Background Community violence interventions (CVIs) aim to reduce firearm-related harm through strategies that center community engagement, credible messengers, and tailored outreach. Despite increasing adoption, few studies use implementation science methods to assess the implementation of adapted CVI models in new contexts. This pilot evaluation describes the implementation of the University of Pennsylvania Community Violence Prevention (PCVP) program, an adaptation of Cure Violence (CV) implementation strategies co-developed with community stakeholders. We assessed implementation outcomes and short-term participant-level impacts to inform future scale-up. Method Using a type 3 hybrid implementation-focused design, we conducted a mixed-methods evaluation over an 18-week pilot period. Guided by the RE-AIM framework and Proctor's implementation outcomes, we examined reach, fidelity, acceptability, and appropriateness. Administrative data, staff-reported checklists, and geospatial outreach analyses were triangulated with survey data from 18 high-risk participants, informed by the COM-B model. Quantitative data were analyzed descriptively and using Pearson correlations; qualitative responses underwent rapid thematic analysis. Results The PCVP team (two full-time, two part-time outreach workers, and one manager) engaged 38 participants, reaching 75% of target caseloads and covering 70% of shooting incidents within two blocks and two weeks. Fidelity was high for case management and community engagement, but low for violence detection/interruption due to staffing limitations. Participants reported high acceptability and appropriateness of the intervention (M = 4.39, SD = 0.98), with COM-B scores indicating strong engagement across capability, opportunity, and motivation domains (M = 25.64/30). Correlations revealed significant links between social/physical opportunity and motivation (r > .70, p < .01). Conclusions This study demonstrates the feasibility and acceptability of a community-adapted CVI model. High acceptability and engagement support continued implementation, though limitations in fidelity to violence interruption underscore the need for targeted staffing and funding. Context-sensitive adaptation, robust community partnerships, and longer-term implementation research are essential for sustaining and scaling CVI efforts.
Background To advance implementation of evidence-based interventions in healthcare, research teams need methods that center engagement, inclusivity, and creativity. We address this challenge by exploring design probes for implementation research. Design probes are packaged materials given to users that prompt them to asynchronously capture data about their context and experience, subsequently reflecting upon aspects of that data salient to the topic of study. This study had three objectives: (1) explore the potential utility of design probes in implementation research, (2) describe researcher and participant experiences with design probes, and (3) generate considerations for leveraging design probes to enhance engagement in implementation research. Method We used a multi-informant, multimethod approach. For objective 1, we undertook a literature scan and elicited expert (n = 8) input to explore how, when, and why design probes could be used in implementation research. For objective 2, we pilot tested the method with practitioners (n = 22) in an implementation research project exploring barriers and facilitators to implementing measurement-based care in community mental health settings. For objective 3, we sought feedback about the method in focus groups with youth (n = 8) and practitioners (n = 9). Results The literature scan and expert input identified five scenarios in which design probes may enhance implementation research, including enhancing engagement among implementation partners, accessing hard-to-reach populations, and identifying partner-centered implementation strategies. Our pilot experience demonstrated that design probes are feasible for implementation research from the perspective of research teams and participants. Focus group findings indicated that design probes hold promise for engaging youth but may have variable appeal and utility with practitioners. Conclusions We explore design probes for implementation research at a time of critical need for partner engagement. Future research will examine feasibility and value of design probes in a range of implementation initiatives.
