Implementation Climate Research Articles

Team Time as a wellbeing intervention for NHS staff: a qualitative evaluation of implementation during the COVID-19 pandemic

BackgroundSupport for NHS staff was vital during the COVID-19 pandemic and Team Time was developed as an adaptation of Schwartz Rounds™ – a well-evidenced, facilitated group intervention. Building on the existing evidence base for Schwartz Rounds implementation, this study aims to understand the key factors associated with Team Time implementation and sustainability in this context.MethodsTwenty semi-structured interviews were conducted within 10 NHS acute, community and mental health organisations that ran Team Time during the pandemic: six with no prior experience of Schwartz Rounds and four that ran Schwartz Rounds prior to the pandemic. Additionally, three Team Time mentors who provided support to these organisations were also interviewed. Data analysis was underpinned by the Consolidated Framework for Implementation Research (CFIR). Data were analysed thematically, and key implementation factors were mapped onto CFIR constructs using the Framework method to explore patterns.ResultsImplementation of Team Time was challenging in organisations that did not run Schwartz Rounds previously. Facilitating factors included having incentives in the outer setting (wider context of the organisation), the adaptability of the intervention, and wide ownership across the organisation. However, barriers to implementation were the perception that the intervention was complex and resource intensive and an unsupportive organisational culture and communication difficulties which hindered engagement. In those organisations which already ran Schwartz Rounds the burden of setting up the organisational infrastructure for Team Time was smaller and the implementation climate more supportive.ConclusionsSimilar to Schwartz Rounds, Team Time needed broad and sustained organisational support for implementation to become embedded in organisations and deliver benefits. Implementing it as an entirely new and stand-alone online intervention during the pandemic was challenging. Team Time should therefore be considered as an addition to Schwartz Rounds and as part of a long-term organisational investment in staff psychological wellbeing, not as a short-term intervention in a period of crisis.

Climate actions on the neighbourhood level—Individual, collective, cultural, and socio-structural factors

This paper takes a multi-perspective approach to understand drivers and barriers of climate action on the neighbourhood level. We start with the assumption that climate actions on the level of citizens are most motivating and promising, when conducted jointly within established social systems like neighbourhoods. A survey implemented in neighbourhoods (3 in Austria, 2 in Norway, 2 in Italy, 2 in Finland). The neighbourhoods were partly in rural communities (4) and partly in urban or semi-urban areas (5). In total, 1.084 answers were retained between summer 2022 and summer 2023. The impact of factors from the different perspectives on the self-reported number of implemented climate actions were tested in a stepwise structural-equation-modelling-approach. The analyses show that intentions to act both on the individual and collective level impact climate actions as represented by behaviour in four domains (travel, diet, protest, and general climate action) implemented by citizens in the neighbourhoods, but individual intentions are more important. In addition, local cultural aspects have an impact on climate action, as indicated by the two extremely rural Finnish neighbourhoods being different on many variables. On the socio-structural level, males and households with younger children report less climate action, whereas larger households in general and people with university degree report more. Intentions to act individually are mostly determined by perceived individual efficacy and attitudes, but also selected cultural and socio-structural factors. Collective intentions to act depend on the social capital in the neighbourhood, collective efficacy, and social norms, as well as selected socio-structural and cultural factors. Concluding, this paper emphasises that in order to understand and stimulate climate-related action of citizens, the individual, collective, cultural and socio-structural factors must be taken into account and that the level of neighbourhoods, where everyday action takes place, is a relevant unit of analysis to do so.

Harmonizing data across the accelerating colorectal cancer screening and follow-up through implementation science (ACCSIS) program to enhance data quality and promote data sharing

