Multilevel Implementation Research Articles

Tools to improve discharge equity: Protocol for the pilot TIDE trial.

Written discharge instructions after hospitalization promote patient understanding and positive clinical outcomes. Despite the rising prevalence of patients with non-English language preference (NELP) in the U.S., most hospitals do not routinely provide discharge instructions in their preferred language, thereby placing them at higher risk for medical errors and hospital readmission. Innovative solutions to close this implementation gap at hospital discharge for patients with NELP are needed. The Tools to Improve Discharge Equity (TIDE) intervention leverages communication practices proven effective in addressing communication barriers to create language concordant discharge tools from hospital discharge paperwork. We present the protocol for a type I hybrid implementation-effectiveness pilot randomized trial. The TIDE intervention includes a translated medication calendar, pictographs, and an audio recording of the discharge instructions in the patient's preferred language. We will recruit an estimated 50 patient participants from the hospital's top four non-English language groups-Spanish, Haitian Creole, Cape Verdean Creole, and Vietnamese-as well as the nurse and in-person interpreter caring for them. Outcomes include patient recall of primary diagnosis and overall understanding of discharge instructions using a newly developed 24-point score, patient experience, implementation measures (acceptability, feasibility, and appropriateness), and clinical effectiveness (including hospital reutilization). A mixed methods evaluation will identify determinants of intervention uptake to guide selection of multi-level implementation strategies to test in a future hybrid type III trial. The TIDE intervention is the first hospital discharge intervention designed for patients with NELP. Result will inform future efforts to improve the safety and equity of the hospital discharge process. clinicaltrials.gov NCT05988229 (August 14, 2023) https://classic.clinicaltrials.gov/ct2/show/NCT05988229.

Midwives perspectives of barriers and facilitators for the practice of promoting women's positive childbirth experience in China: A qualitative study.

Women-centered care for positive childbirth experiences is currently a global trend. However, there are some barriers to promoting women's positive childbirth experiences in practice. This study explored midwives' perspectives on the barriers and facilitators to promoting women's positive childbirth experience in practice. Qualitative semi-structured interviews were undertaken with 18 midwives in the birth unit of four tertiary care hospitals in Hefei, Anhui Province, China. Thematic analysis was used to code the interviews with deductive codes, and we organized findings according to levels of influence within the Dahlgren and Whitehead rainbow model, a socioecological model of health. Midwives reported barriers to women's positive childbirth experience were identified on four levels: individual factors included psychological barriers and childbirth expectations (micro level), social and community and organization factors included interpersonal violence, medical mistrust and obstetric violence and outcome (meso level), healthcare system factors included midwife shortage and hospital environment (macro level). Facilitators for a positive birth experience include antenatal education, community continuum of care, and respectful and understanding care. This study indicated that midwives experienced several barriers and facilitators in providing positive childbirth experience care to women in the Chinese context. The findings will help maternity care providers and policymakers develop multi-level implementation strategies at the individual, social, community, organization, and healthcare system levels.

Study protocol for a hybrid type 3 effectiveness-implementation trial of a team-based implementation strategy to support educators’ use of a social engagement intervention

BackgroundRemaking Recess (RR) is a school-based evidence-based peer social engagement intervention for autistic students. RR involves direct training and coaching with educators; however, educators face several barriers to implementation at both the individual- and organizational-levels. This protocol paper describes a multi-site study that will test whether an educator-level implementation strategy, coaching, with or without a school-level implementation strategy, school-based teams, will maximize educators’ use (fidelity and sustainment) of RR for autistic students and their peers who are socially-isolated, rejected, or peripheral and may need additional support during recess.MethodsThis study will employ a hybrid type-3 effectiveness-implementation trial. Fifty-five elementary schools will be recruited as well as 121 educators (e.g., classroom assistants, aides), 55 general and special educator teachers, and 83–138 other school personnel (e.g., administrators). Additionally, at least 118 autistic students and allistic or non-autistic classmates will be recruited as RR recipients. Participants will complete baseline assessments at the beginning of the year, and all schools will be provided RR training. Schools will be randomized to coaching with or without school-based teams. This study will measure RR fidelity (primary outcome), RR sustainment, as well as peer engagement, social network inclusion, and social skills (secondary outcomes). It is expected that coaching with school-based teams will improve both RR fidelity and social network inclusion, while coaching with and without school-based teams will result in improved peer engagement and social skills.DiscussionPrevious research has documented barriers to RR implementation at both the individual- (provider) and organization-level (school). Using multi-level implementation strategies such as coaching with school-based teams may address these barriers and support RR implementation in schools. Findings from this study may guide future efforts to scale up tailored implementation strategies for use in public school districts, with the ultimate goal of increasing intervention access and improving student outcomes.Trial registrationName of the Registry: clinicaltrials.gov.Trial Registration: Clinical Trials ID: NCT06559267.Date of Registration: August 15, 2024. Prospectively registered.

Effectiveness of Multilevel Implementation Strategies for Autism Interventions: Outcomes of Two Linked Implementation Trials.

