Multi-level Contextual Factors Research Articles

Evaluation of a youth-focused suicide prevention HOPE aftercare service: protocol for a non-randomized hybrid effectiveness-implementation type I design

BackgroundSuicide is the fourth leading cause of death among young people aged 15–29 worldwide. Young people often present to emergency departments (EDs) with self-harm and suicide-related behaviors. The period following discharge from the ED is recognized as one of elevated risk for both repeated self-harm and suicide. During this critical time, suicide prevention aftercare services are recommended. Despite their increased popularity, evidence demonstrating the effectiveness of these models is very limited.MethodsUsing a hybrid effectiveness-implementation type I design, this evaluation will assess the effectiveness and implementation of a suicide prevention aftercare (Hospital Outreach Post-suicidal Engagement; HOPE) service designed to reduce risk of self-harm and suicide in young people aged 12–25 who are referred to the service following an ED presentation for self-harm or suicide attempt. Two complementing theoretical frameworks will guide this evaluation, specifically the design, data collection, analysis, and interpretation of results. The RE-AIM evaluation framework will be used to assess Reach, Effectiveness (including cost-effectiveness), Adoption, Implementation and Maintenance of the HOPE aftercare service. The PRISM implementation framework will be used to assess multi-level contextual factors hypothesized to affect the RE-AIM outcomes. Several data sources will be used to assess the changes in primary and secondary outcomes from baseline to post–intervention, and at follow-up, including user and provider self-report surveys, semi-structured interviews, and routinely collected hospital data. An historical control study will also be conducted using data from the Self-Harm Monitoring System for Victoria to examine the impact of the service on rates of self-harm and suicide-related presentations to ED, and compare trends prior to and following commencement of the HOPE aftercare service. In addition, dynamic systems modelling will be used to assess the future scalability of the service.DiscussionFindings from this evaluation will determine the effectiveness, including cost-effectiveness, of the HOPE aftercare service and describe the implementation context. They will inform the future development and sustainability of this and other similar services across Australia and internationally.Trial registrationThis trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the 19th December 2023 (Registration number ACTRN12623001332617). We do not foresee any amendments to this protocol however, if any unforeseen modifications are required, they will be submitted to ANZCTR.Trial sponsorOrygen, 35 Poplar Road, Parkville, VIC, 3052, Australia.

The Application and Evolution of the Practical, Robust Implementation and Sustainability Model (PRISM): History and Innovations

Implementation science theories, models, and frameworks (TMF) should help users understand complex issues in translating research into practice, guide selection of appropriate implementation strategies, and evaluate implementation outcomes. They should also be sensitive to evidence from projects that apply the framework, evolve based on those experiences, and be accessible to a range of users. This paper describes these issues as they relate to the Practical, Robust Implementation and Sustainability Model (PRISM). PRISM was created to assess key multilevel contextual factors related to the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) outcomes of health interventions. We describe key aspects of PRISM and how it has been applied, evolved, and adapted across settings, time, and content areas. Since its development in 2008 PRISM has been used in over 200 publications, with increased use in recent years. It has been used for a wide variety of purposes and more recent applications have focused on increasing its accessibility for non-researcher groups and more rapid and iterative application for use in learning heath systems. PRISM has been applied to address health equity issues including representation, representativeness, and co-creation activities in both US and non-US settings. We describe common types of adaptations made by implementation teams when applying PRISM to fit with the resources and priorities of diverse and low-resource settings. We conclude by summarizing lessons learned and providing recommendations for future research and practice using PRISM.

Digital health literacy: A concept analysis.

To elucidate the concept of digital health literacy by delineating its primary dimensions, origins and effects. Through this clarification, we seek to augment our understanding of the contemporary use of the concept of digital health literacy. Rodgers's concept analysis was employed to investigate digital health literacy as a context-influenced concept evolving with technological progress. Six databases (PubMed, Embase, CINAHL, RISS, KISS and DBpia) and Google Scholar were searched from 2006 to 2023, focusing on the terms 'digital health literacy', 'eHealth literacy' and 'mHealth literacy'. Of 2,819 papers, 32 were included in the analysis to identify the conceptual structure of digital health literacy. The conceptual structure of digital health literacy was identified, and its evolution was traced. Currently, the four critical attributes are (a) goal-driven regulation, (b) information processing, (c) communication and (d) utilisation. Functional literacy, prior health knowledge and experience, and access to technology are antecedents, while positive health outcomes, increased perceived control and enhanced health-related quality of life emerged as consequences. Additionally, the concept was influenced by multilevel contextual factors. By enhancing our understanding of digital health literacy; standardising its terminology; and exploring the interactions among its antecedents, consequences and influencing factors, this study aims to reduce health disparities and promote equitable health in the digital era. The results of this foundational work, which establishes a basis for future research and policy development, provide clear pathways for developing targeted interventions and measurement tools of digital health literacy, ultimately contributing to better health practices.

