Publications by authors named "Gregory A Aarons"

207 Publications

Advancing mechanisms of implementation to accelerate sustainable evidence-based practice integration: protocol for generating a research agenda.

BMJ Open 2021 10 18;11(10):e053474. Epub 2021 Oct 18.

Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA.

Introduction: Mechanisms explain implementation strategies work. Implementation research requires careful operationalisation and empirical study of the causal pathway(s) by which strategies effect change, and factors that may amplify or weaken their effects. Understanding mechanisms is critically important to replicate findings, learn from negative studies or adapt an implementation strategy developed in one setting to another. Without understanding implementation mechanisms, it is difficult to design strategies to produce expected effects across contexts, which may have disproportionate effects on settings in which priority populations receive care. This manuscript outlines the protocol for an Agency for Healthcare Research and Quality-funded initiative to: (1) establish priorities for an agenda to guide research on implementation mechanisms in health and public health, and (2) disseminate the agenda to research, policy and practice audiences.

Methods And Analysis: A network of scientific experts will convene in 'Deep Dive' meetings across 3 years. A research agenda will be generated through analysis and synthesis of information from six sources: (1) systematic reviews, (2) network members' approaches to studying mechanisms, (3) new proposals presented in implementation proposal feedback sessions, (4) working group sessions conducted in a leading implementation research training institute, (5) breakout sessions at the Society for Implementation Research Collaboration's (SIRC) 2019 conference and (6) SIRC conference abstracts. Two members will extract mechanism-relevant text segments from each data source and a third member will generate statements as an input for concept mapping. Concept mapping will generate unique clusters of challenges, and the network will engage in a nominal group process to identify priorities for the research agenda.

Ethics And Dissemination: This initiative will yield an actionable research agenda to guide research to identify and test mechanisms of change for implementation strategies. The agenda will be disseminated via multiple channels to solicit feedback and promote rigorous research on implementation mechanisms.
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http://dx.doi.org/10.1136/bmjopen-2021-053474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524292PMC
October 2021

Provider REport of Sustainment Scale (PRESS): development and validation of a brief measure of inner context sustainment.

Implement Sci 2021 08 30;16(1):86. Epub 2021 Aug 30.

Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA, 92123, USA.

Background: Implementation scientists and practitioners often rely on frontline providers for reporting on implementation outcomes. Furthermore, measures of sustainment are few, and available sustainment measures are mainly setting or evidenced-based practice (EBP) specific, require organizational and system-level knowledge to complete, and often lack psychometric rigor. The aim of this study was to develop a brief, pragmatic, and generalizable measure for completion by frontline service providers of the implementation outcome, sustainment.

Methods: We utilized a Rasch measurement theory approach to scale the development and testing of psychometric parameters. Sustainment items were developed to be relevant for direct service providers to complete. In order to promote generalizability, data were collected and items were tested across four diverse psychosocial evidence-based practices (motivational interviewing [MI], SafeCare®, classroom pivotal response training [CPRT], and an individualized mental health intervention for children with autism spectrum disorder [AIM-HI]) and in four service settings (substance use disorder treatment, child welfare, education, and specialty mental health). Associations between the sustainment measure and sustainment leadership, sustainment climate, and attitudes towards the adoption and use of each of the EBPs were assessed to confirm construct validity.

Results: Three items for the Provider REport of Sustainment Scale (PRESS) were assessed for measuring the core component of sustainment: continued use of the EBP. Internal consistency reliability was high. The scale indicated fit to the Rasch measurement model with no response dependency, ordered thresholds, no differential item functioning, and supported unidimensionality. Additionally, construct validity evidence was provided based on the correlations with related variables.

Conclusion: The PRESS measure is a brief, three-item measure of sustainment that is both pragmatic and useable across different EBPs, provider types, and settings. The PRESS captures frontline staffs' report of their clinic, team, or agency's continued use of an EBP. Future testing of the PRESS for concurrent and predictive validity is recommended.
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http://dx.doi.org/10.1186/s13012-021-01152-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8404332PMC
August 2021

Outer-context determinants in the sustainment phase of a reimbursement-driven implementation of evidence-based practices in children's mental health services.

Implement Sci 2021 08 19;16(1):82. Epub 2021 Aug 19.

Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA.

Background: Although there is increasing investment to implement evidence-based practices (EBPs) in public systems across the USA, continued or sustained use of EBPs after initial implementation remains a challenge. The low integration of EBPs in routine practice severely limits their public health impact, highlighting the need to understand factors that affect the return on costly investments in EBP implementation. This study aims to (1) characterize trajectories of EBP delivery volume through a reimbursement-driven implementation and (2) examine impacts of system-level policy regulatory activity and state-level mental health services funding on the implementation reimbursement strategy.

Methods: This study involved secondary data analyses. Psychotherapy administrative claims and regulatory site visit data from the Los Angeles County Department of Mental Health and California state mental health expenditures were extracted from 2010 to 2017. Multilevel regression examined EBP claims volume over time with state expenditures and regulatory compliance as predictors.

Results: EBP claims volume trajectories demonstrated a rapid initial increase, followed by a period of decrease, and a small increase in the final year. State mental health expenditures increased across time reflecting increased funding availability. State mental health expenditures and system regulatory compliance were inversely related to EBP claims volume.

