Outer Context Research Articles

Power and resistance in schools: Implementing institutional change to promote health equity for sexual and gender minority youth.

Schools in the United States are hierarchical institutions that actively (re)produce the power relations of the wider social world, including those associated with heteronormativity. Structural stigma, informed by heteronormativity and perpetuated through schools, contributes to the production of academic and health disparities among youth who are lesbian, gay, bisexual, transgender, queer, or of other gender and sexual identities (LGBTQ+). We draw upon 5 years of qualitative data from a cluster randomized controlled trial conducted in New Mexico that used implementation science frameworks to promote the uptake and sustainment of evidence-informed practices (EIPs) to examine how power operates to hinder or promote the ability of school staff to change school environments, disrupt structural stigma, and increase safety and support for LGBTQ+ youth. Data sources included annual individual and small group qualitative interviews with school professionals (e.g., administrators, school nurses, teachers, and other staff), several of whom took part in Implementation Resource Teams (IRTs) charged with applying the EIPs. Other data sources included bi-weekly periodic reflections with implementation coaches and technical assistance experts. Data were recorded, transcribed, and analyzed using deductive and inductive coding techniques. The IRTs experienced variable success in implementing EIPs. Their efforts were influenced by: (1) constraining school characteristics, including staff turnover and resource scarcity; (2) community-based opposition to change and concerns about community backlash; (3) the presence or absence of supportive school leadership; and (4) variations in school, district, and state policies affecting LGBTQ+ students and attitudes about their importance. Findings illustrate how diverse power structures operated in and across outer and inner contexts to bound, shift, amplify, and otherwise shape how new practices were received and implemented. Findings indicate that the efforts of IRTs were often a form of resistant power that operated within and against school hierarchies to leverage epistemic, discursive, and material power toward implementation. To improve health equity, implementation scientists must attend to the multiple real and perceived power structures that shape implementation environments and influence organizational readiness and individual motivation. Implementers must also work to leverage resistant power to counter the institutional structures and social norms that perpetuate inequities, like heteronormativity and structural stigma.

Jail-based reentry programming to support continued treatment with medications for opioid use disorder: Qualitative perspectives and experiences among jail staff in Massachusetts.

Individuals with opioid use disorder released to communities after incarceration experience an elevated risk for overdose death. Massachusetts is the first state to mandate county jails to deliver all FDA approved medications for opioid use disorder (MOUD). The present study considered perspectives around coordination of post-release care among jail staff engaged in MOUD programs focused on coordination of care to the community. Focus groups and semi-structured interviews were conducted with 61 jail staff involved in implementation of MOUD programs. Interview guide development, and coding and analysis of qualitative data were guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Deductive and inductive approaches were used for coding and themes were organized using the EPIS. Salient themes in the inner context focused on the elements of reentry planning that influence coordination of post-release care including timing of initiation, staff knowledge about availability of MOUD in community settings, and internal collaborations. Findings on bridging factors highlighted the importance of interagency communication to follow pre-scheduled release dates and use of bridge scripts to minimize the gap in treatment during the transition. Use of navigators was an additional factor that influenced MOUD initiation and engagement in community settings. Outer context findings indicated partnerships with community providers and timely reinstatement of health insurance coverage as critical factors that influence coordination of post-release care. Coordination of MOUD post-release continuity of care requires training supporting staff in reentry planning as well as resources to enhance internal collaborations and bridging partnerships between in-jail MOUD programs and community MOUD providers. In addition, efforts to reduce systemic barriers related to unanticipated timing of release and reinstatement of health insurance coverage are needed to optimize seamless post-release care.

A mixed-methods evaluation of the ¡Vamos por Más! parenting program implementation in Chile.