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.

Very brief intervention for physical activity behaviour change in cardiac rehabilitation: protocol for the ‘Measure It!’ effectiveness–implementation hybrid trial

IntroductionPhysical inactivity is a risk factor for repeat cardiac events and all-cause mortality in coronary heart disease (CHD). Cardiac rehabilitation, a secondary prevention programme, aims to increase physical activity levels...

“Such an institution represents the circle of life” – bringing an inpatient hospice into an academic setting: a pre-implementation exploratory study

BackgroundTo combine the benefits of hospice and palliative care, the integration of both seems self-evident. Aim of this study was to explore clinical staff’s and volunteers’ expectations and concerns of the first university hospice in Germany planning for implementation.MethodsStaff and volunteers of the Department of Palliative Medicine of the University Hospital in Cologne received questionnaires and were interviewed following three themes of interest: opportunities, challenges, general criteria. Questionnaire results were analyzed descriptively using mean ± SD and percentages, open-ended questions and interviews were analysed using content analysis.ResultsA total of 28/100 questionnaires was returned (n = 17 clinical staff, n = 11 volunteers) and 18 interviews conducted. The majority of both clinical staff and volunteers estimated the need for a university inpatient hospice as rather to very high (64.7% and 81.8%, respectively). Our findings revealed that most clinical staff and volunteers anticipated improvements with the intended university inpatient hospice, although their expectations were divided between both hope and concern while adhering to legal and general requirements, which they feared might oppose such a project. Participants expressed concern about leadership and staffing plans, albeit most pronounced among clinical staff. Nursing staff repeatedly articulated concerns about being interchanged between the palliative care ward and the intended inpatient hospice while they had explicitly chosen to work in palliative medicine.ConclusionsThe overall high level of anticipated progress and excitement is very encouraging. Albeit serious concerns were mentioned, our results indicate that all participants believe in a positive impact and highlight the need of developing a solid concept.In order to implement such a hospice within a university setting, it is important to consider multilevel contextual factors such as system-level factors (funding, external and internal regulations), organization-level factors (leadership, staff motivation), and patient-level factors (adaptability to patients' needs). Our findings illustrate the importance of understanding the context of practice before implementation. Our pre-implementation study helps identify critical views from staff members and volunteers that may hinder or advance the implementation.Trial registrationThe study was registered at the German Clinical Trials Register (#DRKS00021258) on April 17th 2020.

Emergent Talent Management Model and Industry Toolkit During a Pandemic – An Investigation in the Vietnamese Banking Sector

There is still limited research studying multilevel factors influencing talent management (TM) practices in general and TM practices in the Vietnamese banking sector, particularly within the Covid pandemic context. Considering this gap, this article has three research objectives: developing a conceptual framework about multilevel contextual factors affecting TM within the studied sector, assessing the framework's suitability and applicability, and proposing a TM model and toolkit for bank leaders to improve TM strategic planning. The study employed the qualitative research method and semi-structured interviews with bank managers from different types of banks. The conceptual framework formulated in this study indicates a progression in examining factors influencing TM practices in developing countries. All the interviewees revealed their interest in studying the framework and their agreement with the arrangement of the relevant factors in the framework. As per the suggestion from the interviewees about the need to develop a TM model or guideline to execute TM practices, this paper also provides a suggested TM model with specific steps and an industry toolkit used for TM strategic planning and decision-making process based on the proposed framework. The model's steps, indicating explicit recommendations for bank managers to enhance TM effectiveness, are arranged in accordance with the process included in the proposed framework's TM flow. Besides, the reflection questions in the toolkit are helpful for managers to improve their critical thinking about their actual TM flow. The transformation from the framework to the toolkit can be viewed as how theoretical contribution can lead to managerial implications. This study contributes to the progress of contemporary TM literature during historical events in unstable business environments. It can be seen as a contribution to the applications of TM literature in practice.

Multi-Level Factors Associated with Relationship-Centred and Task-Focused Mealtime Practices in Long-Term Care: A Secondary Data Analysis of the Making the Most of Mealtimes Study.