This study tests the effectiveness of leader and provider-level implementation strategies to implement evidence-based interventions (EBIs) in two of the service systems caring for autistic children. The TEAMS Leadership Institute (TLI) targets implementation leadership and climate, and TEAMS Individualized Provider Strategy (TIPS) targets provider motivation and engagement. A cluster randomized hybrid type 3 implementation-effectiveness trial tested the effects of the implementations strategies when paired with AIM HI (An Individualized Mental Health Intervention for Autism) in mental health programs (Study 1) and CPRT (Classroom Pivotal Response Teaching) in classrooms (Study 2). The combined sample included 65 programs/districts across four training cohorts (2018-2019 to 2020-2021). Organizations were randomized to receive a leader-level strategy, provider strategy, both strategies, or neither strategy (EBI provider training only). Leader and provider participants were recruited from enrolled programs/districts and child participants were recruited from providers' caseloads or classrooms. Data from a total of 387 providers (mean age = 36.39 years; 91% female participants; 30% Latino/a/x participants) and 385 children (mean age = 9.13 years; 84% male participants; 60% Latino/a/x participants) were analyzed/ Outcomes were assessed over 6 months. Provider outcome measures included provider EBI certification and observed EBI fidelity. Clinical outcome measures included the Eyberg Child Behavior Inventory (ECBI) (Study 1) and Pervasive Developmental Disorder Behavior Inventory (PDD-BI) (Study 2). Outcomes were analyzed using intent-to-treat models. There was no significant effect of TLI on EBI Certification. TLI was associated with significantly higher EBI fidelity compared to non-TLI (B=.37, p=.04). Moreover, a statistically significant TLIXTime interaction was found for child outcome T-scores (B=-10.47, p=.03), with a significant reduction in T-scores across time only for those in the TLI condition. There were no significant effects of TIPS on any outcomes. Findings support the effectiveness of leader focused strategies to promote implementation and clinical outcomes of autism EBIs in multiple public service systems and for multiple EBIs.

Mapping Implementation Strategies to Address Barriers to Pre-Exposure Prophylaxis Use Among Women Through POWER Up (Pre-Exposure Prophylaxis Optimization Among Women to Enhance Retention and Uptake): Content Analysis.

Black cisgender women (hereafter referred to as "women") experience one of the highest incidences of HIV among all populations in the United States. Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention option, but uptake among women is low. Despite tailored strategies for certain populations, including men who have sex with men and transgender women, Black women are frequently overlooked in HIV prevention efforts. Strategies to increase PrEP awareness and use among Black women are needed at multiple levels (ie, community, system or clinic, provider, and individual or patient). This study aimed to identify barriers and facilitators to PrEP uptake and persistence among Black cisgender women and to map implementation strategies to identified barriers using the CFIR (Consolidated Framework for Implementation Research)-ERIC (Expert Recommendations for Implementing Change) Implementation Strategy Matching Tool. We conducted a secondary analysis of previous qualitative studies completed by a multidisciplinary team of HIV physicians, implementation scientists, and epidemiologists. Studies involved focus groups and interviews with medical providers and women at a federally qualified health center in Chicago, Illinois. Implementation science frameworks such as the CFIR were used to investigate determinants of PrEP use among Black women. In this secondary analysis, data from 45 total transcripts were analyzed. We identified barriers and facilitators to PrEP uptake and persistence among cisgender women across each CFIR domain. The CFIR-ERIC Implementation Strategy Matching Tool was used to map appropriate implementation strategies to address barriers and increase PrEP uptake among Black women. Barriers to PrEP uptake were identified across the CFIR domains. Barriers included being unaware that PrEP was available (characteristics of individuals), worrying about side effects and impacts on fertility and pregnancy (intervention characteristics), and being unsure about how to pay for PrEP (outer setting). Providers identified lack of training (characteristics of individuals), need for additional clinical support for PrEP protocols (inner setting), and need for practicing discussions about PrEP with women (intervention characteristics). ERIC mapping resulted in 5 distinct implementation strategies to address barriers and improve PrEP uptake: patient education, provider training, PrEP navigation, clinical champions, and electronic medical record optimization. Evidence-based implementation strategies that address individual, provider, and clinic factors are needed to engage women in the PrEP care continuum. Tailoring implementation strategies to address identified barriers increases the probability of successfully improving PrEP uptake. Our results provide an overview of a comprehensive, multilevel implementation strategy (ie, "POWER Up") to improve PrEP uptake among women. RR2-10.1371/journal.pone.0285858.

Actor Sensemaking and its Role in Implementation of the Decentralized Drug-Resistant TB Policy in South Africa.