Substance use is a significant global concern. Strengthening parenting in families with adolescents has been shown to reduce substance use initiation. The ¡Vamos por Más! (¡VxM!) program is a positive-parenting program developed in Chile to improve family relations and reduce adolescent substance use that combines in-person school workshops, multimedia messaging and personalized support. This manuscript reports a mixed-methods evaluation of the pilot implementation of the ¡VxM! program utilizing the Consolidated Framework for Implementation Research and Proctor's taxonomy for process outcomes. An explanatory sequential design was used. Quantitative methods evaluated program use, acceptability, appropriateness, and fidelity, and were followed by qualitative focus groups (FGs) to assess the implementation process and understand these outcomes. Thirteen FGs stratified by school and role, including school leaders, program facilitators, participants, and researchers, were conducted. The program was implemented in three schools, reaching 253 families with in-person workshops (40.5% of potential participants), 257 parents who viewed on average 72.1% of sent multimedia messages, and 2 families who used the personalized support (0.3%). Overall, the program was viewed as acceptable and appropriate by participants and implementers due to the high quality of program materials, targeted content, and activities. Implementation differed by schools. Key implementation factors were the outer context, inner school setting, and implementation processes. This comprehensive evaluation, including both intervention implementers and participants, identified implementation facilitators, barriers, and outcomes. Future ¡VxM! implementations should alter program components of schools with lower engagement to improve program implementation and outcomes.

Protocol for the implementation evaluation of an integrated paediatric and primary care model: Strengthening Care for Children (SC4C)

IntroductionImplementation evaluations provide insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines a detailed protocol of...

A model for fostering community capacity to support adults with intellectual disabilities who engage in challenging behaviour: A scoping review.

Developmental support agencies support many adults with intellectual disabilities in the community. Unfortunately, these adults often exhibit high rates of challenging behaviour, which present significant pressures on these service providers. Agencies need to develop effective means of increasing their capacity to provide quality support. Previous systematic reviews found that training staff in positive behaviour supports can improve outcomes; however, the factors facilitating training's effects, long-term effectiveness, and outcomes for service users have yet to be determined. We conducted a scoping review of 98 journal articles and book chapters to develop a model for fostering capacity development drawing from Organizational Behaviour Management and Knowledge Translation theories. Some relevant factors include features of the inner and outer organizational contexts, training approaches (e.g., behavioural skills training & in-situ coaching), ongoing support and feedback. This model may lead to more effective and enduring treatment programs and improved support for adults with intellectual disabilities.

Theory-guided assessment of barriers and facilitators to adequate informed consent for childhood cancer clinical trials: Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

6539 Background: To participate in childhood cancer clinical trials, parents/legal guardians must provide informed consent (IC), which is a fundamental ethical right. However, barriers to achieving valid IC include: use of medical jargon, misunderstanding about clinical trials procedures, tremendous emotional distress surrounding the initial cancer diagnosis, and the complexity and length of the IC forms. There are scarce data on using theory to assess perspectives of parents of children with cancer on barriers and facilitators for adequate IC in diverse populations. Methods: Using implementation science theory and methods, we assessed parent-reported barriers and facilitators to adequate IC, in a convenience sample that included a significant number of Hispanics. Twelve qualitative semi-structured interviews and 224 open-ended surveys were conducted with 236 parents of children with newly-diagnosed cancer at Rady Children’s Hospital-San Diego, a large quaternary children’s hospital in California. Fifty-three percent of participants were Hispanic and 38% were monolingual Spanish-speakers. We utilized the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework, specifically domains of outer context, inner context, bridging and innovation factors. Four main codes (IC concepts and delivery; desired clinical trial information; motivations and emotions related to clinical trial enrollment; and potential areas for interventions) were used as a coding guide for analysis. Interviews and surveys were transcribed and coded for thematic analysis by three independent coders to identify key barriers and facilitators. Results: Four main themes were identified as barriers: 1) Complexity of the IC forms and discussion (lengthy, confusing, not available in Spanish, and use of medical jargon); 2) parents feeling emotionally overwhelmed, anxious and pressured around the IC; 3) parents viewing the clinical trial as the only treatment option; and 4) mistrust and fear of clinical trial procedures. Four IC facilitators were identified: 1) simpler explanations of study procedures; 2) provider flexibility for accommodations when delivering the IC, including psychosocial support; 3) active promotion of voluntariness and trust; and 4) supplemental education in lay language, including request for peer-education, decision aids, and navigation to “bridge the provider-patient gap.” Conclusions: Our implementation science approach identified multiple barriers and facilitators to adequate IC in a diverse sample of parents. Findings can inform potential interventions to enhance IC for childhood cancer clinical trials, including the use of decision aids, peer-navigation, and interventions tailored to the language and culture of the individual.