Mealtimes in long-term care (LTC) can reinforce relationships between staff and residents through relationship-centred care (RCC) practices; however, meals are often task-focused (TF). This cross-sectional study explores multi-level contextual factors that contribute to RCC and TF mealtime practices. Secondary data from residents in 32 Canadian LTC homes were analyzed (n = 634; mean age 86.7 ± 7.8; 31.1% male). Data included resident health record review, standardized mealtime observation tools, and valid questionnaires. A higher average number of RCC (9.6 ± 1.4) than TF (5.6 ± 2.1) practices per meal were observed. Multi-level regression revealed that a significant proportion of variation in the RCC and TF scores was explained at the resident- (intraclass correlation coefficient [ICC]RCC = 0.736; ICCTF = 0.482), dining room- (ICCRCC = 0.210; ICCTF = 0.162), and home- (ICCRCC = 0.054; ICCTF = 0.356) levels. For-profit status and home size modified the associations between functional dependency and practices. Addressing multi-level factors can reinforce RCC practices and reduce TF practices.

Leveraging health infrastructure to optimize HPV vaccination for adolescents in Zambia: Protocol for an implementation study.

Cervical cancer is the leading cause of cancer death in Zambia, where HIV prevalence is also high (11.3%). HIV heightens the risk of developing and dying from cervical cancer. The human papillomavirus (HPV) vaccine can prevent 90% of cervical cancers, and in Zambia is recommended for adolescent girls ages 14-15 years, including those with HIV. Currently they mainly deliver HPV vaccination via school-based campaigns, which may exclude the most vulnerable adolescents-those out-of-school or who irregularly attend. Adolescents living with HIV (ALHIV) are more likely to have these vulnerabilities. Further, school-based campaigns are not tailored to the WHO-recommended HPV vaccination schedule for ALHIV (3 versus 2 doses). Integrating HPV vaccination into routine care in adolescent HIV clinics may ensure that ALHIV have access to vaccine at the WHO-recommended schedule. Such integration requires a multilevel approach, stakeholder engagement, and diversified implementation strategies, given known challenges of providing the HPV vaccine in LMICs, including Zambia. Our study aims to integrate HPV vaccination into routine care in adolescent HIV clinics. To achieve success, we will co-design a package of implementation strategies using a previously successful implementation research approach developed for cervical cancer prevention in LMICs: the Integrative Systems Praxis for Implementation Research (INSPIRE). INSPIRE is a novel, comprehensive approach to develop, implement, and evaluate implementation science efforts. Following key elements of INSPIRE, our specific aims are to: 1) Identify the unique multilevel contextual factors (barriers and facilitators) across HIV settings (rural, urban, peri-urban) that influence HPV vaccine uptake; 2) Use Implementation Mapping to translate stakeholder feedback and findings from Aim 1 into a package of implementation strategies to integrate HPV vaccine into HIV clinics; 3) Conduct a Hybrid Type 3 effectiveness-implementation trial to evaluate the package of multilevel implementation strategies for integrating HPV vaccine into HIV clinics. Our research team has strong support, technical expertise, and resources (e.g., vaccines) from the Zambian Ministry of Health; and political will for scale-up. This stakeholder-based implementation model has the potential to be transported to HIV clinics across Zambia and serve as a model to address cancer prevention priorities for those with HIV in other LMICs. To be registered prior to Aim 3, when implementation strategies finalized.

Contextual factors of child behavioral health across developmental stages.

This study examines the relative influence of environmental contexts (family, school, neighborhood) on child behavioral health at ages 3, 5, 9, and 15 years. Path analysis was conducted on a sample of 4,898 urban children from a longitudinal dataset called the Fragile Families and Child Wellbeing Study. Child physical abuse, emotional abuse, maternal depression, substance use, neighborhood social cohesion, neighborhood poverty, school connectedness, and peer bullying had concurrent relationships with child behavior problems at one or more developmental stages. Early childhood abuse (age 3) and school age environmental contexts (age 9) had lasting effects on later behavior problems. Findings underscore the importance of both multilevel contextual factors and developmental timing in determining behavioral health outcomes in children.

Exploratory qualitative study examining acceptability of strategies to improve access to substance use treatment and HIV prevention services for young adults on probation in Ukraine

ObjectiveAdults <30 years’ of age experience elevated HIV-rates in Ukraine. Young adults (YA) involved in the criminal justice system (CJS) are at an increased HIV-risk given elevated rates of substance...

"Let's Use This Mess to Our Advantage": Calls to Action to Optimize School Nutrition Program beyond the Pandemic.