Conclusions: The impact of reimbursement-driven EBP implementation strategy is sensitive to multiple outer-context determinants. At the system level, commitment to fidelity of implementation regulations resulted in reduced use of the reimbursement strategy. Alternative reimbursement streams not tied to EBPs coupled with an expanded array of reimbursable services also impacted the use of the reimbursement strategy to implement EBPs.
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http://dx.doi.org/10.1186/s13012-021-01149-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375074PMC
August 2021

Implementation of school-based services for students with autism: Barriers and facilitators across urban and rural districts and phases of implementation.

Autism 2021 11 16;25(8):2291-2304. Epub 2021 Jun 16.

Child and Adolescent Services Research Center, USA.

Lay Abstract: The law requires that schools use evidence-based practices to educate students with autism spectrum disorder. However, these practices are often not used, or are not used correctly in school programs. Understanding barriers and facilitators of use of evidence-based practices in schools will help improve the implementation process. This study uses focus groups to characterize how school-based providers representing urban or rural school districts perceive barriers and facilitators for implementing new practices for students with autism spectrum disorder. Guiding questions include the following: (1) Are contextual factors perceived as barriers or facilitators and how do these vary by district location? and (2) What are the key factors impacting implementation across the Exploration, Preparation, Implementation, and Sustainment phases? Focus group participants ( = 33) were service providers to children with autism spectrum disorder from urban- and rural-located school districts. Several personnel-related themes (attitudes and buy-in, knowledge and skills, staffing, and burnout) were shared by participants representing both urban and rural districts. However, some personnel-related themes and organizational factors were unique to rural or urban districts. For example, themes related to system and organizational factors (leadership approval, support and expectations, district structure, competing priorities, time for effective professional development, litigation and due process, and materials and resources) differed between the district locations. This project serves as an initial step in identifying implementation strategies that may improve the use of evidence-based practices in schools.
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http://dx.doi.org/10.1177/13623613211016729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446299PMC
November 2021

Cross-cultural adaption and psychometric investigation of the German version of the Evidence Based Practice Attitude Scale (EBPAS-36D).

Health Res Policy Syst 2021 Jun 2;19(1):90. Epub 2021 Jun 2.

Department of Clinical and Biological Psychology, Catholic University of Eichstätt-Ingolstadt, Levelingstr. 7, 85049, Ingolstadt, Germany.

Background: The implementation of evidence-based practice (EBP) in mental health care confers many benefits to patients, and research into factors facilitating the implementation of EBP is needed. As an important factor affecting the implementation of EBP, service providers' attitudes toward EBP emerged. The Evidence-Based Practice Attitude Scale (EBPAS-36) is an instrument with good psychometric characteristics that measures positive and ambivalent attitudes toward EBP. However, a German version is missing. The present study therefore aims to provide a validated German translation of the EBPAS-36.

Methods: The scale was translated and back-translated as recommended by standard procedures. German psychotherapists were recruited to participate in an online survey. They provided demographic and professional information, completed the EBPAS-36, the Implementation Climate Scale (ICS) and the Intention Scale for Providers (ISP). Standard item and reliability analyses were conducted. Construct validity was evaluated with exploratory (EFA) and confirmatory factor analyses (CFA) in two subsamples (random split). Convergent validity was tested by predicting a high positive correlation of the EBPAS-36D with two scores of attitudes of the ISP and an interest in EBP score. It was tested whether the EBPAS-36D predicts the intention to use EBP.

Results: N = 599 psychotherapists participated in the study. The item analyses showed a mean item difficulty of p= 0.64, a mean inter-item correlation of r = 0.18, and a mean item-total correlation of r = 0.40. The internal consistency was very good for the total scale (α = 0.89) and ranged from adequate to very good for the subscales (0.65-0.89), indicating high reliability. The original factor structure showed an acceptable model fit (RMSEA = 0.064 (90% CI = 0.059-0.068); SRMR = 0.0922; AIC = 1400.77), confirming the 12-factor structure of the EBPAS-36. However, a second-order factor structure derived by the EFA had an even better model fit (RMSEA = 0.057 (90% CI = 0.052-0.062); SRMR = 0.0822; AIC = 1274.56). When the EBPAS-36D was entered in a hierarchical regression model with the criterion Intention to use EBP, the EBPAS-36D contributed significantly to the prediction (Change in R = 0.28, p < 0.001) over and above gender, age and participants' report of ever having worked in a university context.

Conclusions: The present study confirms good psychometric properties and validity of a German version of the EBPAS-36 in a sample of psychotherapists.
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http://dx.doi.org/10.1186/s12961-021-00736-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173815PMC
June 2021

Implementation determinants and mechanisms for the prevention and treatment of adolescent HIV in sub-Saharan Africa: concept mapping of the NIH Fogarty International Center Adolescent HIV Implementation Science Alliance (AHISA) initiative.

Implement Sci Commun 2021 May 22;2(1):53. Epub 2021 May 22.

NIH Fogarty International Center, Center for Global Health Studies, Bethesda, MD, USA.

Introduction: Adolescent HIV prevention and treatment is a high priority for youth healthcare in sub-Saharan Africa.

Methods: This study employed concept mapping to identify factors that impact the implementation of HIV prevention and intervention programs for adolescents in sub-Saharan Africa. Key stakeholders including researchers, policymakers, and non-governmental organization (NGO) personnel constituting membership of the NIH-sponsored Adolescent HIV Prevention and Treatment Implementation Science Alliance responded to the question: "In your experience, what factors have facilitated or hindered implementation of evidence-based HIV prevention or treatment for adolescents in sub-Saharan Africa?" Participants generated statements in response to the focus question, sorted them into thematically relevant groups, and rated each statement on its importance and changeability.

