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A Mixed Methods Study of the Stages of Implementation for an Evidence-Based Trauma Intervention in Schools.

ABSTRACT: A mixed methods study was conducted to examine the implementation process of 26 urban school-based mental health clinics that took part in a training and implementation support program for an evidence-based school trauma intervention. Implementation process was observed using the Stages of Implementation Completion (SIC) measure. Qualitative interviews were conducted with clinic leaders in order to gain insight into clinic processes related to the SIC. Results showed that almost all of the clinics engaged in some activities related to pre-implementation (engagement, feasibility, and readiness), but only 31% of the sites formally started delivering the program to youth. Completing more pre-implementation activities, particularly those related to readiness, predicted program start-up. Qualitative analysis comparing those that implemented the program to those that did not revealed critical differences in decision-making processes, leadership strategies, and the presence of local champions for the program. This study documented the patterns of clinic behavior that occurs as part of large-scale training efforts, suggests some unique challenges that occur in schools, and highlights the importance of engaging in particular implementation activities (i.e., readiness planning, stakeholder consensus and planning meetings) as part of program start-up. Findings indicate that pre-implementation and readiness-related consultation should be employed as part of broad-scale implementation and training efforts.

SUBMITTER: Nadeem E

PROVIDER: S-EPMC6020145 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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A Mixed Methods Study of the Stages of Implementation for an Evidence-Based Trauma Intervention in Schools.

Nadeem Erum E Saldana Lisa L Chapman Jason J Schaper Holle H

Behavior therapy 20171215 4

A mixed methods study was conducted to examine the implementation process of 26 urban school-based mental health clinics that took part in a training and implementation support program for an evidence-based school trauma intervention. Implementation process was observed using the Stages of Implementation Completion (SIC) measure. Qualitative interviews were conducted with clinic leaders in order to gain insight into clinic processes related to the SIC. Results showed that almost all of the clini ...[more]

PMID: 29937254

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Project description:This protocol describes the 'development of outcome measures and suitable methodologies for dissemination and implementation approaches,' a priority for implementation research. Although many evidence-based practices (EBPs) have been developed, large knowledge gaps remain regarding how to routinely move EBPs into usual care. The lack of understanding of 'what it takes' to install EBPs has costly public health consequences, including a lack of availability of the most beneficial services, wasted efforts and resources on failed implementation attempts, and the potential for engendering reluctance to try implementing new EBPs after failed attempts.The Stages of Implementation Completion (SIC) is an eight-stage tool of implementation process and milestones, with stages spanning three implementation phases (pre-implementation, implementation, sustainability). Items delineate the date that a site completes implementation activities, yielding an assessment of duration (time to complete a stage), proportion (of stage activities completed), and a general measure of how far a site moved in the implementation process.We propose to extend the SIC to EBPs operating in child service sectors (juvenile justice, schools, substance use, child welfare). Both successful and failed implementation attempts will be scrutinized using a mixed methods design. Stage costs will be measured and examined. Both retrospective data (from previous site implementation efforts) and prospective data (from newly adopting sites) will be analyzed. The influence of pre-implementation on implementation and sustainability outcomes will be examined (Aim 1). Mixed methods procedures will focus on increasing understanding of the process of implementation failure in an effort to determine if the SIC can provide early detection of sites that are unlikely to succeed (Aim 2). Study activities will include cost mapping of SIC stages and an examination of the relationship between implementation costs and implementation performance (Aim 3).This project fills a gap in the field of implementation science by addressing the measurement gap between the implementation process and the associated costs. The goal of this project is to provide tools that will help increase the uptake of EBPs, thereby increasing the availability of services to youth and decreasing wasted resources from failed implementation efforts.

Project description:BackgroundTimely and comprehensive treatment in the form of early psychosis intervention (EPI) has become the standard of care for youth with psychosis. While EPI services were designed to be delivered in person, the COVID-19 pandemic required many EPI programs to rapidly transition to virtual delivery, with little evidence to guide intervention adaptations or to support the effectiveness and satisfaction with virtual EPI services.ObjectiveThis study aims to explore the adaptations required to deliver NAVIGATE, a model of coordinated specialty care used in EPI, in a virtual format. This study will evaluate implementation of the NAVIGATE model delivered virtually by describing the nature of the adaptations to the intervention, assessing fidelity to the EPI model and the satisfaction of clients, family members, and care providers. We will investigate barriers and facilitators to virtual NAVIGATE implementation, service engagement, and health equity impacts of this work.MethodsThe Centre for Addiction and Mental Health (Toronto, Ontario, Canada) transitioned to delivering NAVIGATE virtually early in the COVID-19 pandemic. The Framework for Reporting Adaptations and Modifications for Evidence-Based Interventions will be used to describe the adaptations required to deliver NAVIGATE virtually. Fidelity to the EPI model will be measured using the First Episode Psychosis Services Fidelity Scale and fidelity to NAVIGATE will be assessed by investigating adherence to its core components. Implementation facilitators and barriers will be explored using semistructured interviews with providers informed by the Consolidated Framework for Implementation Research. Satisfaction with virtually delivered NAVIGATE will be assessed with virtual client and provider experience surveys and qualitative interviews with clients, family members, and providers. Service engagement data will be collected through review of medical records, and potential impacts of virtually delivered NAVIGATE on different population groups will be assessed with the Health Equity Impact Assessment.ResultsVirtual clinical delivery of NAVIGATE started in March 2020 with additional adaptations and data collection is ongoing. Data will be analyzed using descriptive statistics and survival analysis for quantitative data. Qualitative data will be analyzed using thematic content analysis. Integration of qualitative and quantitative data will occur at the data collection, interpretation, and reporting levels following a convergent design.ConclusionsThis study will provide information regarding the type of intervention adaptations required for virtual delivery of NAVIGATE for youth with early psychosis, ensuring access to high-quality care for this population during the pandemic and beyond by guiding future implementation in similar contexts.International registered report identifier (irrid)DERR1-10.2196/34591.