South Africa has a high burden of drug-resistant tuberculosis (DR-TB). A policy to decentralize DR-TB treatment from specialized central hospitals to more accessible district facilities was introduced in 2011, but to date implementation has been suboptimal, with variable pace, coverage and models of care emerging. This study explored multilevel policy implementation of DR-TB decentralization in two provinces of South Africa, Western Cape and KwaZulu-Natal. Applying interpretive policy analysis, this paper describes how actors across health system levels and geographies made sense of the DR-TB policy and how this shaped implementation. In an embedded qualitative case study, districts of the two provinces were compared, through data collected in 94 in-depth interviews, and analysed using Vickers' framework of reality, value and action judgements. Five district cases characterise variation in the pace of implementation and models of DR-TB care that emerged. Individual and collective attitudes for and against the policy were underpinned by different systems of meaning for interpreting policy problems and making decisions. These meaning systems were reflected in actor stances on whether DR-TB care needed to be specialized or generalized, nurse- or doctor-led, and institutionalized or ambulatory. Actors' stances influenced their actions and implementation strategies adopted. Resistance to decentralized DR-TB care related to perceived threats of budget cuts to and loss of authority of central facilities, and was often justified in fears of increased transmission, poor quality of care and inadequate resources at lower levels. New advances in diagnosis and treatment to address the growing burden of DR-TB in South Africa will have little impact unless implementation dynamics are better understood, and attention paid to the mindsets, interests and interpretations of policy by actors tasked with implementation. Deliberative policy implementation processes will enhance the quality of discourse, communication and cross-learning between policy actors, critical for reaching synthesis of meaning systems.

The sustainability of a community-based learning collaborative to improve the use of trauma-informed evidence-based practices

PurposeMost youth who experience trauma do not receive evidence-based trauma intervention. Efforts to increase use oftrauma-informed evidence-based practices (EBPs) have identified the learning collaborative (LC) as an effective training and implementation model, yet few studies have evaluated sustainability outcomes. This study examined the sustainability of a community-based LC (CBLC) by describing provider, agency, and community-level use of trauma-informed EBPs, an average of 5.3 years after the training. Methods106 participants from 20 agencies completed a follow-up survey after a CBLC training. Participants were trained in Trauma-Focused Cognitive-Behavior Therapy (TF-CBT; clinical track), in Evidence-Based Treatment Planning (EBTP; broker/case manager track), or in strategies to support TF-CBT and EBTP implementation (senior leader track). Clinical and broker track participants reported on their current employment and EBP use within the past three months. Senior leaders for all 20 agencies provided information about the use of trauma-informed EBPs at their agencies. ResultsAt the provider-level, only 36.5 % of the clinical track continued to use TF-CBT and 28.1 % of the broker track continued to use EBTP. Provider promotion to supervisory and leadership positions supported EBP sustainability. Agency-level outcomes indicated that 89 % of clinical agencies and 60% of broker agencies continued to use TF-CBT and EBTP. Although retention of providers within agencies was low, LC trained clinicians and brokers spread to twenty-four new agencies in the community providing psychotherapy and/or case management services to youth. ConclusionsFindings suggest the CBLC model resulted in some sustained community-level changes as agencies continued to use the trauma-informed EBPs and trained providers spread to other agencies within the local community. Provider promotions also increased representation of CBLC trainees in leadership positions. Results suggest that measuring sustainability as a multi-level implementation outcome can lead to a better understanding of implementation success.

Stakeholder preferences for implementation strategies to address barriers to depression treatment among Latino/a/x teens.

U.S. Latino/a/x adolescents experience inequities in depression treatment use in comparison to non-Latino/a/x White peers. The purpose of this study was to describe barriers to depression treatment use and implementation strategy preferences to address these barriers among Latinx teens. A qualitative descriptive study was conducted with Latino/a/x teens diagnosed with depression (n = 7), their parents (n = 7), and health care providers (n = 18) from across the United States. Qualitative content analysis was conducted to determine common barriers and preferences across groups. Family-level barriers included parents' knowledge and beliefs about depression treatment, parents' own stress, and generational gaps between parents and teens. Provider-level barriers were related to the lack of a bilingual and bicultural health care workforce, and health care system-level barriers included difficulties paying for and scheduling care, inadequate systems for follow-up, and policies limiting innovation and adolescent consent to treatment. Participants emphasized that family involvement was crucial and the importance of tailoring implementation strategies to meet the specific needs of individual Latino/a/x teens. Social support, psychoeducation about depression, and resource navigation support were preferred strategy components that should be facilitated by a bilingual Latinx individual with relevant lived experience and address cultural context. Multilevel implementation strategies will need to be developed to address the multilevel barriers to depression treatment use. Future research will further refine and test an implementation strategy package to determine the effect on the use of depression treatment among Latinx teens screening positive for depression in primary care settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Construction of a new emergency management system for potentially viral/viral municipal solid waste in China: Based on the "Beam-Column Structure" framework model