Pedagogy in Health Promotion: The Scholarship of Teaching and Learning Paper of the Year Award

Coronavirus disease 2019 (COVID-19) realities have demanded that educators move swiftly to adopt new ways of teaching, advising, and mentoring. We suggest the centering of a trauma-informed approach to education and academic administration during the COVID-19 pandemic using the Substance Abuse and Mental Health Services Administration’s (SAMHSA) guidance on trauma-informed approaches to care. In our model for trauma-informed education and administration (M-TIEA), SAMHSA’s four key organizational assumptions are foundational, including a realization about trauma and its wide-ranging effects; a recognition of the basic signs and symptoms of trauma; a response that involves fully integrating knowledge into programs, policies, and practices; and an active process for resisting retraumatization. Since educators during the pandemic must follow new restrictions regarding how they teach, we have expanded the practice of teaching in M-TIEA to include both academic administrators’ decision making about teaching, and educators’ planning and implementation of teaching. In M-TIEA, SAMHSA’s six guiding principles for a trauma-informed approach are infused into these two interrelated teaching processes, and include the following: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues. M-TIEA’s organizational assumptions, processes, and principles are situated within an outer context that acknowledges the potential influences of four types of intersectional traumas and stressors that may occur at multiple socioecological levels: pandemic-related trauma and stressors; other forms of individual, group, community, or mass trauma and stressors; historical trauma; and current general life stressors. This acknowledges that all trauma-informed work is dynamic and may be influenced by contextual factors.

Legislatively mandated implementation of medications for opioid use disorders in jails: A qualitative study of clinical, correctional, and jail administrator perspectives

BackgroundIndividuals with legal involvement and opioid use disorders (OUD) are at an increased risk of overdose and premature death. Yet, few correctional systems provide all FDA approved medications for OUD (MOUD) to all qualifying incarcerated individuals. We report on the implementation of MOUD in seven Massachusetts’ jails following a state legislative mandate to provide access to all FDA-approved MOUD and to connect with treatment upon release. Methods/participantsBased on the Exploration, Preparation, Implementation, and Sustainment framework, 61 clinical, corrections, and senior jail administrators participated in semi-structured interviews and focus groups between December 2019 and January 2020. Qualitative analyses focused on external and internal contexts and bridging factors. FindingsParticipants detailed how the outer context (i.e., legislative mandate) drove acceptance of MOUD and assisted with continuity of care. Salient inner context factors included decision-making around administration of agonist medications, staff perceptions and training, and changes to infrastructure and daily routines. Leadership was critical in flattening standard hierarchies and advocating for flexibility. System-based characteristics of incarcerated individuals, specifically those who were pre-sentenced, presented challenges with treatment initiation. Inter- and intra-agency bridging factors reduced duplication of effort and led to quick, innovative solutions. ConclusionsImplementation of MOUD in jails requires collaboration with and reliance on external agencies. Preparation for implementation should involve systematic reviews of available resources and connections. Implementation requires flexibility from institutional systems that are inherently rigid. Accordingly, leaders and policymakers must recognize the cultural shift inherent in such programs and allow for resources and education to assure program success.

Implementation of a campus-based and peer-delivered HIV self-testing intervention to improve the uptake of HIV testing services among university students in Zimbabwe: the SAYS initiative

BackgroundThe uptake of HIV testing services among adolescents and young adults in Zimbabwe is low due to stigma associated with the risk of mental and social harm. The WHO recommends HIV self-testing (HIVST) as an innovative approach to improve access to HIV testing for this hard-to-reach populations. This study describes the development and implementation of a coordinated multifaceted and multidisciplinary campus-based approach to improve the uptake of HIV testing among university students in Zimbabwe.MethodsWe utilized both quantitative and qualitative methods guided by the Exploration, Preparation, Implementation, and Sustainment Framework. A formative survey, in-depth interviews, and a scoping review were conducted as part of the situation analysis. Implementers (peer educators and health workers) were trained and community dialogue sessions were conducted to ascertain the determinants (enablers and barriers) influencing both the inner and outer contexts. Self-test kits were disbursed over 6 months before a summative evaluation survey was conducted. Qualitative data were analyzed thematically while the chi-squared test was used to analyze quantitative data.ResultsThe formative evaluation showed that 66% of students intended to test and 44% of the enrolled students collected HIVST test kits. Giving comprehensive and tailored information about the intervention was imperative to dispel the initial skepticism among students. Youth-friendly and language-specific packaging of program materials accommodated the students. Despite the high acceptability of the HIVST intervention, post-test services were poorly utilized due to the small and isolated nature of the university community. Implementers recommended that the students seek post-test services off-site to ensure that those with reactive results are linked to treatment and care.ConclusionsPeer-delivered HIVST using trained personnel was acceptable among adolescents and young adults offered the intervention at a campus setting. HIVST could increase the uptake of HIV testing for this population given the stigma associated with facility-based HTS and the need for routine HIV testing for this age group who may not otherwise test. An off-site post-test counseling option is likely to improve the implementation of a campus-based HIVST and close the linkage to treatment and care gap.

