The science of deimplementation—reducing harmful or ineffective practices—has focused almost exclusively on clinical prescribing, with no studies conducted in community or educational settings. Early care and education (ECE) settings offer a strategic venue for shaping eating behaviors, with children consuming up to 500 meals annually in these environments. However, ECE educators routinely use feeding practices that undermine self-regulation, including pressuring children to eat, rushing mealtimes, and offering food as reward. These practices contribute to food aversions, diminished self-regulation, and obesity risk. We will conduct a Hybrid Type 3 cluster-randomized trial evaluating a co-designed deimplementation strategy package (WISE Words) across 88 ECE sites in Arkansas and Louisiana. Sites will be randomized 1:1 to WISE Words or usual practice, with usual practice sites receiving the intervention after two years (waitlist design). WISE Words includes six strategies: dynamic training using improvisation methods, peer learning collaboratives with goal setting, external facilitation, audit and feedback, environmental reminders, and tailored educational materials. The primary outcome is de-adoption of inappropriate feeding practices measured via direct mealtime observation (Table Talk). Secondary outcomes include adoption of evidence-based practices, acceptability, appropriateness, and sustainability at 12- and 24-months post-intervention. Child outcomes include Body Mass Index, skin carotenoid levels (Veggie Meter) willingness to try new foods (observed) and food neophobia (teacher and caregiver report). An explanatory sequential mixed methods design will test mechanisms of change derived from the Implementation Trust Building Theory of Change examining whether trust mediates strategy effects on outcomes. This trial extends deimplementation science into community settings by targeting culturally embedded behavioral practices rather than clinical prescribing behaviors. Results will inform approaches to shifting entrenched practices in ECE and similar settings while testing trust as a deimplementation mechanism. Sustainability assessments will address a notable gap, as few studies have examined whether deimplementation effects persist. NCT07101321, July 20, 2025.
Practice facilitation is an effective multicomponent strategy that focuses on building primary care practice capacity for continuous quality improvement. Despite its growing use, few frameworks empirically specify how practice facilitation strategies are operationalized in resource-constrained settings such as small, independent primary care practices (SIPs). This study aimed to further expand our understanding of core practice facilitation processes and strategies used to facilitate the adoption of evidence-based interventions in SIPs. We conducted a qualitative analysis of practice facilitator (PF) field notes from a stepped-wedge randomized controlled trial evaluating the impact of practice facilitation on adoption of team-based care (TBC) for hypertension management in 74 SIPs across New York City. Facilitators conducted 16 structured site visits per practice over a 12-month intervention period and documented implementation activities after each visit using a standardized digital platform. We analyzed 528 visit transcripts using a hybrid deductive–inductive approach. Deductive coding focused on established practice facilitation strategy domains; inductive coding identified novel processes and strategies that emerged from the data. Coding was conducted iteratively with regular team calibration and member checking with the PF team. We identified an iterative process in which PFs observe/listen, diagnose, engage, and problem solve throughout the implementation period – a dynamic approach not described in previous frameworks. This process enhanced PFs’ understanding of each practice’s context and guided their selection and application of a core set of practice facilitation strategies. These included previously documented strategies such as training, coaching, educating, and facilitating, as well as a novel strategy we identified: modeling, in which PFs demonstrated specific tasks or workflows in real-time alongside staff, building confidence and reinforcing learning. This study refines and extends current facilitation frameworks to further define core processes and strategies that drive practice transformation in SIPs. The framework provides practical guidance for implementation efforts targeting small practice settings. ClinicalTrials.gov; NCT05413252; 2022-06-09.
The treatment of depression is essential for improving both psychiatric and medical outcomes for youth with HIV (YWH). Previous studies have shown that the combination of a medication algorithm and CBT tailored for YWH (COMB) is efficacious for decreasing depressive symptoms and improving quality of life, but sustainability of effects remains difficult. Most recently, a cluster-randomized RCT found at Week 24 statistically significant improvement in the site-level mean number of depressive symptoms, the proportion of YWH with a treatment response, and the proportion in remission at COMB sites compared to treatment as usual (TAU) sites (6.7 vs. 10.6, 62
Nurse-initiated care improves timely treatment access, but adoption varies. The Ministry of Health introduced 73 Emergency Care Assessment and Treatment (ECAT) protocols for public emergency departments (EDs) to standardise nurse-initiated care. A behaviour change strategy was used to implement ECAT in 29 EDs as part of a trial, using implementation strategies like education, clinical champions, videos, and audit and feedback. The aim of this study was to evaluate the implementation of the ECAT protocol and the strategies used for reach, effectiveness, adoption, quality, and maintenance (REAIM). This multi-method implementation evaluation used the RE-AIM framework. Methods comprised: i) emergency nurse surveys (Intervention and Control groups); ii) scoring by site implementation nurses of fidelity, adaptation and effectiveness of implementation strategies out of 5; iii) audits determining appropriateness of ECAT protocol use at 6–12 weeks and iv) implementation tracking logs during all study periods. Descriptive statistics were used for quantitative data, and content analysis for qualitative data (surveys/logs). Data from surveys (n = 787), audits (1375 audits, 509 nurses), fidelity scores (n = 11), and implementation tracking logs (>600 entries) were used to evaluate implementation of ECAT protocols in the 29 EDs. Emergency nurses reported high use of ECAT protocols in their daily practice (median (IQR) 9.0 (8.0, 10.0), and audits demonstrated 92.9
Qualitative methods are now central to implementation science, but they are used to do different kinds of work that are not always clearly distinguished. Some studies are designed to develop contextual or conceptual understanding, while others are expected to inform near-term decisions about rollout, adaptation, or implementation strategies. When these differences remain implicit, qualitative studies may be designed and evaluated against expectations they were never intended to meet, particularly around the role of theory, openness to unanticipated findings, and what counts as rigor. In this debate paper, we argue for a more explicit way of thinking about qualitative inquiry in implementation science. Rather than treating qualitative methods as a single approach, we suggest they are being configured in different ways in response to study purpose, time and resource constraints, the state of knowledge about the phenomenon or context, and stakeholder expectations. To make these differences visible, we propose a positioning framework that locates qualitative inquiry along a continuum of three orientations: Generative, Pragmatic, and Action-oriented. Generative inquiry prioritizes contextual depth and conceptual development; Action-oriented inquiry is organized to produce timely, decision-relevant findings; Pragmatic inquiry occupies the space between these poles. We then introduce a positioning guide and an accompanying table to show how these orientations shape key aspects of qualitative design, including question formulation, the role of theory, sampling, data collection, analysis, and reporting. The contribution of this paper is a framework for describing what qualitative studies in implementation science are trying to produce and how they should be assessed. Qualitative rigor cannot be reduced to a single standard when studies are making different kinds of claims. Making methodological positioning more explicit may help reduce mismatched expectations in study design and peer review, and support more consistent judgments about the contribution of qualitative work in implementation science.