Emergency management of municipal solid waste during public health emergencies is crucial for curbing the spread of viruses and controlling environmental pollution. Most existing solid waste management systems, are designed with a top-down approach, covering multiple industries and sectors. However, these systems often fail to effectively manage potentially viral solid waste in household waste, which impedes effective solid waste management during public health emergencies and increases the risk of viral outbreaks. For example, during the COVID-19 outbreak, negligent management of potentially viral solid waste may result in the formation of a potential transmission chain of COVID-19 virus. Improper waste management may contaminate natural vectors such as water, soil and air, thereby increasing the pathways of human contact with infected vectors and promoting the risk of transmission of viral diseases such as dengue, Zika and hepatitis A. In this study, the applicability and limitations of the Chinese public emergency management system in the disposal of Potentially Viral/Viral Municipal Solid Waste (PVMSW) were analyzed in the breakout of public health crises. To address the need for precise risk control, efficient collaboration among key stakeholders, functional integration crossing multiple management organizations and flexible responses to complex situations, we proposed a PVMSW emergency management system based on a “Beam-Column Structure” model. This system consists of four modules: main traction, organizational leadership, functional articulation and demand matching. Each module is supported by the corresponding safeguards, including multi-level subject responsibilities, multi-scenario organization and implementation, multi-chain process connection and multi-demand control methods. The PVMSW emergency management system proposed in this study contributes to extending the framework of existing waste management protocols and enhancing the timely collection, transportation and disposal of PVMSW in public health crises. It offers valuable insights and guidance on the practices for improving risk awareness and management capacity in China's solid waste emergency response.

Integrated Online-to-Offline Model of Care for HIV Prevention and Treatment Among Men Who Have Sex With Men in Malaysia: Protocol for an Intervention Development and a Multiphase Trial.

HIV continues to have a disproportionate impact on specific populations in Malaysia, particularly men who have sex with men (MSM). HIV self-testing (HIVST) is a strategy that has been shown to scale up HIV testing rates. However, it faces shortcomings because of concerns about self-efficacy, result interpretation, and lack of counseling and linkage to care. This underscores the need for an innovative approach that integrates HIVST with timely counseling, expert guidance, and referrals to enhance engagement in relevant HIV prevention or treatment. This study aims to describe the protocol used in developing and testing a web-based platform (ie, CINTAI) providing an HIVST kit and real-time e-counseling to support online-to-offline linkage to HIV care services for MSM in Malaysia. The methods are reported according to the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 guidelines. In phase I, we will adapt existing HIVST web-based platforms to create a new online-to-offline HIVST and counseling platform called "CINTAI" for Malaysian MSM. In phase II, we will use a type 1 hybrid implementation trial design to determine the feasibility, acceptability, and preliminary efficacy of "CINTAI" compared with treatment as usual among Malaysian MSM, with assessments conducted over 6 months. Multilevel implementation factors will also be collected to guide future adoption and scale-up. We will enroll 78 MSM in the pilot randomized controlled trial. Baseline characteristics will be tested for homogeneity between groups using appropriate statistical tests. A generalized linear mixed model with random subject effects will account for within-subject correlation. Treatment assignment, time, interaction, and confounders will be included. The proportion of MSM tested for HIV over 6 months and other outcomes (pre-exposure prophylaxis for HIV or antiretroviral therapy linkage, HIV risk behaviors, and chemsex harm reduction) will be compared using linear contrasts. We completed phase I of the proposed study in April 2024 and started phase II in May 2024, with 15 participants recruited (7 in the CINTAI and 8 in the treatment-as-usual groups). On the basis of a series of formative works completed during phase I, we developed a fully functional, web-based platform that provides a digital platform for MSM in Malaysia to order HIVST kits for free and to receive HIV counseling, followed by offline linkage to HIV prevention services (if HIV negative) or HIV treatment services (if HIV positive). Despite being at high risk for HIV transmission, MSM in Malaysia have alarmingly low testing and linkage to HIV care services, prompting the need for innovative approaches to support HIV prevention efforts. If found to be feasible and acceptable, CINTAI can be easily adapted for a range of health outcomes and health care delivery services for MSM, including adaptation to other low- and middle-income countries. DERR1-10.2196/60962.

Using the IFASIS (Inventory of Factors Affecting Successful Implementation and Sustainment) to Advance Context-Specific and Generalizable Knowledge of Implementation Determinants: Case Study of a Digital Contingency Management Platform.