Background: Measurement-Based Care (MBC) is an evidence-based practice that has demonstrated challenges integrating into care settings even under ideal circumstances. This study uses the PRISM framework to critically examine a systematic integration of MBC as standard behavioral healthcare in an adult ambulatory psychiatric clinic. Since the initial implementation in 2018, 33 distinct implementation strategies were used to enhance the uptake of this practice. To prepare for sustainment, our team developed a digital Measurement-based care Training for Resilient Implementation in a Clinical setting (METRIC) to improve implementation. The present study evaluates the reach, implementation, and contextual domains impacting METRIC. Methods: METRIC was IRB-approved and distributed to 56 multidisciplinary clinicians through the institutional learning hub. Providers completed surveys about implementation and clinician attitudes of METRIC before, 1 month, and 3 months after training. Patient attitudes were assessed before ( n = 98) and after ( n = 80) implementation. Clinician and patient attitudes were analyzed using the Friedman and Wilcoxon tests, respectively. Results: Forty-seven out of 56 (83.9%) clinicians completed METRIC. Implementation measures suggest there were promising acceptability, appropriateness, and feasibility. Clinicians positively rated METRIC. Clinicians answered 84% of module questions correctly, though their attitudes about MBC did not significantly change after METRIC. Patient attitudes did not significantly change. Conclusions: This study evaluated the implementation of METRIC in an ambulatory mental health clinic for its feasibility, acceptability, and appropriateness. After implementing strategies to enhance provider uptake, METRIC was piloted to standardize MBC training and prepare for sustainment. METRIC was well-received and provides an opportunity for less provider reliance on system champions and academic partnerships to sustain MBC utilization in mental health settings. Our findings define positive aspects of digital MBC training and areas for additional research, which include exploring the benefits of MBC training, examining need and frequency, and whether specialized training is beneficial.
Background:Opioid overdoses are a pervasive public health crisis. Overdose education and naloxone distribution (OEND), and medications for opioid use disorder (MOUD) are evidence-based practices (EBPs) that can reduce opioid-related deaths. The HEALing Communities Study (HCS) worked with coalitions of community partner organizations during the Communities That HEAL (CTH) intervention to increase OEND and MOUD access. This study aims to explore how EBP strategies, or the mechanisms by which EBPs were delivered, were sustained after the study ended. Method:Interviews with representatives from organizations who participated in the implementation of an OEND and/or MOUD EBP strategy were conducted 6-8 months after the HCS intervention period to understand how the EBP strategies had been adapted, maintained, or discontinued. A total of 135 interviews were transcribed, coded, and analyzed to identify the barriers and facilitators to sustainment. Results:We identified five themes related to the sustainment of EBP strategies after the end of the HCS intervention period. Our findings highlight the importance of (a) organizational capacity building, (b) collaboration and partnership between implementing organizations, (c) integration of EBP strategies into routine care during the study, (d) adaptation of services after the intervention to better respond to evolving community needs, and (e) community support for the implementation of EBP strategies. Conclusion:Future studies should explore how explicit attention to capacity building, collaboration within and between community agencies, and opportunities for adapting EBPs to better fit the needs and contexts of communities may facilitate sustainment of effective EBP strategies in other public health contexts. ClinicalTrialsgov identifier:NCT0411939.
Background There is an increasing demand for building a workforce capable of using evidence generated from implementation science to support the wide-scale use of evidence-informed interventions to achieve equitable outcomes. This study focuses on the feasibility of growing the competencies of professionals who actively support change efforts in service systems—referred to as implementation support practitioners—through a synchronous, university-based, online certificate program in implementation practice. Method The certificate program consisted of three 2-day courses, each grounded in 15 core competencies linked to skillful implementation support and delivered using an online synchronous approach to three cohorts of participants between February 2023 and May 2024. Enrollment for each cohort was limited to ensure personalized interaction between program faculty and participants, with cohort sizes ranging from 36 to 47. Leveraging a mixed-methods approach, we collected and analyzed both quantitative and qualitative evaluation data to evaluate the certificate program. Results A large majority of participants from all three cohorts agreed that they were satisfied with program and experienced gains in knowledge, skills, and perceived capability, motivation, and opportunity to apply their learnings. Participants also yielded significant gains from pre- to post-program across all 15 targeted competencies. Qualitative analyses indicated that participants appreciated the program's high-qualty faculty, skilled facilitation, respectful learning environment, and practical curriculum. The synchronous format and consistent small-group work also were valued. Suggested program improvement included more small-group time and clearer links between readings and speaker content. Follow-up surveys indicated sustained impacts and content application in participants’ day-to-day work activities. Conclusions Alongside other extant training approaches, university-based, competency-focused certificate programs delivered using an online synchronous approach could offer an effective strategy for bolstering the workforce of implementation support practitioners. Efforts on this front could aid in reducing a growing divide between implementation research and practice.