BackgroundThe purpose of the Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) Program, a Cancer Moonshot℠ Initiative, is to support research to build the evidence base on multilevel interventions that increase rates of colorectal cancer screening, follow-up, and referral to care to address disparities in colorectal cancer screening. The National Cancer Institute funded eight Research Projects to implement multilevel interventions to improve colorectal cancer screening among communities who traditionally have been medically underserved. To analyze the impact of ACCSIS across Research Projects, the consortium developed a set of common data elements. The purpose of this paper is to describe the process of developing the common data elements to facilitate analysis of ACCSIS data as well as support and inform implementation science research studies.MethodsThe ACCSIS Data, Design, and Analysis Work Group was tasked with designing common data elements through a review of existing data collection instruments, examination of data elements proposed by the ACCSIS Research Projects, and deliberations on the data required to compare across the Research Projects. ACCSIS Consortium members drafted, revised, and finalized a common data elements document consisting of variables to collect and surveys to administer to evaluate ACCSIS implementation activities and outcomes in a standardized manner across the Research Projects.ResultsThe ACCSIS Consortium decided to collect the following categories of common data elements: characteristics across multiple levels of the multicomponent interventions, implementation climate, and determinants; interventions and strategies; implementation outcome constructs and definitions; colorectal cancer screening episodes (screening, diagnostic testing follow-up, cancer detection, and cancer treatment); and cost measures. To assess implementation climate, the consortium prioritized constructs from five domains of the Consolidated Framework for Implementation Research.ConclusionsThe ACCSIS common data elements offer a set of harmonization data for future implementation efforts. The consortium is conducting a systematic assessment using both quantitative and qualitative approaches to assess data quality and approaches to improve and sustain data collection. Lessons learned from these ongoing activities will offer additional insights to tailor the ACCSIS common data elements and support efforts to increase colorectal cancer screening for populations experiencing disparities.

Operational and organizational variation in determinants of policy implementation success: the case of policies that earmark taxes for behavioral health services

BackgroundResearch on determinants of health policy implementation is limited, and conceptualizations of evidence and implementation success are evolving in the field. This study aimed to identify determinants of perceived policy implementation success and assess whether these determinants vary according to: (1) how policy implementation success is operationally defined [i.e., broadly vs. narrowly related to evidence-based practice (EBP) reach] and (2) the role of a person’s organization in policy implementation. The study focuses on policies that earmark taxes for behavioral health services.MethodsWeb-based surveys of professionals involved with earmarked tax policy implementation were conducted between 2022 and 2023 (N = 272). The primary dependent variable was a 9-item score that broadly assessed perceptions of the tax policy positively impacting multiple dimensions of outcomes. The secondary dependent variable was a single item that narrowly assessed perceptions of the tax policy increasing EBP reach. Independent variables were scores mapped to determinants in the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Multiple linear regression estimated associations between measures of determinants and policy implementation success.ResultsPerceptions of tax attributes (innovation determinant), tax EBP implementation climate (inner-context determinant), and inter-agency collaboration in tax policy implementation (outer-context and bridging factor determinant) were significantly associated with perceptions of policy implementation success. However, the magnitude of associations varied according to how success was operationalized and by respondent organization type. For example, the magnitude of the association between tax attributes and implementation success was 42% smaller among respondents at direct service organizations than non-direct service organizations when implementation success was operationalized broadly in terms of generating positive impacts (β = 0.37 vs. β = 0.64), and 61% smaller when success was operationalized narrowly in terms of EBP reach (β = 0.23 vs. β = 0.59). Conversely, when success was operationalized narrowly as EBP reach, the magnitude of the association between EBP implementation climate and implementation success was large and significant among respondents at direct service organizations while it was not significant among respondents from non-direct service organizations (β = 0.48 vs. β=-0.06).ConclusionDeterminants of perceived policy implementation success may vary according to how policy implementation success is defined and the role of a person’s organization in policy implementation. This has implications for implementation science and selecting policy implementation strategies.

Cluster randomized trial of a team communication training implementation strategy for depression screening in a pediatric healthcare system: a study protocol

BackgroundPediatric depression is a global concern that has fueled efforts for enhanced detection and treatment engagement. As one example, the US Preventive Services Task Force recommends depression screening for adolescents ages 12–18 years. While many health systems have implemented components of depression screening protocols, there is limited evidence of effective follow-up for pediatric depression. A key barrier is timely team communication and coordination across clinicians and staff within and across service areas for prompt service linkage. However, team effectiveness interventions have been shown to improve team processes and outcomes and can be applied in healthcare settings.MethodsThis project aims to refine and test a team communication training implementation strategy to improve implementation of an existing pediatric depression screening protocol in a large pediatric healthcare system. The team will be defined as part of the study but is expected to include medical assistants, nurses, physicians, and behavioral health clinicians within and across departments. The implementation strategy will target team mechanisms at the team-level (i.e., intra-organizational alignment and implementation climate) and team member-level (i.e., communication, coordination, psychological safety, and shared cognition). First, the project will use mixed methods to refine the team training strategy to fit the organizational context and workflows. Next, a hybrid type 3 implementation-effectiveness pilot trial will assess the initial effectiveness of the team communication training (implementation strategy) paired with the current universal depression screening protocol (clinical intervention) on implementation outcomes (i.e., feasibility, acceptability, appropriateness, workflow efficiency) and clinical/services outcomes (increased frequency of needed screening and reduced time to service linkage). Finally, the study will assess mechanisms at the team and team member levels that may affect implementation outcomes.DiscussionTeam communication training is hypothesized to lead to improved, efficient, and effective decision-making to increase the compliance with depression screening and timely service linkage. Findings are expected to yield better understanding and examples of how to optimize team communication to improve efficiency and effectiveness in the pediatric depression screening-to-treatment cascade. This should also culminate in improved implementation outcomes including patient engagement critical to address the youth mental health crisis.Trial registrationNCT06527196.Trial Sponsor: University of California San Diego.