Results: Through data analyses and participant feedback, 15 distinct themes were derived. "Workforce/Workflow" and "HIV Stigma and Adolescent Development" were rated highest for importance, and "Threshold Conditions for Treatment" and "Structure of Implementation Efforts" were rated most changeable.

Conclusions: Understanding implementation science determinants and mechanisms can facilitate the uptake of successful implementation and sustainment strategies for the prevention and treatment of HIV in a given context. We placed determinants and mechanisms within the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to provide greater contextual integration with broader theories in implementation science. Implementers across multiple disciplines can use these findings to improve the scale-up of evidence-based practices for adolescent HIV prevention and treatment in sub-Saharan Africa. Implementation approaches that consider the determinants and mechanisms identified in this study and integrated in implementation frameworks will likely have utility for other health conditions and contexts.
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http://dx.doi.org/10.1186/s43058-021-00156-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141156PMC
May 2021

COVID-related work changes, burnout, and turnover intentions in mental health providers: A moderated mediation analysis.

Psychiatr Rehabil J 2021 Sep 17;44(3):219-228. Epub 2021 May 17.

Department of Psychiatry, University of California San Diego.

The novel coronavirus disease (COVID-19) has drastically impacted the provision of mental health services. Changes required of providers were substantial and could lead to increased burnout and, subsequently, increased turnover intentions. This study examined burnout experienced by mental health services providers in the context of COVID-19 and through the lens of the job demands-resources (JD-R) model. We examined the effects of work changes on burnout and subsequent turnover intentions, and how job and personal resources may have buffered the extent to which work changes due to COVID-19 impacted burnout. Service providers ( = 93) from six community mental health centers (CMHCs) in one Midwestern state in the United States completed surveys as part of service contracts to implement evidence-based practices. Path analysis tested the unconditional indirect relations between work changes and turnover intentions through burnout. Moderated mediation determined whether the indirect effect of work changes on turnover intentions via burnout varied in strength by job and personal resources. Work changes had a significant indirect effect on turnover intentions through burnout ( β ^ = .140, 95% CI = .072, .217). This indirect effect varied as a function of two job resources, organizational trust and perceived organizational support. Burnout was relatively low only when work changes were low and job resources levels high. When work changes were high, burnout was similarly high across levels of job resources. To minimize burnout, organizations should limit task, setting, and team-related work changes to the extent possible. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/prj0000480DOI Listing
September 2021

Validating the Implementation Leadership Scale in Chinese nursing context: A cross-sectional study.

Nurs Open 2021 11 7;8(6):3420-3429. Epub 2021 May 7.

Department of Psychiatry, University of California, La Jolla, CA, USA.

Aim: This study aimed to evaluate the validity, reliability and acceptability of the Implementation Leadership Scale in the Chinese nursing context.

Design: This study utilized a cross-sectional design.

Methods: This study was conducted in one general tertiary hospital with 234 nurses (85.3% response rate) from 35 clinical units in China. Content validity, structural validity, convergent validity, reliability (internal consistency), agreement indices and acceptability were evaluated. The data collection was from December 1st, 2017 to June 30th, 2018.

Results: Confirmatory factor analysis demonstrated a good model fit to the four-factor implementation leadership model. The psychometric testing also indicated good convergent validity, high internal consistency and acceptable aggregation. Most participants completed the scale in two minutes or less and agreed or strongly agreed that the questions were relevant to implementation leadership, clear and easy to answer.

Conclusions: This study demonstrated that the Chinese Implementation Leadership Scale is a valid, reliable and pragmatic tool for measuring strategic leadership for implementing evidence-based practices.
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http://dx.doi.org/10.1002/nop2.888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8510775PMC
November 2021

Alliances to disseminate addiction prevention and treatment (ADAPT): A statewide learning health system to reduce substance use among justice-involved youth in rural communities.

J Subst Abuse Treat 2021 09 16;128:108368. Epub 2021 Mar 16.

Department of Psychology - Adolescent Behavioral Health Research Program, Indiana University - Purdue University Indianapolis, Indianapolis, IN, United States of America.

Background: Youth in the justice system (YJS) are more likely than youth who have never been arrested to have mental health and substance use problems. However, a low percentage of YJS receive SUD services during their justice system involvement. The SUD care cascade can identify potential missed opportunities for treatment for YJS. Steps along the continuum of the cascade include identification of treatment need, referral to services, and treatment engagement. To address gaps in care for YJS, we will (1) implement a learning health system (LHS) to develop, or improve upon, alliances between juvenile justice (JJ) agencies and community mental health centers (CMHC) and (2) present local cascade data during continuous quality improvement cycles within the LHS alliances.

Methods/design: ADAPT is a hybrid Type II effectiveness implementation trial. We will collaborate with JJ and CMHCs in eight Indiana counties. Application of the EPIS (exploration, preparation, implementation, and sustainment) framework will guide the implementation of the LHS alliances. The study team will review local cascade data quarterly with the alliances to identify gaps along the continuum. The study will collect self-report survey measures longitudinally at each site regarding readiness for change, implementation climate, organizational leadership, and program sustainability. The study will use the Stages of Implementation Completion (SIC) tool to assess the process of implementation across interventions. Additionally, the study team will conduct focus groups and qualitative interviews with JJ and CMHC personnel across the intervention period to assess for impact.