Background Despite the importance of organizational readiness for implementing evidence-based practices in schools, few studies have empirically examined contextual and attitudinal factors that may shape how implementation team members perceive their schools’ preparedness to implement new practices. We examined associations between theorized factors and perceptions of organizational readiness among school teams preparing to launch a universal prevention initiative. Method Data came from implementation team members ( n = 166) from 40 Idaho schools participating in the baseline wave of a hybrid Type 3 effectiveness-implementation trial of supports to improve scale-up of universal prevention. Multilevel regression models tested individual and school-level predictors of perceived team and staff readiness, including indicators of task demands, resource availability, and situational factors. Results Analyses indicated positive associations of system support and protective factors with both team and staff readiness, as well as belief in the program and school resources as predictors of team members’ readiness, and transformational leadership as a predictor of perceived staff readiness. Conclusions Findings highlight the importance of fostering positive attitudes toward evidence-based practices to enhance team members’ perceptions of readiness to implement and potentially improve downstream success. Administrators seeking to strengthen the implementation of evidence-based programming may also benefit from targeted investments connecting staff members to available resources.
Background Educators endorse challenging behavior as a concern for autistic students, which is compounded by the lack of adequate resources for behavioral intervention use at school. The RUBI program is an evidence-based intervention, initially developed for clinicians to implement with parents of autistic children ages 3–14 with co-occurring challenging behavior in outpatient settings. Using the Discover, Design/Build, Test framework, which combines human-centered design and implementation science, implementation usability issues of RUBI were identified for redesign to ensure intervention-setting fit when used in schools. Method RUBI content was collaboratively and iteratively redesigned with elementary school partners, including 41 staff members from 28 schools. During the Discover Phase, the research team conducted in-class behavioral observations (N = 8) and cognitive walkthroughs (N = 15) with educators to identify implementation usability issues in the original RUBI intervention. In the Design/Build Phase, collaborative redesign sessions (N = 6) and demonstration studies (N = 12) were conducted to develop potential solutions to these issues. Implementation usability issues were systematically rated for importance and feasibility prior to redesign to guide the adaptation process. Results Conventional content analysis was used to code qualitative data and identify implementation usability issues. Two implementation usability issues were identified: (1) integration with other school-based systems of support and (2) data collection in schools. Conclusion Identifying and addressing usability issues may promote greater utility and successful implementation of RUBI in schools. Using partner-engaged methods allowed for the identification of critical implementation usability issues prior to the implementation of the redesigned intervention, RUBI in Educational Settings, or RUBIES. Implications to implementation in school settings are discussed, including potential ways to integrate RUBIES within existing school frameworks (i.e., MTSS) and streamline data collection with the use of technology.
Background Research has revealed persistent disparities in meeting the needs of racially minoritized youth identified with suicide risk in schools. An evidence-based trauma-informed suicide prevention practice, such as SAFETY-A (Safe Alternatives for Teens and Youth-Acute), may reduce unmet need and promote equitable care outcomes. Yet, it is highly challenging to implement practice innovations in under-resourced non-specialty settings, such as schools. Method We conducted a multi-level assessment of barriers to implementing SAFETY-A in school districts serving predominantly immigrant families of color. School-based providers ( N = 17) and caregivers and students ( N = 10) were interviewed about their perceptions of the feasibility and acceptability of SAFETY-A within their school and community context. Immersion and crystallization analytical methods were used to identify implementation barriers that align with the Health Equity Implementation Framework (HEIF). Results Eleven themes were identified across multiple determinant levels. Findings show that implementation barriers are interrelated across determinant levels. Major barriers were related to the lack of resources in schools; the historical context of system over-involvement with communities of color that contribute to (l)earned mistrust; and cultural and linguistic differences working with families. Conclusions Results aligned with HEIF domains implicated in maintaining health disparities. Implementation strategies for SAFETY-A in schools should be responsive to these determinants of disparities.