Unit Leadership and Climates for Evidence-Based Practice Implementation in Maternal-Infant Health Units: A Cross-Sectional Descriptive Study.

To describe unit leadership and climates for evidence-based practice implementation and test for differences in unit leader and staff nurses' perceptions within maternal-infant units. A cross-sectional descriptive study. A convenience sample of maternal-infant unit leaders and nurses (labour, postpartum, neonatal intensive care, paediatrics) from four Midwestern United States hospitals completed a survey including the Implementation Leadership Scale (ILS) and Implementation Climate Scale (ICS). Descriptive statistics described items, subscales and total scores. Independent t-tests with Bonferroni correction tested for differences in perceptions. A total of 470 nurses and 21 unit leaders responded, representing 17 units. Ratings of unit leadership and climates for implementation were modest at best [ICS: M = 2.17 (nurses), 2.41 (leaders); ILS: M = 2.4 (nurses), 2.98 (leaders)]. Unit leader ratings were statistically significant and higher than nurse ratings. This study is one of the first to describe unit leadership and climates for implementation in maternal-infant health. To improve outcomes and equity in maternal-infant health, attention on leadership behaviours and unit climates for evidence-based practice implementation is needed. Nurse leaders are encouraged to evaluate their leadership behaviours and the unit climates they facilitate, and work to improve areas of concern or where staff perceptions differ. Staff nurses should work with their leaders to identify resources and rewards/recognition which support and facilitate EBP implementation. This study addressed a gap in research examining the social dynamic factors of unit leadership and climate for evidence-based practice implementation in maternal-infant units. Leadership behaviours for implementation and unit climate were rated moderately by both staff and leaders. Unit leaders rated their implementation leadership and climates higher in almost all items. This study is relevant to unit leaders and nurses in maternal-infant units in the United States. This study adhered to STROBE guidelines. No patient or public contribution.

Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the written exposure therapy training program in the Veterans Health Administration.

The Veterans Health Administration (VHA) has rolled out evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD); however, reach has remained low, and there is a need for briefer interventions. The National Center for PTSD conducted a facilitated learning collaborative to train clinicians and support VHA PTSD teams in their adoption of an emerging best practice, written exposure therapy (WET). Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework, the present study utilized longitudinal data from 178 clinicians and 556 patients across seven training cohorts to evaluate key clinical and implementation outcomes and whether clinic (i.e., implementation climate) or clinician factors (i.e., treatment attitudes) were associated with effectiveness and implementation. Intent-to-treat analyses indicated WET was effective in reducing PTSD (d = 0.54) and depression symptoms (d = 0.39). Data indicated that 87.60% of clinicians reported using WET 6 months postconsultation. Clinic-wide reach was modest after training (14.53% of individuals with PTSD); however, WET-trained clinicians continued to offer WET to an average of 87.38% of their patients. Fidelity remained high after training, with essential session elements most often being offered "always" (M = 6.65 on a scale from 1 to 7). More positive postconsultation clinician treatment attitudes predicted higher posttraining rates of having patients engaged in WET. Clinician treatment attitudes and implementation climate did not predict any other implementation or effectiveness outcomes examined. Results suggest that WET implementation is advancing in VHA, with good clinical outcomes. Data provide evidence that a facilitated learning collaborative can be used to support and scale EBPs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

“We just need to create as many avenues for access as we possibly can”: Clinician and administrator attitudes toward telehealth medication abortion in the U.S. South