Discussion: Findings have the potential to increase SUD need identification, referral to services, and treatment for YJS.
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http://dx.doi.org/10.1016/j.jsat.2021.108368DOI Listing
September 2021

Forms and functions of bridging factors: specifying the dynamic links between outer and inner contexts during implementation and sustainment.

Implement Sci 2021 04 1;16(1):34. Epub 2021 Apr 1.

Department of Psychiatry, University of California-San Diego, La Jolla, USA.

Background: Bridging factors are relational ties, formal arrangements, and processes that connect outer system and inner organizational contexts. They may be critical drivers of evidence-based practice (EBP) implementation and sustainment. Yet, the complex interplay between outer and inner contexts is often not considered. Bridging factors were recently defined in the updated Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Further identification and specification of this construct will advance implementation models, measures, and methods. Our goal is to advance bridging factor research by identifying relevant dimensions and exemplifying these dimensions through illustrative case studies.

Methods: We used a multiple case study design. Each case (n = 10) represented different contexts, EBPs, and bridging factor types. Inclusion criteria were the presence of clearly distinguishable outer and inner contexts, identifiable bridging factor, sufficient information to describe how the bridging factor affected implementation, and variation from other cases. We used an iterative qualitative inquiry process to develop and refine a list of dimensions. Case data were entered into a matrix. Dimensions comprised the rows and case details comprised the columns. After a review of all cases, we collectively considered and independently coded each dimension as function or form.

Results: We drew upon the concepts of functions and forms, a distinction originally proposed in the complex health intervention literature. Function dimensions help define the bridging factor and illustrate its purpose as it relates to EBP implementation. Form dimensions describe the specific structures and activities that illustrate why and how the bridging factor has been customized to a local implementation experience. Function dimensions can help researchers and practitioners identify the presence and purpose of bridging factors, whereas form dimensions can help us understand how the bridging factor may be designed or modified to support EBP implementation in a specific context. We propose five function and three form bridging factor dimensions.

Conclusions: Bridging factors are described in many implementation models and studies, but without explicit reference or investigation. Bridging factors are an understudied and critical construct that requires further attention to facilitate implementation research and practice. We present specific recommendations for a bridging factors research agenda.
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http://dx.doi.org/10.1186/s13012-021-01099-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015179PMC
April 2021

Validation of the Implementation Climate Scale in Nursing.

Worldviews Evid Based Nurs 2021 Apr 25;18(2):85-92. Epub 2021 Mar 25.

University of California San Diego, La Jolla, CA, USA.

Background: One critical factor in effective implementation of evidence-based practices (EBPs) in nursing is an organizational context that facilitates and supports implementation efforts. Measuring implementation climate can add useful insights on the extent to which the organizational context supports EBP implementation.

Aims: This study cross-validates and examines the psychometric properties of the Implementation Climate Scale (ICS), which measures nurses' perceptions of their unit's climate for EBP implementation.

Methods: This study analyzed ICS data from two cross-sectional studies, including 203 nurses from California and 301 nurses from Florida. Analyses included evaluation of internal consistency, multilevel aggregation statistics, and confirmatory factor analyses.

Results: The 18-item ICS demonstrated comparable psychometric properties to the original measure development paper in both samples. Confirmatory factor analyses provided support for the scale's factor structure in both samples.

Linking Evidence To Practice: The ICS is a pragmatic measure that can be used to assess unit implementation climate in nursing contexts. Results from the ICS from nurses and nurse leaders can provide insights into implementation-specific barriers and facilitators within the organizational context.
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http://dx.doi.org/10.1111/wvn.12500DOI Listing
April 2021

An observational study of the impact of COVID-19 and the rapid implementation of telehealth on community mental health center providers.

Implement Sci Commun 2021 Mar 11;2(1):29. Epub 2021 Mar 11.

University of California San Diego Department of Psychiatry, 9500 Gilman Drive (0812), La Jolla, CA, 92093-0812, USA.

Background: The COVID-19 pandemic has remarkably altered community mental health service delivery through the rapid implementation of telehealth. This study reports provider perspectives on the impact that COVID-19 and the transition to telehealth had on their work and their ability to deliver evidence-based practices (EBPs).

Methods: Providers (n = 93) completed online surveys with quantitative measures and open-ended items exploring their reactions to COVID-19 and to the transition to providing services via telehealth.

Results: Perceptions of personal risk and rumination around COVID-19 were low, while telehealth was viewed positively by providers. Three major themes emerged regarding the major impacts of COVID-19 on work: (1) the altered nature of interactions between patient/client and provider due to telehealth implementation, (2) changes in provider expectations regarding productivity, and (3) challenges maintaining work-life balance. In regard to the major impacts of COVID-19 on EBP delivery, three themes emerged: (1) increased difficulty delivering certain therapies via telehealth, (2) potential limitations to session confidentiality, and (3) challenge of engaging children in telehealth.

Conclusions: In the context of the COVID-19 pandemic, community mental health providers continued to engage with clients and deliver EBPs while navigating a number of changes related to the rapid transition to and implementation of telehealth. This study highlights the need for further work on what supports providers need to effectively engage with clients and deliver EBPs via telehealth, and has implications for how telehealth is sustained or de-implemented post-COVID-19.
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http://dx.doi.org/10.1186/s43058-021-00123-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948664PMC
March 2021

Racial and Ethnic Differences in Depressive Profiles of Child Welfare-Involved Families Receiving Home Visitation Services.

Psychiatr Serv 2021 05 11;72(5):539-545. Epub 2021 Mar 11.