Introduction Despite an increased interest in implementation costs, there is little to no practical guidance on how to conduct implementation cost evaluations. Recommendations, tools, and examples are needed to incorporate reliable and feasible costing approaches into implementation studies and guidance on when an economist is necessary. To this end, we identified key issues and developed this paper and a guide on pragmatic approaches for assessing and reporting implementation costs. Method We assembled a team of implementation scientists and health economists working in various settings to identify central issues related to implementation costing. Our objective was to support the broad application of costing in implementation studies that is consistent, feasible, and can be practically applied. We engaged in a limited, iterative process of developing initial guidelines and soliciting feedback, consistent with principles of USE-EBPI (Usability Evaluation for Evidence-Based Psychosocial Interventions) methodology, to make refinements and enhance broad applicability. Results We developed initial recommendations for a limited number of critical issues to advance the application of costing in implementation science and illustrated them using a study example. These issues were: (a) identifying relevant resource costs, (b) capturing resources using activity-based costing (ABC), (c) valuing resource units, summarizing and reporting, and (d) estimating replication and sustainment costs. We also emphasize the need to tailor approaches to meet different contexts and project-specific needs, and provide guidance when additional help may be needed. Conclusions Key to ensuring any program's successful adoption, implementation, and sustainment is understanding the costs and resources required. Costing implementation in the “real world” is both an art and a science; teams must make decisions about give-and-take related to precision and burden on participants and the research team while still producing generalizable estimates. Transdisciplinary costing guidance can address these issues and provide details and resources to help pragmatically cost and report implementation efforts.
Background Patients with opioid use disorder (OUD) experience low treatment retention in primary care. Measurement-based care informed by patient-reported outcome measures (PROMs) is an evidence-based intervention to improve OUD outcomes. The study explored the key contextual factors to support the future planning of a PROM-based intervention package to improve primary care-based OUD treatment retention. Method A qualitative contextual inquiry used the Practical, Robust Implementation and Sustainability Model to assess the following contextual domains: Perspective of Intervention Characteristics, Partner Characteristics, and Implementation and Sustainability Infrastructure. Data were collected through interviews with system administrators, clinicians, and patients. Prioritized themes were triangulated with focus groups of community members with lived experience or interest in substance use care. Rapid thematic analysis identified emergent themes. Results We conducted 21 interviews (6 administrators, 10 clinicians, 5 patients) and two focus groups (22 community members). Fifteen themes emerged which fell into three categories: (1) maintaining patient trust while PROMs are integrated into workflows, (2) perspectives on PROM content and use, and (3) implementation considerations. PROMs were viewed as tools for enhancing communication, tracking recovery in a holistic and individualized way, and informing care decisions at the individual- and system-level. Patients emphasized trust, confidentiality, and potential negative consequences of PROM results being stored in health records. Clinicians highlighted the need for workflow integration and result interpretation support. All groups recommended PROMs be embedded in the electronic health record with collection managed by the integrated substance use treatment counselors. Conclusions The qualitative contextual inquiry identified partner perspectives relevant to the implementation of PROMs in primary care settings. The patient desire for trust and confidentiality may be at odds with integrating PROM results into existing systems. Continued engagement with implementation partners in a process of co-creation may improve implementation to support patient-centered, recovery-oriented care and enhance retention in primary care settings.