ObjectivesThere is currently a gap in literature on the perspectives of sexual and reproductive health clinicians and administrators in the South toward telehealth abortion services. This research seeks to explore these perspectives to understand clinician and administrator attitudes toward importance and priority of telehealth abortion to contribute to the development of a richer understanding of telehealth abortion in the South. Study DesignThis study conducts a secondary analysis of data from the Provider Readiness for Virtual Implementation and Delivery of Medication Abortion Services (PROVIDA) study. We collected qualitative data regarding perspectives of 13 clinicians and 7 administrators toward importance and priority of telehealth abortion during a series of in-depth interviews that took place from June 2021-2022 and analyzed data using MAXQDA. ResultsWe identified four main themes: telehealth abortion is important for patient benefit in mitigating physical, administrative, financial, and privacy-related barriers; telehealth abortion is important for clinic benefit in improving clinic flow and sustainability; the political climate affects personal prioritization of telehealth abortion; and staff hesitance affects clinic prioritization of telehealth abortion. ConclusionsOur analysis revealed telehealth abortion to be particularly important in mitigating physical access barriers for patients and for clinic sustainability. We found the political climate to be the most notable factor influencing personal prioritization of telehealth abortion, with most participants noting it made telehealth abortion less of a priority. Additionally, our analysis found participant perception of staff hesitation to implement telehealth abortion to be the most notable factor affecting clinic prioritization. Future research should utilize these findings to inform studies examining the implementation climate of telehealth abortion in the South.

Normalising the Implementation of Pharmacogenomic (PGx) Testing in Adult Mental Health Settings: A Theory-Based Systematic Review.

Pharmacogenomic (PGx) testing can help personalise psychiatric prescribing and improve on the currently adopted trial-and-error prescribing approach. However, widespread implementation is yet to occur. Understanding factors influencing implementation is pertinent to the psychiatric PGx field. Normalisation Process Theory (NPT) seeks to understand the work involved during intervention implementation and is used by this review (PROSPERO: CRD42023399926) to explore factors influencing PGx implementation in psychiatry. Four databases were systematically searched for relevant records and assessed for eligibility following PRISMA guidance. The QuADS tool was applied during quality assessment of included records. Using an abductive approach to codebook thematic analysis, barrier and facilitator themes were developed using NPT as a theoretical framework. Twenty-nine records were included in the data synthesis. Key barrier themes included a PGx knowledge gap, a lack of consensus in policy and guidance, and uncertainty towards the use of PGx. Facilitator themes included an interest in PGx use as a new and improved approach to prescribing, a desire for a multidisciplinary approach to PGx implementation, and the importance of fostering a climate for PGx implementation. Using NPT, this novel review systematically summarises the literature in the psychiatric PGx implementation field. The findings highlight a need to develop national policies on using PGx, and an education and training workforce plan for mental health professionals. By understanding factors influencing implementation, the findings help to address the psychiatric PGx implementation gap. This helps move clinical practice closer towards a personalised psychotropic prescribing approach and associated improvements in patient outcomes. Future policy and research should focus on the appraisal of PGx implementation in psychiatry and the role of pharmacists in PGx service design, implementation, and delivery.

Applying CFIR to assess multi-level barriers to PrEP delivery in rural South Africa: Processes, gaps and opportunities for service delivery of current and future PrEP modalities

Despite established efficacy for oral pre-exposure prophylaxis (PrEP) in reducing HIV incidence, multi-level barriers within the health system, clinics, and the processes that shape practice have hindered service delivery and subsequent population-level effects. We applied the Consolidated Framework for Implementation Research (CFIR) to assess the context of PrEP delivery for adolescent girls and young women (AGYW) in rural South Africa and identify the factors supporting and impeding PrEP implementation to develop strategies to improve PrEP delivery. Between 2021 and 2022, we conducted in-depth interviews with five young women with PrEP use experience and 11 healthcare providers as well as four key informant stakeholder interviews. Tailored interviews organized around the CFIR domains provided multiple perspectives on the inter-connected processes, gaps, and opportunities between health systems, clinics, communities, and PrEP services. Shifts in PrEP policies, funding pressures, and inconsistent communications from the National Department of Health spurred fragmented planning, engagement, execution, and monitoring of PrEP delivery processes within clinics already struggling to address multiple population health needs. Resulting challenges included: conflicting priorities within clinics and across NGO partners, unclear goals and targets, staffing and space constraints, and insufficient community engagement. Individual clinics’ implementation climate and readiness to deliver PrEP varied in terms of operational plans and delivery models. Interviewees reported complexity of initiation procedures and support for PrEP maintenance, with opportunities to improve systems communications and processes to facilitate integrated services and more user-friendly experiences. Applying CFIR identified opportunities to strengthen PrEP delivery across levels within this complex service delivery setting.