Applying implementation science in mental health services: Technical assistance cases from the Mental Health Technology Transfer Center (MHTTC) network

ObjectiveCritical gaps exist between implementation of effective interventions and the actual services delivered to people living with mental disorders. Many technical assistance (TA) efforts rely on one-time trainings of clinical staff and printed guidelines that alone are not effective in changing clinical practice. The Mental Health Technology Transfer Center (MHTTC) Network uses implementation science to accelerate the use of evidence-based practices (EBPs), improve performance, and bring about systems-level change. MethodFour case examples illustrate how MHTTCs employ the Exploration-Preparation-Implementation-Sustainment (EPIS) implementation framework and intensive implementation strategies to educate clinicians, manage change, and improve processes. These examples include implementing motivational interviewing, cognitive-behavioral therapy for people with psychosis, strategies to decrease the no show rate for virtual appointments, and school mental health systems development. ResultsFrom Preparation through Sustainment, MHTTCs successfully employed implementation strategies including learning communities, audit and feedback, and coaching to bring about change. Each project attended to inner and outer contexts to eliminate barriers. The examples also show the benefit of integrating process improvement alongside implementation. ConclusionsThe MHTTCs are a model for using implementation science to design technical assistance that leads to more successful practical execution of EBPs; thus reducing the gap between research and practice.

Applying the EPIS framework to policy-level considerations: Tobacco cessation policy implementation among California Medicaid managed care plans.

In 2016, the California Department of Healthcare Services (DHCS) released an "All Plan Letter" (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage among Medicaid beneficiaries. However, implementation remains poor. We apply the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify barriers and facilitators to fidelity to APL 16-014 across California Medicaid MCPs. We assessed fidelity through semi-structured interviews with MCP health educators (N = 24). Interviews were recorded, transcribed, and reviewed to develop initial themes regarding barriers and facilitators to implementation. Initial thematic summaries were discussed and mapped onto EPIS constructs. The APL (Innovation) was described as lacking clarity and specificity in its guidelines, hindering implementation. Related to the Inner Context, MCPs described the APL as beyond the scope of their resources, pointing to their own lack of educational materials, human resources, and poor technological infrastructure as implementation barriers. In the Outer Context, MCPs identified a lack of incentives for providers and beneficiaries to offer and participate in tobacco-cessation programs, respectively. A lack of communication, educational materials, and training resources between the state and MCPs (missing Bridging Factors) were barriers to preventing MCPs from identifying smoking rates or gauging success of tobacco-cessation efforts. Facilitators included several MCPs collaborating with each other and using external resources to promote tobacco cessation. Additionally, a few MCPs used fidelity monitoring staff as Bridging Factors to facilitate provider training, track providers' identification of smokers, and follow-up with beneficiaries participating in tobacco-cessation programs. The release of the evidence-based APL 16-014 by California's DHCS was an important step forward in promoting tobacco-cessation services for Medicaid MCP beneficiaries. Improved communication on implementation in different environments and improved Bridging Factors such as incentives for providers and patients are needed to fully realize policy goals. In 2016, the California Department of Healthcare Services (DHCS) in California released an "All Plan Letter" (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage to address tobacco use among Medicaid beneficiaries. We conducted semi-structured interviews with health educators in California Medicaid MCPs to explore the barriers and facilitators to implementing the APL using the Exploration, Preparation, Implementation, Sustainment framework. According to MCPs, barriers included a lack of clarity in the APL guidelines; a lack of resources, including educational materials, infrastructure to identify smokers, and human resources; and a lack of incentives or penalties for providers to provide tobacco-cessation materials to beneficiaries. Facilitators included collaboration between MCPs and state and/or national public health programs. Overall, our findings can provide avenues for improving the implementation of tobacco-cessation services within Medicaid MCPs.