Background Overdose education and naloxone distribution (OEND) is a vitally important evidence-based practice for addressing the ongoing opioid epidemic. During the HEALing Communities Study in Kentucky, OEND was dramatically scaled up in eight counties using a “hub with many spokes” model and multifaceted implementation strategies. This aim of this manuscript is to describe qualitative perspectives of partner organizations regarding the utility of the implementation strategies used to expand OEND. Method Twenty small-group and 24 individual qualitative interviews were conducted with staff from 44 agencies that implemented OEND through partnerships with the study team. Interviews were conducted 6–8 months after the study's Communities That HEAL intervention had ended, allowing participants the ability to reflect on their experiences. Inductive coding in NVivo 12 and thematic analysis were used to identify themes regarding agencies’ perspectives regarding the implementation strategies deployed during the study. Results In describing implementation strategies that supported their efforts to implement OEND, interview participants largely focused on strategies that provided resources, such as shipments of no-cost naloxone and overdose education tools. Flexibility in how the requisite overdose education was delivered allowed agencies to identify an educational approach that fit their workflow and addressed OEND recipients’ needs. Participants also viewed implementation facilitation and technical assistance provided by study staff as helpful in facilitating the implementation process. Conclusions These qualitative data highlight the importance of multifaceted implementation strategies in the process of scaling up EBPs in communities. Future efforts should continue to explore how implementation strategies can be optimized to meet the needs of diverse types of organizations seeking to implement OEND and other evidence-based practices that can mitigate the harms of the opioid epidemic.
Background To design accessible interventions, understanding how best to implement them in context is essential. Strategies that reflect community perspectives may be most relevant and impactful. This study aimed to identify and specify community-sourced implementation strategies for delivering a mental health and alcohol use intervention for fathers in Kenya and to map them to the Expert Recommendations for Implementing Change (ERIC) taxonomy.Method In Eldoret, Kenya, focus groups (seven groups; 31 participants) and key informant interviews (n = 18) were conducted with hospital leaders, policymakers, mental health providers, community leaders, fathers, lay providers, patients, and men currently experiencing mental health and alcohol use challenges. Data were analyzed using the framework method to generate high-level codes, followed by a second phase to extract, specify, and review implementation strategies.Results Community members identified lay providers recruited from the community as a promising delivery approach, with professional providers contributing to linkage to care and support for more acute needs. Engagement of community leaders and leveraging existing infrastructure were seen as key to enhancing implementation and reach, particularly among men. Multiple delivery settings (e.g., church, hospital, school) were considered acceptable depending on patient preference. A total of 25 unique community-sourced strategies were identified: three directly matched ERIC strategies, 19 were adapted, and two were unique to the community context.Conclusions This study identified locally grounded implementation strategies to guide early-stage intervention delivery for fathers in Kenya. Findings contribute to the growing body of implementation science in non-Western contexts and highlight a participatory approach for identifying and specifying strategies relevant to local systems and populations.
Introduction Around 55,000 pregnant individuals enter US jails annually, with over one-third having a substance use disorder (SUD), putting them at risk of perinatal morbidity and mortality. Yet, uptake of perinatal/SUD care best-practices into jails is slow, impacted by many organizational factors. This study explores the organizational contexts that shape decision-making structures and policy development regarding perinatal/SUD care in North Carolina (NC) jails.Method We conducted semi-structured interviews with employees at 26 NC jails in 2023. Interview transcripts were de-identified and analyzed using ideal-type analysis methodology. Two team members created organizational context summaries, proposed ideal-types (i.e., categories based on shared characteristics), and categorized each interviewed jail. A third team member performed a credibility check, and discrepancies were resolved through team consensus.Results We constructed three jail ideal-types based on organizational capacity to implement new care policies, identify medical care alternatives to incarceration through community and judiciary connections, and foster collaborative decision making between custody and medical staff regarding perinatal/SUD care. Proactive and Collaborative jails (n = 6) had recently implemented evidence-based programs and/or policies, facilitated referrals to alternatives to incarceration, and collaborated across roles in perinatal/SUD care innovation. Responsive and Coordinated jails (n = 15) had more limited perinatal/SUD implementation experience, fewer connections for alternatives to incarceration, and less management collaboration. Traditional jails (n = 5) had not implemented new programs and/or policies, did not identify local alternatives to incarceration, and maintained centralized and siloed decision-making structures.Conclusions These typologies provide a conceptual framework for understanding leadership structures and care innovation in NC jails regarding perinatal/SUD care. This framework can be applied to collaborative initiatives with jails to help develop context-specific implementation teams and strategies for integrating perinatal/SUD best-practices. Understanding these organizational contexts is crucial for developing tailored approaches that support jails in their uptake and delivery of perinatal/SUD evidence-based practice to ultimately improve perinatal outcomes.