Department of Psychiatry, University of California, San Diego, San Diego (Fettes, Sklar, Sandhu, Aarons); Child and Adolescent Services Research Center, San Diego (all authors); Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles (Hurlburt).

Objective: Profiles of depressive symptoms were identified among Hispanic, Black, and White parents involved in the child welfare service system, including changes in symptoms over time.

Methods: Participants (N=2,109) were parents receiving SafeCare, a home visitation intervention provided in a large, diverse child welfare system. Depressive symptoms were assessed with the Centers for Epidemiological Studies Depression Scale at baseline and at approximately every sixth home visit, up to a total of four times. Univariate tests examined the relationship between baseline symptoms, race-ethnicity, and service participation. Latent class growth analyses identified trajectories of depressive symptoms during participation in child welfare services.

Results: Participation in services was affected by depressive symptoms. Forty percent of parents did not remain long enough in the program to complete a second CES-D assessment, and those who reported more symptoms at baseline were significantly less likely to do so. Among parents who engaged in services, distinct profiles of depressive symptoms emerged that differed by race-ethnicity. For non-Hispanic Black parents, no changes in depressive symptoms over time were noted, regardless of level of severity at baseline. Parents with the highest levels of symptoms did not improve over time.

Conclusions: Despite receipt of supportive and recovery-oriented services specifically focused on empowering child welfare-involved parents, many experienced elevated depressive symptoms. Integration of child welfare and community mental health systems may improve both service engagement and mental health among child welfare-involved families.
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http://dx.doi.org/10.1176/appi.ps.201900256DOI Listing
May 2021

Leader-member exchange and organizational climate effects on clinician turnover intentions.

J Health Organ Manag 2020 Dec;35(1):68-87

Child and Adolescent Services Research Center, San Diego, California, USA.

Purpose: Clinician turnover in mental health settings impacts service quality, including availability and delivery of evidence-based practices. Leadership is associated with organizational climate, team functioning and clinician turnover intentions (TI). This study examines leader-member exchange (LMX), reflecting the relationship between a supervisor and each supervisee, using mean team LMX, dispersion of individual clinician ratings compared to team members (i.e. relative LMX) and team level variability (i.e. LMX differentiation), in relation to organizational climate and clinician TI.

Design/methodology/approach: Survey data were collected from 363 clinicians, nested in children's mental health agency workgroups, providing county-contracted outpatient services to youth and families. A moderated mediation path analysis examined cross-level associations of leader-member exchange with organizational climate and turnover intentions.

Findings: Lower relative LMX and greater LMX differentiation were associated with higher clinician TI. Higher team-level demoralizing climate also predicted higher TI. These findings indicate that poorer LMX and more variability in LMX at the team level are related to clinician TI.

Originality/value: This study describes both team- and clinician-level factors on clinician TI. Few studies have examined LMX in mental health, and fewer still have examined relative LMX and LMX differentiation associations with organizational climate and TI. These findings highlight the importance of leader-follower relationships and organizational climate and their associations with clinician TIs. Mental health service systems and organizations can address these issues through fostering more positive supervisor-supervisee relationships.
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http://dx.doi.org/10.1108/JHOM-10-2019-0311DOI Listing
December 2020

Toward the data-driven dissemination of findings from psychological science.

Am Psychol 2020 11;75(8):1052-1066

Department of Psychiatry, University of California, San Diego.

The public health impact of psychological science is maximized when it is disseminated clearly and compellingly to audiences who can act on it. Dissemination research can generate knowledge to help achieve this, but dissemination is understudied in the field of implementation science. As a consequence, the designs of dissemination strategies are typically driven by anecdote, not evidence, and are often ineffective. We address this issue by synthesizing key theory and findings from consumer psychology and detailing a novel research approach for "data-driven dissemination." The approach has 3 parts: (a) formative audience research, which characterizes an audience's awareness about, adoption of, and attitudes toward an intervention, as well as preferences for receiving information about it; (b) audience segmentation research, which identifies meaningful subgroups within an audience to inform the tailoring of dissemination strategies; and (c) dissemination effectiveness research, which determines the strategies that are most effective. This approach is then illustrated using the dissemination of the American Psychological Association's (APA, 2017) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults as a case study. Data are presented from a 2018-2019 survey of licensed APA-member psychologists who treat adults with PTSD (n = 407, response rate = 29.8%). We present survey findings on awareness about, attitudes toward, and adoption of the guideline and find significant differences across these domains between psychologists who do and do not regularly use clinical practice guidelines. We conclude by discussing future directions to advance dissemination research and practice. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/amp0000721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182894PMC
November 2020

Implementation of a trauma-informed, evidence-informed intervention for Latinx families experiencing interpersonal violence and child maltreatment: protocol for a pilot randomized control trial of SafeCare+®.

Pilot Feasibility Stud 2020 8;6:153. Epub 2020 Oct 8.

Health Sciences Center, The University of Oklahoma, Oklahoma City, OK USA.

Background: A consistently demonstrated overlap exists between the occurrence of domestic violence and child maltreatment, yet these issues are historically addressed by distinct systems and programming. The randomized control trial pilot study presented in this article adapts, implements, and tests a new approach for addressing family violence for Latinx families with co-occurring risk for domestic violence and child maltreatment. In doing so, this pilot study addresses the clear need for collaboration between the two fields and focuses on Latinx families, who often face specific challenges regarding seeking and receiving needed services. The primary aim of the current study is a pilot implementation of SafeCare+®, an evidence-based parenting curriculum (SafeCare®) augmented with a healthy relationships curriculum (SafeCare+®). The objectives are a reduction of family violence, improved communication, and a healthy home environment for children in Latinx families with co-occurring domestic violence and child maltreatment.