School nutrition programs mitigate food insecurity and promote healthy eating by offering consistent, nutritious meals to school-aged children in communities across the United States; however, stringent policy guidelines and contextual challenges often limit participation. During COVID-19 school closures, most school nutrition programs remained operational, adapting quickly and innovating to maximize reach. This study describes semi-structured interviews with 23 nutrition directors in North Carolina, which aimed to identify multi-level contextual factors that influenced implementation, as well as ways in which the innovations during COVID-19 could translate to permanent policy and practice change and improve program reach. Interviews were conducted during initial school closures (May–August 2020) and were deductively analyzed using the Social Ecological Model (SEM) and Consolidated Framework for Implementation Research (CFIR). Analysis elicited multiple relevant contextual factors: director characteristics (motivation, leadership style, experience), key implementation stakeholders (internal staff and external partners), inner setting (implementation climate, local leadership engagement, available resources, structural characteristics), and outer setting (state leadership engagement, external policies and incentives). Findings confirm the strength and resilience of program directors and staff, the importance of developing strategies to strengthen external partnerships and emergency preparedness, and strong support from directors for policies offering free meals to all children.

Understanding the (lack of) utilization of work-family practices: a multilevel perspective

PurposeMany employees do not use work-family practices to their full extent, even when they are in need of them. Drawing on the concept of psychological safety the authors propose a new construct: psychological accessibility– employees' sense of embracing the benefits of work-family practices without experiencing a fear of using them. The authors argue that the psychological accessibility of work-family practices could explain the variations in the utilization of work-family practices among employees with similar levels of family needs. Furthermore, the authors propose multilevel contextual factors that could affect the psychological accessibility of work-family practices.Design/methodology/approachThe authors develop a theoretical multilevel framework for work-family practices that places psychological accessibility at its core and addresses accessibility of work-family practices from a macro level that includes institutions and the different attributes of the national culture, a meso level that includes work time norms in organizations, and a micro level, that includes the social context at the team level in organizations.FindingsAs part of the conceptual development the authors offer 10 propositions.Originality/valueThe authors' multilevel model of psychological accessibility could explain the variations in the utilization of work-family practices across different national, organizational and group contexts. This paper refocuses scholarly attention to the psychological antecedents of the utilization of work-family practices. The authors offer some practical recommendations to make the utilization of work-family practices a psychologically safe activity.

Multilevel determinants of community health workers for an effective maternal and child health programme in sub-Saharan Africa: a systematic review

BackgroundCountries in sub-Saharan Africa (SSA) continue to have the highest maternal and under-five child deaths in the world. The ongoing COVID-19 pandemic is amplifying the problems and overwhelming already fragile...

Study Protocol: Type 1 Hybrid Effectiveness-Implementation Trial of a Behavioral Parent Training Intervention for Parents of Young Children Who Are Deaf or Hard of Hearing.

Children who are deaf or hard of hearing (DHH) and who use hearing aids or cochlear implants are more likely than their peers with typical hearing to exhibit behavior problems. Although multiple evidence-based interventions for child behavior problems exist, they are rarely delivered to children who are DHH, and no rigorous randomized controlled trials have been conducted to determine their effects with this population. This protocol describes a study aiming to test the effectiveness of an evidence-based behavioral parent training intervention adapted for parents of young children who are DHH and simultaneously to assess key implementation outcomes and multilevel contextual factors influencing implementation. The protocol for a Type 1 hybrid effectiveness-implementation trial of a behavioral parent training intervention for parents of young children who are DHH is presented, including details of the study design, participants, assessments, and analyses. Using a stakeholder-engaged, mixed-methods approach, we will test the effects of the intervention versus treatment as usual on parenting behaviors, child behaviors, and a range of secondary effectiveness outcomes, including adherence to using hearing aids and cochlear implants as well as measures of child speech and language. We will assess the acceptability, feasibility, fidelity, and costs of the intervention from the perspectives of peer coaches who deliver the intervention, hearing health care clinicians (including audiologists and speech-language pathologists), and administrators of programs serving young children who are DHH. Results of this trial will inform future efforts to close the gap between prevalence of behavioral problems in young children who are DHH and access to and use of evidence-based interventions to prevent and treat them. If effective, this intervention could be widely implemented using strategies informed by the findings of this study to benefit young children who are DHH and followed in hearing health care and their families.

