection to map the cervical cancer screening and follow-up system, visualize system barriers, and identify potential solutions. As research partners, we analyzed findings from the workshop using the Consolidated Framework for Implementation Research, a framework from implementation science that identifies multilevel contextual factors that influence program implementation and guides the tailoring of strategies for improvement. Results: We identified three key context-specific challenges including 1) power hierarchies between specialists and midwives that obstruct the efficiency of screening services, 2) the complexities around communicating screening results, appointments, and referrals, are burdensome for patients and cause loss to follow up, and 3) implementation plans are not adequately matched to resources and workforce capacity. We identified feasible implementation strategies to address these challenges including 1) develop relationships between midwives and specialists through facilitated discussions to surface assumptions and align screening goals, 2) co-create counseling tools to help patients understand results and follow up steps for early detection and treatment of precancerous lesion that also reduce patients’ burden, and 3) Apply design workshops with key actors to develop an implementation plans to guide processes, acceptable adaptations, clinical workflows, and planning (ordering tests, supplies, training human resources, etc.) to align goals to prevention objectives and resources. Conclusions: Engaging with health systems actors through participatory action research is a strategy that enables collective learning, identifying context-specific priorities, and developing tailored implementation strategies that are likely to accelerate integration of sustainable cervical cancer screening programs globally. Citation Format: Margarita Correa-Mendez. Identifying implementation strategies to support cervical cancer screening programs in resource-limited countries through participatory action research [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C109.