Methods: This protocol outlines a feasibility, randomized control trial to examine the potential efficacy of SafeCare+. The pilot study is divided into two phases. Components of phase one involve developing a detailed implementation and evaluation plan, including a community needs assessment, determining screening and outcome measures, and assuring all components are culturally appropriate for the target population. Phase two implements the randomization of parents, who are involved in the child welfare system and referred for in-home parenting services, into SafeCare+ or SafeCare as usual. Participants complete assessments regarding mental health, provider-parent relationship, interpersonal violence experiences, and fidelity to the intervention. Analyses will focus on improvement on target outcomes for the intervention group, as well as comparison to the control group.

Discussion: This study will provide evidence on the feasibility and potential effectiveness of an early intervention program aimed at improving communication skills and mental health and reducing incidents of violence for Latinx parents who are involved with the child welfare service system. The findings of the study will inform the decision to progress to a full scale, definitive randomized control trial to test the effectiveness of an intervention, delivered as part of home visitation, for improving outcomes for families with histories of domestic violence.

Trial Registration: ClinicalTrials.gov, NCT03041558; registered 2 February, 2017-retrospectively registered.
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http://dx.doi.org/10.1186/s40814-020-00681-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545833PMC
October 2020

Advancing the pragmatic measurement of sustainment: a narrative review of measures.

Implement Sci Commun 2020 17;1:76. Epub 2020 Sep 17.

Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA.

Background: Sustainment, an outcome indicating an intervention continues to be implemented over time, has been comparatively less studied than other phases of the implementation process. This may be because of methodological difficulties, funding cycles, and minimal attention to theories and measurement of sustainment. This review synthesizes the literature on sustainment measures, evaluates the qualities of each measure, and highlights the strengths and gaps in existing sustainment measures. Results of the review will inform recommendations for the development of a pragmatic, valid, and reliable measure of sustainment.

Methods: A narrative review of published sustainment outcome and sustainability measures (i.e., factors that influence sustainment) was conducted, including appraising measures in the Society of Implementation Research Collaboration (SIRC) instrument review project (IRP) and the Dissemination and Implementation Grid-Enabled Measures database initiative (GEM-D&I). The narrative review used a snowballing strategy by searching the reference sections of literature reviews and definitions of sustainability and sustainment. Measures used frequently and judged to be comprehensive and/or validated by a team of implementation scientists were extracted for analysis.

Results: Eleven measures were evaluated. Three of the included measures were found in the SIRC-IRP, three in the GEM-D&I database, (one measure was in both databases) and six were identified in our additional searches. Thirteen constructs relating to sustainment were coded from selected measures. Measures covered a range of determinants for sustainment (i.e., construct of sustainability) as well as constructs of sustainment as an outcome. Strengths of the measures included, development by expert panels knowledgeable about particular interventions, fields or contexts, and utility in specific scenarios. A number of limitations were found in the measures analyzed including inadequate assessment of psychometric characteristics, being overly intervention or context specific, being lengthy and/or complex, and focusing on outer context factors.

Conclusion: There is a lack of pragmatic and psychometrically sound measures of sustainment that can be completed by implementation stakeholders within inner context settings (e.g., frontline providers, supervisors).
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http://dx.doi.org/10.1186/s43058-020-00068-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499830PMC
September 2020

Implementation-as-Usual in Community-Based Organizations Providing Specialized Services to Individuals with Autism Spectrum Disorder: A Mixed Methods Study.

Adm Policy Ment Health 2021 05 18;48(3):482-498. Epub 2020 Sep 18.

Child and Adolescent Services Research Center, San Diego, CA, USA.

Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental disorder. ASD community-based organizations (ASD-CBOs) underutilize or inconsistently utilize evidence-based practices (ASD-EBPs) despite numerous available EBPs to treat ASD. Nonetheless, ASD-CBOs implement changes to practices regularly. Understanding ASD-CBO's implementation-as-usual (IAU) processes may assist to develop strategies to facilitate ASD-EBP adoption, implementation and sustainment. A convergent mixed methods (quan + QUAL) design was utilized. Twenty ASD-CBO agency leaders (ALs) and 26 direct providers (DPs), from 21 ASD-CBOs, completed the Autism Model of Implementation Survey Battery, including demographic and agency IAU process questions. Surveys were analyzed through descriptive and content analyses. A subset of 10 ALs provided qualitative interview data that were analyzed using coding, consensus and comparison methods to allow for a more comprehensive understanding of the IAU process within their ASD-CBOs. Quantitative analyses and qualitative coding were merged utilizing a joint display and compared. Results suggest that the IAU process follows some phases identified in the Exploration, Preparation, Implementation, Sustainment (EPIS) framework but were conducted in an informal manner-lacking specificity, structure and consistency across and within ASD-CBOs. Moreover, data suggest adding a specific adoption decision phase to the framework. Nonetheless, most ALs felt previous implementation efforts were successful. IAU processes were explored to determine whether the implementation process may be an area for intervention to increase ASD-EBP utilization in ASD-CBOs. Developing a systematized implementation process may facilitate broader utilization of high quality ASD-EBPs within usual care settings, and ultimately improve the quality of life for individuals with ASD and their families.
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http://dx.doi.org/10.1007/s10488-020-01084-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120738PMC
May 2021

Incorporators, Early Investors, and Learners: a longitudinal study of organizational adaptation during EBP implementation and sustainment.