Implementation factors for patient navigation program success: a qualitative study

BackgroundPatient navigation (PN) is an evidence-based practice that involves assessing and addressing individual barriers to care for patients. While PN has shown effectiveness in numerous studies, designing successful, sustainable PN programs has remained challenging for many healthcare organizations. The purpose of the present study was to examine implementation factors for successful PN programs to optimize the sustainability of PN services across cancer care settings in the USA.MethodsData were collected via semi-structured interviews with PN stakeholders (n=17) from diverse cancer care settings. Thematic content analysis was conducted by deductively coding major themes based on constructs from the Exploration-Preparation-Implementation-Sustainability framework and by inductively coding emergent themes.ResultsFacilitators in the outer context included payer guidelines, accreditation requirements, community partnerships, and demonstrated need and demand for services. Inner context factors such as alignment with organizational and leadership priorities, appropriate staff support and workloads, and relative advantage were important to program success. Innovation characteristics such as the presence of innovation champions, clear role and scope of practice, clear protocols, strong communication channels, and innovation fit were facilitators of program success. Community-Academic partnerships and funding stability also emerged as facilitators for program sustainability.ConclusionOur qualitative analysis from a diverse sample of PN stakeholders and programs across the USA supports intentional use of implementation theory to design PN programs to optimize implementation success.

The ECC Methodology for Architecture Design Theory and Practices Research

This study proposes the ECC methodology to improve design practices systematically. The article describes the research strategy called the evaluation-creation cycle (ECC) the foundation of the ECC methodology. Recent studies showed that a failure of desired outcomes is often a result of a failure of to understand existing practices. This suggests that improving design requires more than a theory of what exists, it also requires using this understanding to change the design process to one that leads from the existing to the desired through the evaluation-creation cycle approach. This requires understanding the relations of knowledge creation through the analytic and the synthetic practices within the design process, as well as the relations between the design process and the outer design context. The study draws insight from the Renaissance theory in order to obtain understanding the development of descriptive ‘knowledge of design’ focused on increasing design understanding, and based on this prescriptive ‘knowledge for design’ providing design support are created. This has informed the development of the evaluation-creation cycle (ECC) strategy and the ECC methodology based on it. The aims of the ECC methodology are the evaluation of existing practices and the principles that support them, and based on this the development of understanding with which to change the current situations into preferred ones. In this article the evaluation-creation cycle (ECC) approach is described and the ECC methodology based on it introduced, and the way in which design principles can be developed, improved and used to predict desired outcomes is discussed.

Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework

BackgroundScreening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients’ health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response.MethodsGuided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis.ResultsPatients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach.ConclusionOur results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.

Lessons learned from the implementation of Canada's first alongside midwifery unit: A qualitative explanatory study

BackgroundIn July 2018, Canada's first midwife-led alongside midwifery unit (AMU) opened at Markham Stouffville Hospital (MSH) in Markham, Ontario. Our objectives were to examine how the conditions at MSH made it possible for the hospital to create the first AMU in Canada and to identify lessons to inform spread by examining how characteristics of the intervention, the inner and outer settings, the individuals involved, and the processes used influenced the MSH-AMU implementation process. MethodsWe conducted key informant interviews and document analysis using Yin's research methods. We used the Consolidated Framework for Implementation Research to conceptualize the study and develop semi-structured interview guides. We recruited key informants, including midwives and other health professionals, hospital leaders, leaders of midwifery organizations, and consumers, by email using both purposive and respondent driven sampling. Interviews were digitally recorded and professionally transcribed. We identified documents through key informants and searches of Nexis Uni, Hansard, and Google databases. We analyzed the data using a coding framework based on Greenhalgh et al.’s evidence-informed theory of the diffusion of innovations. ResultsBetween November 2018 and February 2019, we conducted fifteen key informant interviews. We identified thirteen relevant documentary sources of evidence, including news media coverage, website content, Ontario parliamentary records, and hospital documents. Conditions that influenced implementation of the AMU fell within the following domains from Greenhalgh's diffusion of innovations theory: the innovation, the outer context, the inner context – system antecedents for innovation and system readiness for innovation, communication and influence, linkage – design phase and implementation stage, and the implementation process. While several unique features of MSH supported innovation, factors that could be adopted elsewhere include organizational investment in the development of midwifery leadership skills, intentional use of change management theory, broad stakeholder involvement in the design and implementation processes, and frequent, open communication. ConclusionsThe example of the MSH-AMU illustrates the value of utilizing best practices with respect to change management and system transformation and demonstrates the potential value of using implementation theory to drive the successful implementation of AMUs. Lessons learned from the MSH-AMU can inform successful spread of this innovative service model.