Testing an Organizational Implementation Process Model Related to Teachers' Implementation-Related Attitudes and Behaviors: a Multilevel Mediation Analysis.

The effectiveness of school-based universal prevention programs is frequently diminished due to low-quality implementation. Organizational factors support high-quality implementation because of their broad influence across implementers. Conceptually, implementation leadership (i.e., behaviors that prioritize, reward, and support evidence-based practice [EBP] implementation) works to embed a favorable implementation climate (i.e., implementers' collective perceptions that their organization prioritizes, rewards, and support EBP implementation) leading to improved implementation citizenship behavior and attitudes toward EBP. This organizational implementation process model has some empirical support but has not been tested in a multilevel framework or related to hypothesized attitudinal and behavioral outcomes. The sample included 319 teachers across 39 US public elementary schools; all were implementing Schoolwide Positive Behavior Interventions and Supports. Multilevel mediation (level 1 = teacher, level 2 = school) was used to test the indirect association of implementation leadership on implementation-related attitudes and behaviors via implementation climate across two time points (fall and spring). At the school level, the organizational implementation process model was validated related to implementation citizenship behavior, but not attitudes toward EBP. At the teacher level, the process model was validated related to both outcomes, and there was a significant direct effect of implementation leadership on attitudes toward EBP. Developing strong leaders for implementation seems key to achieving high-quality EBP implementation. Implications for schools, principal training, and research are discussed.

Implementation of delirium screening in the emergency department: A qualitative study with early adopters.

Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one-third of cases. Evidence-based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation. We conducted semi-structured interviews with clinician-administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives. Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff. Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion.

Relationship between the inner setting of CFIR and the delivery of the Healthy School Recognized Campus initiative: a mixed-methods analysis

IntroductionHealthy School Recognized Campus (HSRC) is a Texas A&M AgriLife Extension initiative that promotes the delivery of multiple evidence-based physical activity and nutrition programs in schools. Simultaneous delivery of programs as part of HSRC can result in critical implementation challenges. The study examines how the inner setting constructs from the Consolidated Framework for Implementation Research (CFIR) impact HSRC program delivery.MethodsWe surveyed (n = 26) and interviewed (n = 20) HSRC implementers (n = 28) to identify CFIR inner setting constructs related to program acceptability, appropriateness, and feasibility. Using a concurrent mixed-methods design, we coded interviews using the CFIR codebook, administered an inner setting survey, tested for relationships between constructs and implementation outcomes via chi-square tests, and compared quantitative and qualitative results.ResultsStakeholders at schools that implemented one program vs. more than one program reported no differences in acceptability, appropriateness, or feasibility outcomes (p > .05); however, there was a substantial difference in reported program minutes (1118.4 ± 951.5 vs. 2674.5 ± 1940.8; p = .036). Available resources and leadership engagement were related to HSRC acceptability (r = .41; p = .038 and r = .48; p = .012, respectively) and appropriateness (r = .39; p = .046 and r = 0.63; p = .001, respectively). Qualitative analyses revealed that tangible resources (e.g., curriculum, a garden) enabled implementation, whereas intangible resources (e.g., lack of time) hindered implementation. Participants also stressed the value of buy-in from many different stakeholders. Quantitative results revealed that implementation climate was related to HSRC acceptability (r = .46; p = .018), appropriateness (r = .50; p = .009), and feasibility (r = .55; p = .004). Learning climate was related to HSRC appropriateness (r = .50; p = .009). However, qualitative assessment of implementation climate subconstructs showed mixed perspectives about their relationship with implementation, possibly due to differences in the compatibility/priority of different programs following COVID-19. Networks/communication analysis showed that schools have inner and outer circles of communication that can either benefit or hinder implementation.ConclusionFew differences were found by the number of programs delivered. Implementation climate (i.e., compatibility, priority) and readiness for implementation (i.e., resources and leadership engagement) were important to HSRC implementation. Strategies that focus on reducing time-related burdens and engaging stakeholders may support HSRC’s delivery. Other constructs (e.g., communication, access to knowledge) may be important to the implementation of HSRC but need further exploration.