Contingency management (CM) is the most effective treatment for stimulant use disorder but is underutilized by opioid treatment programs (OTPs), despite the high prevalence of stimulant use in this setting. As part of a state-wide initiative, we piloted a novel assessment, the Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS), to examine determinants of implementation of a digital CM platform across a set of OTPs. We describe how the IFASIS was used to elucidate both generalizable and context-specific implementation determinants, and to guide the provision of implementation facilitation. Six OTPs received a multi-level implementation strategy (including facilitation) to promote programmatic uptake of a digital CM platform. Pre-implementation, OTPs completed the IFASIS, a 27-item questionnaire that assesses both the valence (positive/negative) and importance of determinants across 4 domains: outside the organization, within the organization, about the intervention, and about intervention recipients. OTP staff completed the IFASIS as a team, identifying consensus ratings during recorded discussions. Transcripts of IFASIS recordings were analyzed using rapid qualitative analysis. Quantitative IFASIS results were aggregated into medians and ranges within and across organizations. Implementation facilitation meeting notes were analyzed to examine how the IFASIS was used to guide facilitation. Quantitative ratings and qualitative feedback revealed common barriers to implementation of the digital CM platform, including a lack of sustainable funding sources, absence of external and organizational policies, insufficient higher-level leadership support, and mixed attitudes among staff members toward CM. Common implementation facilitators included enthusiasm and commitment among organization leadership and the perception that the digital CM platform would reduce the workload and burden on OTP counselors. The IFASIS was used to guide facilitation in several ways, including stimulating discussion about barriers and facilitators, brainstorming strategies to address barriers rated as "very important", and identifying facilitators that could be harnessed as part of implementation efforts. The IFASIS identified important determinants of CM implementation in OTPs and was instrumental in shaping facilitation. The IFASIS may be a valuable assessment for the implementation science community to identify and address generalizable and context-specific implementation determinants.

Patient and clinician perspectives on the timing of serious illness conversations in oncology.

223 Background: Serious illness conversations (SICs) about patients’ values and care preferences are tied to improved outcomes and quality of life. However, SICs can be hard to implement early in the cancer care journey, and questions remain about how and when to start. Following a pragmatic trial testing behavioral nudges to promote SICs in oncology (NCT04867850), we used an explanatory-sequential mixed methods design to gauge patient and clinician perspectives on the best communication strategy for SICs. Methods: Thirty patients with cancer at high mortality risk and 16 oncology clinicians were recruited from our academic cancer center. Guided by the Consolidated Framework for Implementation Research, our interviews systematically assessed multi-level factors shaping SIC implementation. In addition to interviews, patients completed a structured survey with validated measures on patient-focused communication and care planning. Survey data were studied descriptively, interviews were analyzed thematically, and both were integrated to triangulate qualitative and quantitative results. Results: Participants described two SIC types, which we classified as event-triggered and phased . Clinicians identified event-triggered SICs as prompted by acute incidents (e.g., disease stage transition) and more likely to lead to EHR documentation. However, they were seen as prohibitively time-consuming, and as such, did not become a top priority until a crisis arose. Patients were also uncomfortable with extensive early SICs, wanting to keep hope and avoid information overload soon after a diagnosis. They preferred not to discuss “turns for the worse” until they faced an acute challenge, at which point they valued thorough SICs. In surveys, almost all patients reported asking about benefits (96%), risks (93%), and quality of life (81%) tied to treatment, but few raised sensitive topics like planning for if things got worse (44%). By contrast, phased SICs were described as ongoing, progressive conversations not prompted by specific events and that arose early but deepened over time as a patient and care team nurtured their relationship. Patients and clinicians described phased SICs as better at promoting person-centered care and an essential foundation for SICs prompted by potential transitions. However, since these discussions occur gradually, clinicians reported challenges documenting them, reducing their value at informing future decisions and the ability to know whether conversations occurred at all. Conclusions: Interventions to increase SICs often focus on acute moments in the care trajectory. However, our study suggests that ongoing, staged approaches to SICs are vital for goal-concordant care as well and may be more easily integrated into busy clinical workflows. Further work should investigate ways to support clinicians in both SIC types, such as flexible documentation tools aligned with each approach.

Abstract A122: Predictors of mailed fecal immunochemical test return for Hispanic patients receiving care at community health centers

Abstract Background and Purpose: Mailed fecal immunochemical testing (FIT) is an evidence-based strategy to increase colorectal cancer (CRC) screening. We have previously reported that a multi-level mailed FIT intervention resulted in higher CRC screening rates compared to usual care among Hispanic patients receiving care at Community Health Centers (CHCs). The objective of this study was to assess predictors of mailed FIT completion among Hispanic individuals. Methods: The San Diego Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) project tested a multi-level mailed FIT intervention in 3 CHC systems in Southern California. Using a cluster-randomized trial design, 9 clinics were randomized to mailed FIT and 16 to usual care. The intervention was delivered in Spanish and English and included an invitation letter, a mailed FIT kit with completion instructions, and phone and text-based reminders. Multi-level implementation strategies (i.e., training, centralized facilitation, etc.) were utilized to increase uptake. For this analysis, we assessed mailed FIT completion at 1 year among Hispanic participants ages 50-75 years not up-to-date with CRC screening at baseline and who were randomized to clinics in the mailed FIT intervention. We conducted logistic regression to assess relationships between sex, language preference, health insurance and mailed FIT return. Results: Among the 9 intervention clinics, 2,199 Hispanic patients who were age-eligible and not up-to-date with CRC screening at baseline were included in the present analysis. In this group, 1,457 (66.3%) were female, 1,449 (65.9%) were Spanish-speaking, and 769 (35.0%) returned the FIT kit. Variation in FIT return for Hispanic individuals was shown across CHC systems: 53.2% in CHC1, 31.4% in CHC2, and 24.7% in CHC3. The percentage of individuals who returned the mailed FIT was highest among 55 to 59-year-olds (39.4%) and lowest among 50 to 54-year-olds (30.6%). Results from univariate logistic regression showed that individuals who preferred Spanish language had higher return rate than those who preferred English (OR=1.44; 95% CI: 1.17-1.77). FIT return was higher among participants who were privately insured compared with Medicaid-insured individuals (OR=1.57; 95% CI: 1.20-2.06). Return rate was higher among females compared to males, but the difference was not statistically significant (OR=1.13, 95% CI: 0.98-1.29). Conclusions: Among Hispanic patients who receive care at CHCs, a regional mailed FIT intervention was effective at increasing screening rates. Mailed FIT completion among participants randomized to clinics in the intervention group varied by language preference and health insurance status. These results suggest that future efforts could be tailored to increase FIT return rates among English-speaking Hispanics and those with Medicaid insurance. Citation Format: Joshua Demb, Maria Elena Martinez, Scott Roesch, Samir Gupta, Valesca Largaespada, Sheila F. Castañeda, Borsika A. Rabin, Jennifer Covin, Kristine Ortwine, Yesenia Preciado-Hidalgo, Nicole Howard, James Schultz, Nannette Stamm, Daniel Ramirez, Michael T. Halpern, Jesse Nodora. Predictors of mailed fecal immunochemical test return for Hispanic patients receiving care at community health centers [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A122.