Implement Sci 2020 09 10;15(1):74. Epub 2020 Sep 10.

Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.

Background: The majority of literature on evidence-based practice (EBP) adaptation focuses on changes to clinical practices without explicitly addressing how organizations must adapt to accommodate a new EBP. This study explores the process of organizational-rather than EBP-adaptation during implementation and sustainment. To the authors' knowledge, there are no previous implementation studies that focus on organizational adaptation in this way.

Methods: This analysis utilizes a case study approach to examine longitudinal qualitative data from 17 community-based organizations (CBOs) in one state and seven county-based child welfare systems. The CBOs had sustained a child-neglect intervention EBP (SafeCare®) for 2 to 10 years. The unit of analysis was the organization, and each CBO represented a case. Organizational-level profiles were created to describe the organizational adaptation process.

Results: Three organizational-level adaptation profiles were identified as follows: incorporators (n = 7), early investors (n = 6), and learners (n = 4). Incorporators adapted by integrating SafeCare into existing operations to meet contractual or EBP fidelity requirements. Early Investors made substantial organizational adaptations during the early implementation period, then operated relatively consistently as the EBP became embedded in the organization and service system. Learners were characterized by steady and continuous attention to new ways that the organization could adapt to support the EBP.

Conclusion: The profiles demonstrated that there can be multiple effective paths to EBP sustainment. Organizational adaptation was calibrated to fit a CBO's operations (e.g., size of the program) and immediate environmental constraints (e.g., funding levels). Additionally, organizations fulfilled different functional roles in the network of entities involved in EBP implementation. Knowing organizational roles and adaptation profiles can guide implementation planning and help to structure contract designs that bridge the outer (system) and inner (organizational) contexts. Adaptation profiles can also inform the intensity of the implementation strategy tailoring process and the way that strategies are marketed to organizations.
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http://dx.doi.org/10.1186/s13012-020-01031-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488112PMC
September 2020

Ten recommendations for using implementation frameworks in research and practice.

Implement Sci Commun 2020 30;1:42. Epub 2020 Apr 30.

Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA.

Background: Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.

Discussion: Ideally, an implementation framework, or multiple frameworks should be used prior to and throughout an implementation effort. This includes both in implementation science research studies and in real-world implementation projects. To guide this application, outlined are ten recommendations for using implementation frameworks across the implementation process. The recommendations have been written in the rough chronological order of an implementation effort; however, we understand these may vary depending on the project or context: (1) select a suitable framework(s), (2) establish and maintain community stakeholder engagement and partnerships, (3) define issue and develop research or evaluation questions and hypotheses, (4) develop an implementation mechanistic process model or logic model, (5) select research and evaluation methods (6) determine implementation factors/determinants, (7) select and tailor, or develop, implementation strategy(s), (8) specify implementation outcomes and evaluate implementation, (9) use a framework(s) at micro level to conduct and tailor implementation, and (10) write the proposal and report. Ideally, a framework(s) would be applied to each of the recommendations. For this article, we begin by discussing each recommendation within the context of frameworks broadly, followed by specific examples using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Summary: The use of conceptual and theoretical frameworks provides a foundation from which generalizable implementation knowledge can be advanced. On the contrary, superficial use of frameworks hinders being able to use, learn from, and work sequentially to progress the field. Following the provided ten recommendations, we hope to assist researchers, intermediaries, and practitioners to improve the use of implementation science frameworks.
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http://dx.doi.org/10.1186/s43058-020-00023-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427911PMC
April 2020

An Observational Study of the Impact of COVID-19 and the Transition to Telehealth on Community Mental Health Center Providers.

Res Sq 2020 Jul 29. Epub 2020 Jul 29.

University of California San Diego.

Background: The COVID-19 pandemic has swiftly and remarkably altered community mental health service delivery and evidence-based practice (EBP) implementation. This study reports provider perspectives on the impact that COVID-19 had on their work and EBP implementation.

Methods: Providers ( = 93) completed online surveys with quantitative measures and open-ended items targeting their responses and/or reactions to COVID-19, and to the transition to providing services via telehealth.

Results: Perceptions of personal risk and rumination around COVID-19 were low, while telehealth was viewed positively by providers. Three major themes emerged regarding the major impacts of COVID-19 on work: 1) the altered nature of interactions between patient/client and provider, 2) changes in provider expectations regarding productivity, and 3) challenges maintaining work-life balance. In regard to the major impacts of COVID-19 on EBP implementation, three themes emerged: 1) increased difficulty delivering certain therapies via telehealth, 2) potential limitations to session confidentiality, and 3) challenge of engaging children in telehealth.

Conclusions: In the context of the COVID-19 pandemic, community mental health providers continued to engage with clients and implement EBPs while navigating a number of changes related to the transition to telehealth. This study highlights the need for further work on what supports providers need to effectively engage with clients and deliver EBPs via telehealth and has implications for how telehealth is sustained or de-implemented in response to COVID-19.
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http://dx.doi.org/10.21203/rs.3.rs-48767/v1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402050PMC
July 2020

Adaption and pilot implementation of an autism executive functioning intervention in children's mental health services: a mixed-methods study protocol.

Pilot Feasibility Stud 2020 27;6:55. Epub 2020 Apr 27.

Child and Adolescent Services Research Center, San Diego, CA USA.