(Mis)Adapting Domestic Law to Meet New International Environmental and Trade Rules: How Peru Changed Its Environmental and Land Use Rights Laws in Response to the European Union Deforestation Regulation

Abstract International and domestic laws are being enacted or adjusted to implement climate goals, such as to fight deforestation—a key source of carbon emissions in tropical countries like Peru. These laws are increasingly connecting trade and the environment and becoming more intertwined at the national and international levels. This analysis reviews Peru’s recent change of its domestic environmental and land tenure laws partially in response to the European Union Deforestation Regulation (EUDR) as one recent example of the complexities involved in this interaction. Promoters of this legislative change in Peru frame it as a necessary alignment with the EUDR, but environmentalists argue that it is an excuse to weaken domestic forest protection rules, contrary to the intentions of the EUDR. This case study shows the importance of understanding the specific context of each of the countries targeted by new international zero-deforestation rules and highlights the tensions these new policies can encourage.

Using machine learning to map research on implemented city-level climate action on health and wellbeing

Using machine learning to map research on implemented city-level climate action on health and wellbeing

The potential of individuals to reduce greenhouse gas emissions through their own actions: a case of a suburb in Finland

Household consumption accounts for 65–72% of total greenhouse gas emissions globally, and therefore, a change in current consumption patterns has the potential to mitigate climate change and provide emission reductions. There is knowledge on the consumption options with a high mitigation potential, but this information has not been combined with a consumer behavior information. This study examines the emission-reduction potential of suburban residents in Finland through a survey that assesses their willingness to adopt climate actions, and by calculating the potential impact of various actions. Finnish suburban households have already implemented low-impact climate actions (recycling, reducing food waste), but the implementation of high-impact actions in households could also be increased. Transitioning to a vegetarian diet, reducing air travel and limiting consumption are identified as the most effective mitigation actions when the potential increase in the implementation rate and impact on greenhouse gas emissions are considered. However, the results suggest that voluntary individual efforts alone are not sufficient to achieve the 1.5 °C carbon budget. Thus, alongside behavioural changes, strong policy measures and technological advancements are necessary. These findings emphasise the specific individual actions that should be prioritised when formulating climate policies at the national or city levels.

Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a parallel cluster-randomized type 3 hybrid trial.

Substance use disorders (SUDs) have a serious adverse impact on the physical and mental well-being of people with HIV. Previously, using a 39-site dual-randomized type 2 hybrid trial design, findings from the Substance Abuse Treatment to HIV Care Project supported the Implementation and Sustainment Facilitation (ISF) strategy to improve implementation and effectiveness of a motivational interviewing brief intervention (MIBI) for SUD within HIV service settings across the United States (US). Building on this trial, this parallel cluster-randomized type 3 hybrid trial aimed to test the incremental effectiveness of a pay-for-performance (P4P), a form of the "alter incentive/allowance structures" strategy. Twenty-six HIV service organizations, their staff participants (N=87), and their client participants (N=341) were cluster-randomized to one of two implementation conditions. The control condition included staff-focused training, feedback, and consultation (TFC) and team-focused implementation and sustainment (ISF). The experimental condition included TFC+ISF as well as P4P (TFC+ISF+P4P). P4P used financial incentives to reward MIBI implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined. The addition of P4P had a large and significant effect on the number of MIBIs implemented (d=1.30, p<.05) and reduction in anxiety (d=-1.54), but there was no impact on days of substance use. P4P had large effects on MIBI quality (d=1.24) and MIBI implementation effectiveness (d=1.28), but these were not significant (p<.10). P4P is a form of the "alter incentive/allowance structures" strategy. Its function is to reward the implementation of a clinical innovation. Rewarding implementation is consistent with the theory of implementation effectiveness, which suggests implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded) is a key antecedent of implementation effectiveness (i.e., the consistency and quality of implementation). We found that P4P had a significant, positive impact on MIBI implementation in HIV service settings, but client-level outcomes were mixed. Future research should examine the effectiveness of the P4P strategy to improve implementation and sustainment of other evidence-based innovations. ClinicalTrials.gov: NCT04687917. Registered 12/18/2020.