Strategies for Implementing GlobalConsent to Prevent Sexual Violence in University Men (SCALE): Study Protocol for a National Implementation Trial.

Globally, women 15-24 years are at heightened risk of sexual violence victimization, a risk factor for adverse mental, physical, and behavioral health outcomes. Sexual violence is common at universities and most often perpetrated by men, yet few evidence-based prevention strategies targeting men have been tested in low- and middle-income countries. GlobalConsent is a six-module, web-based educational program adapted from an efficacious U.S.-based program. Nine months post-treatment in a randomized trial in Vietnam, GlobalConsent reduced men's sexually violent behavior (Odds Ratio [OR] = 0.71, 95%CI 0.50-1.00) and increased prosocial intervening behavior (OR = 1.51, 1.00-2.28) relative to an attention-control. Evidence regarding optimal implementation strategies for scale up is needed. We will randomize six medical universities in North, Central, and South Vietnam to deliver GlobalConsent using two different packages of implementation strategies that vary in intensity. Higher-intensity strategies will include greater 1) pre- and post-implementation engagement with university leaders and faculty, and 2) greater pre-implementation outreach, follow-up, and incentives for students to promote engagement and completion of GlobalConsent. Higher intensity universities will receive additional training and support for their added activities. We will compare implementation drivers and outcomes, intervention effectiveness, and cost-effectiveness across the two implementation bundles. Our mixed-methods comparative interrupted time-series design includes 1) qualitative interviews and quantitative surveys with university leaders and implementation teams to assess implementation barriers and facilitators; 2) repeated surveys with leaders and faculty, implementation teams, and male students to assess multilevel implementation drivers and outcomes, 3) repeated surveys with male students to assess behavioral outcomes (sexual violence and intervening behavior) and mediating variables (knowledge, attitudes, affect, and capacities), and 4) time diaries and cost tracking to assess cost effectiveness of the two implementation-strategies bundles. This project is the first to assess packages of implementation strategies to deliver an efficacious web-based sexual-violence-prevention program for undergraduate men across all regions of Vietnam and synergizes with a violence-prevention training initiative (D43TW012188). This approach will produce rigorous evidence about how to disseminate GlobalConsent nationally, which holds promise to reduce gender-based health inequities linked to sexual violence as GlobalConsent is brought to scale. NCT06443541. Retrospectively registered with clinicaltrials.gov.

Identifying Barriers and Implementation Strategies to Inform TBI Screening Adoption in Behavioral Healthcare Settings.

Identify barriers to the adoption of the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) in behavioral healthcare organizations and match these barriers to implementation strategies to inform future implementation efforts. Twenty behavioral health providers. Qualitative study involving individual, semi-structured interviews regarding barriers to adopting the OSU TBI-ID. Data were thematically analyzed around constructs from the Consolidated Framework for Implementation Research (CFIR). Results were matched to strategies using the Expert Recommendations for Implementing Change (CFIR/ERIC) matching tool. Ten barriers were identified across 4 CFIR domains. Inner-Setting barriers were inadequate leadership engagement, priorities, resources, and organizational incentives. Individual-Characteristics barriers were insufficient knowledge about the connection between TBI and behavioral health and how to conduct the OSU TBI-ID with fidelity, low self-efficacy to conduct screening, and inadequate motivation and buy-in to conduct screening. Outer-Setting barriers were lack of state-level mandates and inadequate incentives to conduct screenings. The Process domain barrier was an insufficient engagement of key personnel. Strategy recommendations include: identify and prepare champions; alter incentive and allowance structures; inform local opinion leaders; build a coalition; access new funding; conduct local consensus discussions; involve executive boards; capture/share local knowledge; conduct educational meetings; assess for readiness and identify determinants; identify early adopters; fund and contract for the clinical innovation; create a learning collaborative; and conduct a local needs assessment. This is the first study to examine barriers to adopting the OSU TBI-ID in real-world practice settings. Our results suggest that multilevel implementation strategies addressing mechanisms of change are necessary at the provider, organizational, and systems levels to overcome the complex barriers affecting TBI screening adoption and implementation. Future research is needed to test these strategies and their mechanisms of action on the adoption, implementation, and sustainment of TBI screening, as well as their effect on client-level outcomes.