Project description:IntroductionFlipped classroom pedagogy (FCP) is recognised as an effective and efficient teaching-learning method. However, nursing students and teachers may be hesitant to adopt FCP due to technophobia and time constraints linked to academic and clinical responsibilities. This necessitates the provision of promotional training for adopting FCP. However, there is a dearth of research regarding how the practice of FCP could be promoted and in demonstrating its efficacy in developing countries. Thus, this study aimed to examine the educational impact of a web-based education intervention, branded as the Flipped Classroom Navigator (FCN), for promoting FCP in nursing education in Sri Lanka.MethodsThis mixed-methods study employed pre- and post-training knowledge tests, the Instructional Materials Motivation Survey (IMMS), the Perceived Transfer of Learning Questionnaire survey, and collected students' and teachers' open-ended responses to evaluate the impact of the FCN. Fifty-five undergraduate nursing students and 15 university teachers participated in the study from two state universities in Sri Lanka. Repeated-measures ANOVA, t-tests, Levene's test of homogeneity, Cohen's d, and an inductive thematic approach were employed in the data analysis.ResultsPost-training knowledge test scores were significantly higher than the pre-training knowledge test scores indicating improved understanding of FCP. Participants were also highly motivated to learn in the FCN instructional materials. Participants exhibited positive attitudes towards FCN training with transfer of learning to their teaching-learning practice. The inductive thematic analysis identified the following themes: user experiences, FCN learning content, behaviour changes, and suggested improvements.ConclusionOverall, the FCN enhanced both students' and teachers' knowledge and understanding of FCP in undergraduate nursing education.Supplementary informationThe online version contains supplementary material available at 10.1007/s40670-022-01706-7.

Project description:BackgroundCommunity-based educational programs can complement clinical strategies to increase cancer screenings and encourage healthier lifestyles to reduce cancer burden. However, implementation quality can influence program outcomes and is rarely formally evaluated in community settings. This mixed-methods study aimed to characterize implementation of a community-based cancer prevention program using the Consolidated Framework for Implementation Research (CFIR), determine if implementation was related to participant outcomes, and identify barriers and facilitators to implementation that could be addressed.MethodsThis study utilized quantitative participant evaluation data (n = 115) and quantitative and qualitative data from semi-structured interviews with program instructors (N = 13). At the participant level, demographic data (age, sex, insurance status) and behavior change intention were captured. Instructor data included implementation of program components and program attendance to create a 7-point implementation score of fidelity and reach variables. Degree of program implementation (high and low) was operationalized based on these variables (low: 0-4, high: 5-7). Relationships among degree of implementation, participant demographics, and participant outcomes (e.g., intent to be physically active or limit alcohol) were assessed using linear or ordinal logistic mixed effects models as appropriate. Interview data were transcribed and coded deductively for CFIR constructs, and constructs were then rated for magnitude and valence. Patterns between ratings of high and low implementation programs were used to determine constructs that manifested as barriers or facilitators.ResultsProgram implementation varied with scores ranging from 4 to 7. High implementation was related to greater improvements in intention to be physically active (p < 0.05), achieve a healthy weight (p < 0.05), and limit alcohol (p < 0.01). Eight constructs distinguished between high and low implementation programs. Design quality and packaging, compatibility, external change agents, access to knowledge and information, and experience were facilitators of implementation and formally appointed internal implementation leaders was a barrier to implementation.ConclusionsAs higher implementation was related to improved participant outcomes, program administrators should emphasize the importance of fidelity in training for program instructors. The CFIR can be used to identify barriers and/or facilitators to implementation in community interventions, but results may be unique from clinical contexts.