Background Traumatic brain injury (TBI) is common among individuals seeking treatment for substance use disorders in behavioral healthcare settings, but evidence-based TBI screening methods are underutilized. We investigated provider perceptions of the acceptability, feasibility, and appropriateness of TBI screening, and whether these perceptions influenced the relationships between screening intentions and behaviors. Understanding how these implementation outcomes are interrelated can help clarify the temporal sequencing of implementation processes and lead to more precise and cost-effective dissemination and implementation (D&I) strategies.Method In Phase 1 of this explanatory sequential mixed methods study, 215 behavioral healthcare providers completed an electronic survey assessing their intentions to screen for TBI using the Ohio State University TBI Identification Method (OSU TBI-ID). After 1-month, a second survey assessed the number of screens conducted, and perceptions of the acceptability, feasibility, and appropriateness of the OSU TBI-ID. Binary logistic regressions were used to examine whether acceptability, feasibility, and appropriateness moderated the relationship between screening intentions and behaviors. In Phase 2, 20 providers participated in an interview to contextualize the quantitative results. Qualitative data were analyzed thematically and integrated with the quantitative results.Results The mean acceptability, feasibility, and appropriateness scores were 4.12, 4.02, and 3.69, respectively. Acceptability (OR = 0.80, p = .29), feasibility (OR = 0.93, p = .88), and appropriateness (OR = 0.97, p = .65) of TBI screening did not moderate the relationship between intentions and behaviors. Providers endorsed the OSU TBI-ID as easy to use and integrate into practice, relevant to clients, and helpful in guiding referrals and treatment decision-making.Conclusions Positive perceptions of an intervention are important but insufficient for shaping the transition from intentions to behavior. This study begins to disentangle interrelationships between early-phase implementation outcomes, which can help guide more precise D&I strategy development to enhance implementation efficiency and effectiveness.
Background Strategies to implement evidence-based practices often require modifications. A systematic approach to documenting these changes was not widely adopted until the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS) emerged in 2021, enabling researchers to characterize both proactive and reactive implementation changes. While publications demonstrating the FRAME-IS's application are emerging, few have reflected on the use of the tool itself. The National Institutes of Health-funded Deidentified Opioid Initiative R01 trial, testing strategies to implement the Centers for Disease Control and Prevention guidelines on opioid prescribing, offered a timely chance to assess the FRAME-IS's utility in a multisite, hybrid type-3 trial. Method An interdisciplinary team of researchers, clinicians, and implementers documented modifications using the FRAME-IS across four implementation strategies that comprise an implementation package called systems consultation: (1) audit and feedback, (2) educational meetings, (3) practice facilitation, and (4) prescriber peer consulting. Modifications were needed due to COVID-19, the rise in telemedicine, changes in opioid prescribing, and healthcare system variations. Results The Deidentified Opioid Initiative was implemented in 32 clinics within two Midwestern healthcare systems using a sequential, multiple-assignment randomized trial. The implementation team completed the FRAME-IS's seven modules for each strategy's modifications and reflected on the process of using the tool, strengths, and limitations. Conclusions The team found the FRAME-IS is practical, comprehensive, and user-friendly. It effectively documents modifications and fosters reflection, raising critical questions about implementation. Challenges included role blurring (i.e., researcher/implementer/coordinator), capturing the complexity of cascading modifications (i.e., how one modification leads to another), and a lack of reporting options to capture modifications in a clustered, multisite trial (i.e., clinical staff nested in clinics nested in healthcare systems). Considerations and recommendations from this case study can enhance the FRAME-IS, guide other scholars in its use, and improve the research community's ability to measure the dynamic evolution of implementation strategies systematically. Future research should explore how documented modifications impact implementation outcomes.