Situating real estate law for the new outer-space economy

PurposeWith current commercial space activities accelerating, the purpose of this paper is to contexualise enlivening the discipline of real estate law for outer space.Design/methodology/approachDrawing on essential topics in real estate law, contracts and insurance, this paper discusses these themes in their terrestrial and extra-terrestrial contexts.FindingsReal estate law for the outer space environment carries many similarities to real estate law but also significant differences. At this early stage in human space exploration and travel, there is a need to deal more with goods/chattels (property assets); however, this will change as land – the Moon, asteroids, planets – are made available for mining and other activities. Given outer space activities carry high risk for spacecraft and humans, there are reciprocal lessons for real estate law and practice.Practical implicationsReal estate law for outer space is an area already in existence. However, as access to space develops further, particularly with inevitable human presence on the Moon and exploration to Mars, real estate law will also grow in importance and sophistication. Real estate law for outer space relies on contract and property law. These are levers for commercial activities, and a further array of complex law and governance – the Outer Space Treaties, international and national law, international custom, guidelines, codes and standards. Real estate law for space will require an interdisciplinary and global approach in an era where human needs are already reliant on goods and services derived from space, as well as in the quest for exploration beyond the earth and the moon itself.Originality/valueThe time is ripe for space law to be taken into nuanced areas, with real estate law being an important step. Entrenched into the combined real estate and outer space disciplinary context must be consideration of the environment (earth and beyond), sustainability, heritage protection issues, etc., as well as ensuring outer space has equitable opportunities for all nations and citizens.

How do healthcare professionals make decisions concerning low-value care practices? Study protocol of a factorial survey experiment on de-implementation

BackgroundA large number of practices used in health care lack evidence of effectiveness and may be unnecessary or even cause harm. As such, they should be de-implemented. While there are multiple actors involved in de-implementation of such low-value care (LVC) practices, ultimately, the decision to abandon a practice is often made by each health care professional. A recent scoping review identified 6 types of factors affecting the utilization vs. abandonment of LVC practices. These factors concern health care professionals, patients, outer context, inner context, processes, and the characteristics of LVC practice itself. However, it is unclear how professionals weigh these different factors in and how these determinants influence their decisions about abandoning LVC practices. This project aims to investigate how health care professionals account for various factors as they make decisions regarding de-implementation of LVC practices.MethodsThis project will be carried out in two main steps. First, a factorial survey experiment (a vignette study) will be applied to empirically test the relevance of factors previously identified in the literature for health care professionals’ decision-making about de-implementation. Second, interactive workshops with relevant stakeholders will be carried out to develop a framework for professionals’ decision-making and to offer suggestions for interventions to support de-implementation of LVC practices.DiscussionThe project has the potential to contribute to improved understanding of the decision-making involved in de-implementation of LVC practices. We will identify which factors are more important when they make judgments about utilizing versus abandoning LVC practices. The results will provide the basis for recommendations concerning appropriate interventions to support de-implementation decision-making processes.