Implementation of a diabetes prevention program within two community sites: a qualitative assessment

BackgroundDespite numerous translations of diabetes prevention programs, implementation evaluations are rarely conducted. The purpose of this study was to examine the implementation process and multilevel contextual factors as an evidence-based diabetes prevention program was implemented into two local community organization sites to inform future scale-up. To build the science of implementation, context and strategies must be identified and explored to understand their impact.MethodsThe program was a brief-counseling diet and exercise modification program for individuals at risk of developing type 2 diabetes. A 1-year collaborative planning process with a local not-for-profit community organization co-developed an implementation plan to translate the program. A pragmatic epistemology guided this research. Semi-structured interviews were conducted with staff who delivered the program (n = 8), and a focus group was completed with implementation support staff (n = 5) at both community sites. Interviews were transcribed verbatim and thematically analyzed using a template approach. The consolidated framework for implementation research (CFIR) is a well-researched multilevel implementation determinant framework and was used to guide the analysis of this study. Within the template approach, salient themes were first inductively identified, then identified themes were deductively linked to CFIR constructs.ResultsImplementation strategies used were appropriate, well-received, and promoted effective implementation. The implementation plan had an impact on multiple levels as several CFIR constructs were identified from all five domains of the framework: (a) process, (b) intervention characteristics, (c) outer setting, (d) inner setting, and (e) individual characteristics. Specifically, results revealed the collaborative 1-year planning process, program components and structure, level of support, and synergy between program and context were important factors in the implementation.ConclusionThis study offers insights into the process of implementing a community-based diabetes prevention program in two local sites. Successful implementation benefited from a fully engaged, partnered approach to planning, and subsequently executing, an implementation effort. The CFIR was a useful and thorough framework to evaluate and identify multilevel contextual factors impacting implementation. Results can be used to inform future implementation and scale-up efforts.

Implementing the Federal Smoke-Free Public Housing Policy in New York City: Understanding Challenges and Opportunities for Improving Policy Impact.

In 2018, the U.S. Department of Housing and Urban Development required public housing authorities to implement a smoke-free housing (SFH) policy that included individual apartments. We analyzed the policy implementation process in the New York City Public Housing Authority (NYCHA). From June–November 2019, we conducted 9 focus groups with 64 NYCHA residents (smokers and nonsmokers), 8 key informant interviews with NYCHA staff and resident association leaders, and repeated surveys with a cohort of 130 nonsmoking households pre- and 12-month post policy. One year post policy implementation, participants reported widespread smoking violations and multi-level factors impeding policy implementation. These included the shared belief among residents and staff that the policy overreached by “telling people what to do in their own apartments”. This hindered compliance and enforcement efforts. Inconsistent enforcement of illegal marijuana use, staff smoking violations, and a lack of accountability for other pressing housing issues created the perception that smokers were being unfairly targeted, as did the lack of smoking cessation resources. Resident support for the policy remained unchanged but satisfaction with enforcement declined (60.1% vs. 48.8%, p = 0.047). We identified multilevel contextual factors that are influencing SFH policy implementation. Findings can inform the design of strategies to optimize policy implementation.

Behavioral economic implementation strategies to improve serious illness communication between clinicians and high-risk patients with cancer: protocol for a cluster randomized pragmatic trial

BackgroundSerious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics (“nudges”) that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion—either alone or in combination with clinician nudges that additionally compare performance relative to peers—may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer.MethodsWe will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity.DiscussionThis will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies.Trial registrationClinicalTrials.gov, NCT04867850. Registered on April 30, 2021.FundingNational Cancer Institute P50CA244690

Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

BackgroundRoutine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care.MethodsA four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or “nudges”) promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges.DiscussionThis study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers.Trial registrationClinicaltrials.gov, NCT04737031. Registered 3 February 2021.

Shards from the glass ceiling: Deconstructing marginalizing systems in relation to critical consciousness development.

In this qualitative case study, the authors identify, name, and critique multi-level contextual factors in relation to Black, Indigenous, and People of Color college student leaders' and the authors' own critical consciousness development applying Harrel's Difference Framework, and Critical Race Theory. Located in a Northern California Sundown Town, the authors utilize focus groups, Photovoice data, and critical ethnography to document organizational and institutional responses towards student leaders' and the authors' involvement in multicultural programming and a Black Lives Matter Freedom School. Across data sources, the authors chronicle instances of the following: (1) devaluing through unpaid student labor, (2) distancing and siloing of multicultural student organizations on campus, (3) denial of the use of harmful and misinformed programmatic practices, and (4) defensiveness on the part of the administration regarding student narratives. Findings highlight implications within higher education surrounding addressing historic racial inequity, and illustrate the trauma invoked by ameliorative and premature institutional responses.