Background:To help improve the implementation of evidence-based substance use disorder (SUD) treatment in practice settings, the United States funds a support system called the Addiction Technology Transfer Center (ATTC) network. Prior implementation research in HIV care found the team-focused Implementation and Sustainment Facilitation (ISF) strategy as an effective addition to the ATTC's staff-focused training, feedback, and consultation (TFC) strategy. Using the ISF + TFC strategy as the control, this type-3 hybrid trial tested the effectiveness of adding a staff-focused incentivization (INC) strategy (ISF + TFC + INC vs. ISF + TFC). Staff-focused incentivization was selected because prior implementation research found it to be highly effective and cost-effective for improving SUD treatment implementation. Methods:Twenty-six HIV service organizations (HSOs), their staff participants (N = 87), and their client participants (N = 341) were cluster-randomized to either the ISF + TFC control condition or ISF + TFC + INC experimental condition. The INC strategy rewarded/reinforced motivational interviewing brief intervention (MIBI) implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined. Results:The addition of the INC strategy had a large and significant (p < .05) effect on the number of MIBIs implemented (d = 1.30) and reduction in anxiety (d = -1.54). There was no significant impact on days of substance use. Conclusions:The addition a staff-focused INC strategy improved implementation of an evidence-based brief intervention for adults with comorbid HIV and SUD, and also reduced anxiety. To help improve the integration of evidence-based SUD services in HSOs across the United States, use of the ISF + TFC + INC strategy by the ATTC network and/or the AIDS Education and Training Center (AETC) network is recommended.
Introduction: Front-line implementers report that selecting an evidence-based practice is the most challenging aspect of supporting Autistic students, which may contribute to the long-standing implementation gap. There is a need to understand educators’ (special education teachers’, general education teachers’, and paraeducators’) decision-making and determinants of their evidence-based practice (EBP) selection. Method: This study aimed to identify educators’ decision-making factors, focusing on (a) information sources and (b) factors within the student, intervention, educator, and classroom levels. Eighty-one educators (general education teachers, special education teachers, and paraeducators) participated in semistructured interviews regarding their EBP selection for a specific student they served in inclusive classrooms. Results: General and special education teachers cited EBP sources from their teacher preparation and colleagues with autism expertise, while paraeducators relied on existing classroom practices and guidance from other educators. EBP decision-making frequently revolved around student and intervention characteristics, focusing less on educator, environment, and resource determinants. Educators made individualized EBP decisions for each student, selecting EBPs that served all students. They also shared that their decision-making was most supported through collaboration, despite limited opportunity. Conclusion: The study provides insights into key team members’ EBP selection for Autistic students to aid in the development of implementation supports.
Background Dissemination initiatives have the potential to increase consumer knowledge of and engagement with evidence-based treatments (e.g., cognitive behavioral therapy [CBT]). Opinion leaders (OLs) have been used in public health campaigns, but have not been examined for the dissemination of mental health treatments. This study uses the Theory of Planned Behavior to test the dissemination strategy of involving an OL in an educational presentation to increase caregiver demand for CBT for youth anxiety.Method Participants (N = 262; 92% female; 69% White, 82% non-Hispanic) were caregivers who registered for a virtual presentation on youth anxiety treatment through their child's school. Schools within 1.5-hr drive of Philadelphia, PA were cluster-randomized (k = 25; two-arm prospective randomization) to the OL condition (presented by a clinical researcher and local caregiver OL; n = 119 participants) or the researcher-only condition (n = 143 participants). Presentations occurred from May 2021 to May 2022. Measures were completed pre- and post-presentation and at 3-month follow-up.Results Relative to the researcher co-presenter, participants rated the OL as significantly more relatable, familiar, similar, and understanding of their community, but less credible than the researcher co-presenter. In both conditions, there was a significant pre-post increase in participants' knowledge of, attitudes about, subjective norms related to, and intention of seeking CBT for youth anxiety, but not stigma. Presentation conditions did not differ in change on these measures, or on rates of seeking youth anxiety CBT at follow-up.Conclusions Although involvement of a caregiver OL did not increase caregiver demand for evidence-based treatment for youth anxiety, the outreach presentation was associated with increases in knowledge of, attitudes about, subjective norms related to, and intention to seek CBT for youth anxiety. Involving OLs in researcher-delivered dissemination efforts may not be necessary for all consumer audiences, but may be beneficial for engendering a sense of relatability, similarity, and connection with disseminators.