Integrated knowledge translation to advance noncommunicable disease policy and practice in South Africa: application of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework

BackgroundIn response to the “know–do” gap, several initiatives have been implemented to enhance evidence-informed decision-making (EIDM). These include individual training, organizational culture change management, and legislative changes. The importance of relationships and stakeholder engagement in EIDM has led to an evolution of models and approaches including integrated knowledge translation (IKT). IKT has emerged as a key strategy for ensuring that engagement is equitable, demand-driven, and responsive. As a result, the African-German Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA+) incorporated an IKT approach to influence noncommunicable diseases (NCD) policy and practice. We documented the phased process of developing, implementing, and monitoring the IKT approach in South Africa; and explored the appropriateness of using the exploration, preparation, implementation, and sustainment (EPIS) framework for this purpose.MethodsWe mapped the South Africa IKT approach onto the EPIS framework using a framework analysis approach. Notes of team meetings, stakeholder matrices, and engagement strategies were analysed and purposefully plotted against the four phases of the framework in order to populate the different constructs. We discussed and finalized the analysis in a series of online iterations until consensus was reached.ResultsThe mapping exercise revealed an IKT approach that was much more iterative, dynamic, and engaging than initially thought. Several constructs (phase-agnostic) remained important and stable across EPIS phases: stable and supportive funding; committed and competent leadership; skilled and dedicated IKT champions; diverse and established personal networks; a conducive and enabling policy environment; and boundary-spanning intermediaries. Constructs such as “innovations” constantly evolved and adapted to the changing inner and outer contexts (phase-specific).ConclusionsUsing the EPIS framework to interrogate, reflect on, and document our IKT experiences proved extremely relevant and useful. Phase-agnostic constructs proved critical to ensure resilience and agility of NCD deliberations and policies in the face of highly dynamic and changing local contexts, particularly in view of the current coronavirus disease 2019 (COVID-19) pandemic. Bridging IKT with a framework from implementation science helps to reflect on this process and can guide the development and planning of similar interventions and strategies.

Advancing health equity through a theoretically critical implementation science.

While implementation science is driven by theory, most implementation science theories, models, and frameworks (TMF) do not address issues of power, inequality, and reflexivity that are pivotal to achieving health equity. Theories used in anthropology address these issues effectively and could complement prevailing implementation science theories and constructs. We propose three broad areas of theory that complement and extend existing TMF in implementation science to advance health equity. First, theories of postcoloniality and reflexivity foreground attention to the role of power in knowledge production and to the ways that researchers and interventionists may perpetuate the inequalities shaping health. Second, theories of structural violence and intersectionality can help us to better understand the unequal burden of health disparities in the population, thereby encouraging researchers to think beyond single interventions to initiate partnerships that can impact overlapping health vulnerabilities and influence the upstream causes of vulnerability. Finally, theories of policy and governance encourage us to examine the social-political forces of the "outer context" crucial for implementation and sustainability. The incorporation of critical theories could enhance implementation science and foster necessary reflexivity among implementation scientists. We contend that a theoretically critical implementation science will promote better science and, more importantly, support progress toward health equity.

On utilizing the transitivity pursuit-enhanced object partitioning to optimize self-organizing lists-on-lists

In this paper, the Transitivity Pursuit-Enhanced Object Migration Automata (TPEOMA) is used to capture the dependence of elements in a hierarchical Singly-Linked-Lists on Singly-Linked-Lists (SLLs-on-SLLs) “adaptive” data structure. In doing so, the TPEOMA-enhanced hierarchical SLLs-on-SLLs learns the probability distribution of elements in a Non-stationary Environment. In this framework, we divide the hierarchical Singly-Linked-Lists on Singly-Linked-Lists (SLLs-on-SLLs) into an outer and inner list context. The inner-list context is itself a SLLs containing sub-elements of the list, while the outer-list context contains these sublist partitions as its primitive elements. The elements belonging to a particular sublist partition are determined using the TPEOMA reinforcement learning scheme from the theory of Learning Automata. The idea of Transitivity builds on the Pursuit concept that injects a noise filter into the EOMA to filter divergent queries from the Environment, thereby increasing the likelihood of training the Automaton to approximate the “true” distribution of the Environment. The Transitivity phenomenon can infer “dependent” query pairs from non-accessed elements in the transitivity relation based on the statistical distribution of the queried elements. The TPEOMA-enhanced hierarchical SLLs-on-SLLs schemes results in superior performances to the MTF and TR schemes as well as to the EOMA-enhanced hierarchical SLLs-on-SLLs schemes in NSEs.