Project description:BackgroundThis article describes factors related to adoption, implementation, and effectiveness of the Virtual Pediatric Trauma Center intervention, which uses telehealth for trauma specialist consultations for seriously injured children. We aimed at (1) measuring RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation outcomes and (2) identifying PRISM (Practical, Robust, Implementation, and Sustainability Model) contextual factors that influenced the implementation outcomes.MethodsThis interim implementation evaluation of our telehealth trial used a convergent mixed-methods design. The quantitative component was a cross-sectional analysis of pediatric trauma encounters using electronic health records. The qualitative component was a thematic analysis of written and verbal feedback from providers and family advisory board meetings. We compared the quantitative and qualitative data by synthesizing them in a joint display table, organized by RE-AIM dimensions. We categorized these key findings into the PRISM domains.ResultsDuring the first 10 months of this trial, 246 subjects were randomized, with 177 assigned to standard care and 69 assigned to telehealth. Four referring sites transitioned from standard care into their intervention period. PRISM contextual factors that influenced RE-AIM implementation outcomes included the following findings: Providers struggle to remember, interpret, and navigate intervention workflows; providers have preconceived ideas about the intervention purpose; the intervention mitigates parents' anxieties about the transfer process.DiscussionThis study revealed implementation challenges that influence the overall success of this telehealth trial. Early identification of these challenges allows our team the opportunity to address them now to optimize the intervention reach, adoption, and implementation. This early action will ultimately enhance the success of our trial and the ability of our intervention to achieve broad impact.

Project description:BackgroundIndividual-level implementation determinants, such as clinician attitudes, commonly influence the successful adoption of evidence-based practices, but few explicit strategies have been tested with regard to their ability to impact these key mechanisms of change. This paper reports on an initial test of a blended, theoretically informed pre-implementation strategy designed to target malleable individual-level determinants of behavior change. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a brief and pragmatic pre-implementation strategy that uses strategic education, social influence techniques, and group-based motivational interviewing to target implementation attitudes, perceived social norms, perceived behavioral control, and behavioral intentions to implement among mental health clinicians working in the education sector.MethodsAs part of a pilot trial, 25 school mental health clinicians were randomized to BASIS (n = 12) or an attention control placebo (n = 13), with both conditions receiving training and consultation in an evidence-based intervention for youth experiencing trauma (the Cognitive Behavioral Intervention for Trauma in Schools). Theorized mechanisms of change (attitudes, perceived social norms, perceived behavioral control, and behavioral intentions) were assessed at baseline, post-training, and 4-month follow-up. Clinician participation in post-training consultation and intervention adoption were also tracked.ResultsA series of regression models and independent sample t tests indicated that BASIS had significant, medium to large effects on the majority of its proximal mechanisms from baseline to post-training. BASIS was also associated with a greater latency between initial training in the intervention and discontinuation of participation in post-training consultation, with clinicians in the BASIS condition persisting in consultation for an average of 134 days versus 32 days for controls, but this difference was not statistically significant. At 4-month follow-up, most differences in the theorized mechanisms had attenuated, and approximately the same small number of BASIS clinicians adopted the trauma intervention as controls.ConclusionFindings suggest that the brief BASIS pre-implementation strategy had a significant influence on its proximal mechanisms of change, but that these changes did not persist over time or translate into adoption of the trauma intervention. Implications for theory refinement, revisions to the BASIS protocol, and next steps for research surrounding individual-level implementation strategies are discussed.Trial registrationClinicalTrials.gov Identifier: NCT03791281 . Registered 31 December 2018-Retrospectively registered.

Project description:BACKGROUND:Technology-enabled services (TESs), which integrate human service and digital components, are popular strategies to increase the reach and impact of mental health interventions, but large-scale implementation of TESs has lagged behind their potential. OBJECTIVE:This study applied a mixed qualitative and quantitative approach to gather input from multiple key user groups (students and educators) and to understand the factors that support successful implementation (implementation determinants) and implementation outcomes of a TES for universal screening, ongoing monitoring, and support for suicide risk management in the school setting. METHODS:A total of 111 students in the 9th to 12th grade completed measures regarding implementation outcomes (acceptability, feasibility, and appropriateness) via an open-ended survey. A total of 9 school personnel (school-based mental health clinicians, nurses, and administrators) completed laboratory-based usability testing of a dashboard tracking the suicide risk of students, quantitative measures, and qualitative interviews to understand key implementation outcomes and determinants. School personnel were presented with a series of scenarios and common tasks focused on the basic features and functions of the dashboard. Directed content analysis based on the Consolidated Framework for Implementation Research was used to extract multilevel determinants (ie, the barriers or facilitators at the levels of the outer setting, inner setting, individuals, intervention, and implementation process) related to positive implementation outcomes of the TES. RESULTS:Overarching themes related to implementation determinants and outcomes suggest that both student and school personnel users view TESs for suicide prevention as moderately feasible and acceptable based on the Acceptability of Intervention Measure and Feasibility of Intervention Measure and as needing improvements in usability based on the System Usability Scale. Qualitative results suggest that students and school personnel view passive data collection based on social media data as a relative advantage to the current system; however, the findings indicate that the TES and the school setting need to address issues of privacy, integration into existing workflows and communication patterns, and options for individualization for student-centered care. CONCLUSIONS:Innovative suicide prevention strategies that rely on passive data collection in the school context are a promising and appealing idea. Usability testing identified key issues for revision to facilitate widespread implementation.

Dataset Information

A Mixed Methods Study of the Stages of Implementation for an Evidence-Based Trauma Intervention in Schools.

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A Mixed Methods Study of the Stages of Implementation for an Evidence-Based Trauma Intervention in Schools.

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