Background In South Africa, rates of HIV and alcohol use are among the highest globally, with a detrimental synergistic relationship. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, cost-effective approach to identifying people at risk of alcohol-related problems to deliver early intervention. We developed and deployed a cascading train-the-trainer model to promote SBIRT implementation in a large nongovernmental organization offering HIV services across South Africa. Method Between 2021 and 2022, we completed preparatory activities including designing scalable training resources prior to rolling out the train-the-trainer model across two South African provinces. We conducted a comprehensive assessment of outcomes at the trainer- (knowledge, fidelity), provider- (attitudes, confidence, perceived implementation potential, adoption), and client-encounter (reach) levels over approximately one year. Results We trained 12 novice trainers who then trained 206 providers to implement SBIRT. Trainer SBIRT knowledge increased pre- to posttraining, and fidelity of training delivery was high (99.0% of elements covered across sessions). Provider attitudes, confidence, and perceived implementation potential increased over time, and 64% of providers adopted SBIRT. Reach of the model varied by component, with 41,793 clients screened by trained providers. Of those screening positive for risky alcohol use, 86% received brief intervention (BI) and 53% received referral to treatment (RT). Additionally, 15,353 clients who did not screen as having risky alcohol use received BI and 1,122 received RT. Conclusion Results indicated that the cascading training model was delivered with high fidelity, associated with improvements in all provider outcomes, and reached high numbers of clients for the screening component of the model. Rates of BI and RT delivery were moderate to high, though data suggested over-application of these elements with some clients, highlighting the tension between reach and fidelity. Lessons learned will inform future scale-out of this model in HIV service settings in low- and middle-income countries.
Background: Chronic insomnia disorder affects 10–15% of adults, causing significant individual and societal burden. Despite Cognitive Behavioral Therapy for Insomnia (CBT-I) being the recommended first-line, sleep medications remain more common due to limited access to trained providers. Digital CBT-I offers a scalable solution, but evidence of its real-world impact in U.S. clinical settings is lacking. Method: This study evaluates real-world implementation and impact of digital CBT-I in U.S. clinical settings, using Normalization Process Theory (NPT) to guide integration at Henry Ford Health, Detroit, Michigan. Implementation success was assessed through order rates, patient sign-ups and workflow acceptability. We assess the effect on healthcare utilization through a propensity-matched observational treatment-control design. Results: Implementation was successful, with 1,162 patients offered digital CBT-I. From this cohort, we analyzed a sample of 340 patients with sufficient chart data and established care (120 days) who utilized digital CBT-I, comparing them to 340 matched standard care controls. Patients who used digital CBT-I had a 64% reduction in the odds of any medication fill during the postwindow period ( p < .001) and were 53% less likely to fill insomnia medication prescriptions compared with the preperiod ( p = .013). Controls did not have any significant reductions in medication fill rates. Time-varied analysis showed digital CBT-I patients had transiently higher outpatient visit odds at 30–60 days, followed by sustained reductions of 28% (120–150 days) and 31% (150–180 days). After covariate adjustment, early differences were nonsignificant while later reductions remained significant. Conclusions: NPT facilitated integration of digital CBT-I into existing workflows, allowing immediate access while minimizing disruption to routine practice. Provider training sessions and reminders effectively promoted suitable patient uptake. Digital CBT-I was associated with reduced medication fills pre-to-post with an initial rise and then sustained reduction in outpatient service utilization patterns over time. A key limitation is the use of individuals who declined digital CBT-I as comparators, which may introduce selection bias. Generalizability may be limited as the study was conducted within a single healthcare system. Trial Registration: Not applicable—the assignment of the medical intervention to patients was not at the discretion of the investigators.