Complexities of implementing Maternal and Perinatal Death Surveillance and Response in crisis-affected contexts: a comparative case study

BackgroundMaternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts – where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts.MethodsDescriptive case studies were conducted on the implementation of MPDSR in Cox’s Bazar refugee camps in Bangladesh, refugee settlements in Uganda, South Sudan, Palestine, and Yemen. Desk reviews of case-specific MPDSR documentation and in-depth key informant interviews with 76 stakeholders supporting or directly implementing mortality surveillance interventions were conducted between December 2021 and July 2022. Interviews were recorded, transcribed, and analyzed using Dedoose software. Thematic content analysis was employed to understand the adoption, penetration, sustainability, and fidelity of MPDSR interventions and to facilitate cross-case synthesis of implementation complexities.ResultsImplementation of MPDSR interventions in the five humanitarian settings varied in scope, scale, and approach. Adoption of the interventions and fidelity to established protocols were influenced by availability of financial and human resources, the implementation climate (leadership engagement, health administration and provider buy-in, and community involvement), and complex humanitarian-health system dynamics. Blame culture was pervasive in all contexts, with health providers often facing punishment or criminalization for negligence, threats, and violence. Across contexts, successful implementation was driven by integrating MPDSR within quality improvement efforts, improving community involvement, and adapting programming fit-for-context.ConclusionsThe unique contextual considerations of humanitarian settings call for a customized approach to implementing MPDSR that best serves the immediate needs of the crisis, aligns with stakeholder priorities, and supports health workers and humanitarian responders in providing care to the most vulnerable populations.

The Role of Implementation Climate in Moderating Educator Use of Evidence-Based Practices and Outcomes for Autistic Students.

Ensuring effective use of evidence-based practice (EBP) for autism in schools is imperative due to the significantly increasing number of autistic students receiving school services each year. High-quality EBP use has proven challenging in schools. Research indicates implementation climate, or how EBP are supported, rewarded, and valued, and EBP resources are related to successful implementation. However, limited understanding of system-level contextual factors that impact EBP implementation for school-based providers makes development of appropriate implementation supports challenging. Understanding these factors is crucial for selecting and tailoring implementation strategies to support EBP scale up. In this observational study, California school-based providers (n = 1084) completed surveys related to implementation climate, leadership, autism experience and EBP implementation (use, competence, knowledge). Student outcomes included state level academic and behavioral indicators. Using an implementation science framework (Aarons et al., in Administration and Policy in Mental Health and Mental Health Services Research 38:4-23, 2011) and multilevel modeling, we examined the relationship between EBP Implementation and student outcomes and the moderation effects of provider and district level factors. Higher implementation climate predicted better EBP implementation outcomes, and proved more impactful when provider hands-on autism experience was low. Greater EBP resources predicted a higher percentage of students who met math standards only when district poverty level was high. Our findings suggested moderating effects on EBP implementation from both provider and system level factors. Implementation climate and resources may be especially key in addressing equity issues related to high poverty schools in which teachers often have less autism experience.

Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study.

(1) Background: High-intensity gait training (HIT) is a recommended intervention that improves walking function (e.g., speed and distance) in individuals who are undergoing stroke rehabilitation. This study explored clinicians' perceived barriers and facilitators to implementing HIT utilizing a mixed-methods approach comprising a survey and exploratory qualitative research. (2) Methods: Clinicians (n = 13) who were implementing HIT at three facilities participated. We collected and analyzed data using the consolidated framework for implementation research. Three focus groups were recorded and transcribed, and data were coded and thematically categorized. (3) Results: Survey results identified that the facilitators with a strong impact on implementation were access to knowledge/resources and intervention knowledge/beliefs. The only agreed-upon barrier with a strong impact was lack of tension for change. The focus groups resulted in 87 quotes that were coded into 27 constructs. Frequently cited outer setting facilitators were cosmopolitanism and peer pressure, and the only barrier was related to the patient needs. Innovation characteristics that were facilitators included relative advantage and design quality and packaging, and complexity was a barrier. Inner setting facilitators included networks and communication, learning climate, leadership engagement, and readiness for implementation. However, communication, leadership engagement, and available resources were also barriers. Regarding characteristics of individuals, knowledge and beliefs were both barriers and facilitators. In the implementation process domain, common facilitators were formally appointed implementation leaders and innovation participants. Barriers in this domain were related to the patients. (4) Conclusions: Clinicians identified many barriers and facilitators to implementing HIT that often varied between facilities. Further research is warranted to deepen our understanding of clinicians' experiences with HIT implementation.