Community-Engaged Implementation Strategies in Occupational Therapy: A Scoping Review.

Despite the potential of community-engaged implementation research (CEIR) in developing strategies to accelerate the translation of evidence-based interventions (EBIs), there is a noticeable knowledge gap in the current state of CEIR in occupational therapy. A synthesis of the concept, purpose, and operationalization of CEIR is necessary. To identify the contexts, purposes, and operationalization of CEIR, focusing on implementation strategies in occupational therapy. PubMed/MEDLINE, Embase, CINAHL, Scopus, and Web of Science. We included studies that were explicit and intentional about CEIR and that focused on implementation strategies to support the translation of occupational therapy interventions, clinical guidelines, practice models, theories, or assessments. We extracted the research context (e.g., partners, recruitment), purpose (e.g., why community-engaged research was used), and operationalization (e.g., community engagement [CE] activities, how their findings inform the research) using thematic analysis. Of 3,219 records, 6 studies were included. Involved partners were mainly occupational therapy practitioners from existing networks. CEIR that focuses on implementation strategies informs various aspects of research design, ranging from study design to sustainability, by developing community-academia partnerships, building implementation capacity, and creating implementation strategies across diverse research areas. Current research has used various but mostly traditional CE activities (e.g., focus groups). We synthesized evidence on CEIR focused on implementation strategies in occupational therapy. Intentional efforts are needed to collaborate with diverse partners, explore innovative CE activities, produce equitable outputs, and develop multilevel implementation strategies to accelerate the translation of EBIs into practice. Plain-Language Summary: In this review, we synthesize evidence on the contexts, purposes, and operationalization of community-engaged implementation research (CEIR), focusing on implementation strategies in occupational therapy research. We found that current implementation efforts mainly rely on occupational therapy practitioners as community partners and use traditional recruitment methods and community engagement activities. In turn, they develop implementation strategies that mainly target practitioners without comprehensive, multilevel implementation support. We suggest more equitable collaboration with diverse partners to effectively promote the implementation and dissemination of evidence-based interventions in occupational therapy practice.

Using the RE-AIM and TDF frameworks to evaluate the implementation of a standardized cognitive assessment protocol in outpatient rehabilitation.

Impairments in cognition significantly affect patient functioning and rehabilitation outcomes. Assessment is essential to identifying at-risk individuals and guiding care plans. A cognitive assessment protocol was implemented in occupational therapy (OT) and speech-language pathology (SLP) outpatient practice. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and Theoretical Domains Framework (TDF), this study (1) measured the reach and adoption of the cognitive assessment protocol and (2) explored determinants and strategies that may affect adoption. Sequential mixed methods. Two outpatient rehabilitation clinics (A and B) within a health care network. Medical records from 220 adult patients with neurologic diagnosis and 15 OT and SLP clinicians. Cognitive assessment protocol. Reach of the assessment protocol across patient characteristics and adoption across clinical sites were measured quantitatively via retrospective electronic medical records review. Qualitative data on effectiveness and the implementation process were collected via clinician focus groups. Protocol adoption rates were 71% and 54% at clinics A and B, respectively. Site B OT was more likely to be noncompliant with protocol adoption compared to Site A, when controlling for patient characteristics, (81% vs. 16%, respectively; odds ratio = 11.4, 95% confidence interval [3.36-38.64], p ≤ .001). Patient age was a significant factor for protocol reach; older age was associated with noncompliance of the SLP protocol adoption, p < .05. Both sites employed implementation strategies targeting the provider level (eg, education/training); Site A additionally included organization-level strategies (eg, leadership engagement). In the absence of organization-level strategies, OT and SLP clinicians at Site B identified barriers related to leadership support, resources, and workflow. Standardized practice protocols are feasible to implement within the rehabilitation setting, though multilevel implementation strategies may be needed to promote adoption. Aligning practices with the needs, values and priorities of the organization, providers, and patients and families is imperative.

Expert consensus on multilevel implementation hypotheses to promote the uptake of youth care guidelines: a Delphi study

BackgroundThe implementation of youth care guidelines remains a complex process. Several evidence–based frameworks aid the identification and specification of implementation determinants and strategies. However, the influence of specific strategies on certain determinants remains unclear. Therefore, we need to clarify which active ingredients of strategies, known as behaviour change techniques (BCTs), elicit behaviour change and improve implementation outcomes. With this knowledge, we are able to formulate evidence–based implementation hypotheses. An implementation hypothesis details how determinants and in turn, implementation outcomes might be influenced by specific implementation strategies and their BCTs. We aimed to identify (1) determinants relevant to the implementation of youth care guidelines and (2) feasible and potentially effective implementation hypotheses.MethodsA four–round online modified Delphi study was conducted. In the first round, experts rated the implementation determinants based on their relevance. Next, experts formulated implementation hypotheses by connecting BCTs and implementation strategies to determinants and were asked to provide a rationale for their choices. In round three, the experts reconsidered and finalised their hypotheses based on an anonymous overview of all formulated hypotheses, including rationales. Finally, the experts rated the implementation hypotheses based on their potential effectiveness and feasibility.ResultsFourteen experts completed the first, second, and third rounds, with 11 completed the final round. Guideline promotion, mandatory education, presence of an implementation leader, poor management support, knowledge regarding guideline use, and a lack of communication skills were reported as most relevant determinants. In total, 46 hypotheses were formulated, ranging from 6 to 9 per determinant. For each determinant, we provide an overview of the implementation hypotheses that were most commonly deemed feasible and potentially effective.ConclusionThis study offers valuable insights into youth care guideline implementation by systematically identifying relevant determinants and formulating hypotheses based on expert input. Determinants related to engagement and to knowledge and skills were found to be relevant to youth care guideline implementation. This study offers a set of hypotheses that could help organisations, policymakers, and professionals guide the implementation process of youth care guidelines to ultimately improve implementation outcomes. The effectiveness of these hypotheses in practice remains to be assessed.

Factors influencing implementation of digital cardiac rehabilitation: A qualitative analysis of health workers perspectives.

Despite growing evidence for the effectiveness of digital cardiac rehabilitation (CR) uptake of this technology remains low. Understanding the factors that influence implementation of digital CR in clinical practice is a growing area of research. The aim of this nested qualitative study was to explore health worker perspectives on factors influencing implementation of a digital CR programme. Using convenience sampling, semi-structured interviews were conducted with health workers, including health care professionals (nurses, dietitians, physiotherapists) and those in administrative and managerial roles who were involved in delivering and referring patients to Croí MySláinte, a 12-week digital CR intervention delivered during the Coronavirus 2019 pandemic. The updated Consolidated Framework for Implementation Research (CFIR) guided data collection and framework analysis. Interviews were conducted with 14 health workers. Factors influencing implementation of Croí MySláinte were multiple, with some operating independently and others in combination. They related to: (i) characteristics of individuals (e.g., senior leadership support, commitment and motivation of Health workers to meet patient needs, technical capability, workload and perceived fit with role); (ii) features of the programme (e.g., accessibility and convenience for patients, the digital platform, patient self- monitoring tools, the multidisciplinary team and core components); (iii) the external environment (e.g., partnership and connections between organisations, broadband and COVID-19); (iv) the internal environment (e.g., organisational culture, teamwork, resources including funding, digital infrastructure and staffing); and (v) the implementation process (e.g., engaging patients through provision of technical support). The study findings suggest that factors influencing implementation of digital CR operate at multiple levels. Therefore, multi-level implementation strategies are required if the true potential of digital health in improving equitable cardiac rehabilitation access, participation and patient outcomes is to be realised.

Collective Self-Reliance: Restarting the Concept in the Sahel in the Context of a Multipolarizing World Order

This article is devoted to restarting the concept of “Collective Self-Reliance” (CSR) taking into account the emergence of a multipolar world. Particular attention is paid to the attempts of African countries to get out of the center-periphery model of dependent development through the implementation of this concept. The theoretical foundations of the CSR concept, enshrined in the Arusha Declaration of 1967, the Arusha Program for Collective Self-Reliance and Framework for Negotiations of 1979, and in a number of documents of the Organization of African Unity (OAU) and the African Union (AU), are presented. The attitude towards CSR is shown in the works of Western experts, scholars from the USSR and Russia, as well as contemporary researchers from the former republics of Yugoslavia. Interpretations of the concept are given, based on the works of Johan Galtung, Samir Amin, and German experts. The practice of applying the concept in Burkina Faso and the neighboring countries, as well as in Tanzania, is shown. A critical analysis of the results of the implementation of the concept and the possibilities of its implementation in the modern realities of global capitalism was carried out. Particular attention is paid to the levels of implementation of the concept as well as the theory and practice of delinking – a temporary decoupling of economic ties with the countries of the “collective West”. It is concluded that, in the 2020s, multi-level implementation of the CSR concept (local, country level, Alliance of Sahel States level, “World Majority” level) seems even more realistic than at the time of its development. This is facilitated by the dominance of non-Western economies in the global framework, macrohistorical processes of decoupling, as well as the key role of the “World Majority” countries in the current economic ties of the Sahel countries. A limiting factor in this is the large-scale flow of Western aid to the region.