Background: Youth with autism spectrum disorder (ASD) represent a growing population with significant service needs. Prominent among these needs are high rates of co-occurring psychiatric conditions that contribute to increased functional impairments and often necessitate mental health services. Executive functioning deficits are associated with ASD as well as common co-occurring conditions (e.g., attention-deficit/hyperactivity disorder) and an evidence-based intervention has been developed and tested to address executive functioning within the school context. There is an urgent need to implement indicated evidence-based interventions for youth with ASD receiving care in community mental health settings. Interventions that optimally "fit" the mental health services context as well as the complex and co-occurring mental health needs of these youth have the potential to improve key clinical outcomes for this high priority population.

Methods: This mixed-methods developmental study will apply the Exploration, Preparation, Implementation, Sustainment implementation framework and a community-academic partnership approach to systematically adapt and test an evidence-based executive functioning intervention for youth with ASD for delivery in community mental health settings. Specific aims are to (1) conduct a need and context assessment to inform the systematic adaptation an executive functioning evidence-based intervention; (2) systematically adapt the clinical intervention and develop a corresponding implementation plan, together entitled "Executive Functioning for Enhancing Community-based Treatment for ASD," (EFFECT for ASD; and (3) conduct a feasibility pilot test of EFFECT for ASD in community mental health settings.

Discussion: Tailoring evidence-based interventions for delivery in community-based mental health services for youth with ASD has the potential to increase quality of care and improve child outcomes. Results from the current study will serve as the foundation for large-scale hybrid implementation and effectiveness trials and a generalizable approach for different service systems of care and clinical populations.

Trial Registration: Clinicaltrials.gov, NCT04295512.
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http://dx.doi.org/10.1186/s40814-020-00593-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371471PMC
April 2020

Identifying strategies to promote team science in dissemination and implementation research.

J Clin Transl Sci 2019 Sep 9;4(3):180-187. Epub 2019 Sep 9.

Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA 92093-0812, USA.

Introduction: Scientific endeavors are increasingly carried out by teams of scientists. While there is growing literature on factors associated with effective science teams, little is known about processes that facilitate the success of dissemination and implementation (D&I) teams studying the uptake of healthcare innovations. This study aimed to identify strategies used by D&I scientists to promote team science.

Methods: Using a nominal group technique, a sample of 27 D&I scholars responded to the question, "What strategies have you or others used to promote team science?" Participants were asked to individually respond and then discuss within a small group to determine the group's top three strategies. Through a facilitated consensus discussion with the full sample, a rank-ordered list of three strategies was determined.

Results: A total of 126 individual responses ( = 9; SD = 4.88) were submitted. Through small group discussion, six groups ranked their top three strategies to promote team science. The final ranked list of strategies determined by the full sample included: (1) developing and maintaining clear expectations, (2) promoting and modeling effective communication, and (3) establishing shared goals and a mission of the work to be accomplished.

Conclusions: Because of its goal of translating knowledge to practice, D&I research necessitates the use of team science. The top strategies are in line with those found to be effective for teams in other fields and hold promise for improving D&I team cohesion and innovation, which may ultimately accelerate the translation of health innovations and the improvement of care quality and outcomes.
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http://dx.doi.org/10.1017/cts.2019.413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348006PMC
September 2019

Establishing cross-systems collaborations for implementation: protocol for a longitudinal mixed methods study.

Implement Sci 2020 07 16;15(1):55. Epub 2020 Jul 16.

UC San Diego, Department of Psychiatry, 9500 Gilman Drive (0812), La Jolla, San Diego, CA, 92093, USA.

Background: Cross-system interventions can help integrate services across different service delivery systems but require organizations to establish strong collaborative relationships for implementation. Contingency theory suggests that the effectiveness of different collaborative strategies (i.e. specific ways organizations align operations and services) varies by context. This paper describes a study of different strategies for fostering collaboration between child welfare and substance abuse treatment agencies and the conditions under which they are effective for implementation. We also describe the development and piloting of the Collaborating Across Systems for Program Implementation (CASPI) tool-a decision-making guide intended to help researchers and organizational leaders identify and use appropriate collaborative strategies for their context.

Methods/design: This multisite longitudinal, mixed methods study, leverages a naturally occurring implementation initiative -- in up to 17 Ohio counties -- to implement Ohio START (Sobriety Treatment and Reducing Trauma). START is a child welfare model that requires strong collaboration with local substance use treatment organizations to promote integrated services. During the first two years, we will identify collaborative strategies associated with improved START implementation (penetration and fidelity) and service delivery outcomes (timeliness), given system, and organizational features. We will conduct a convergent mixed methods study drawing on worker surveys, agency documents, administrative data, formal partner agreements, and group interviews. Data will be integrated and analyzed using Qualitative Comparative Analysis (QCA). To develop the CASPI, an expert panel comprised of implementation experts, and community stakeholders will convene to synthesize our findings and develop contents (including a decision tree). During the final year of the study, we will assess the acceptability, appropriateness, and feasibility of the CASPI in a randomized vignette experiment, and a pilot-test with 3 child welfare agencies that have not yet implemented START.

Discussion: Our results will lay the groundwork for a larger controlled trial that will test the CASPI's effectiveness for supporting effective and efficient implementation of cross-system interventions like START. The CASPI is expected to help leaders and researchers select and use collaboration strategies tailored to their context and be applicable in a wide range of settings including rural communities. Our work also advances system-level implementation strategies.

Trial Registration: NCT03931005 , Registered April 29, 2019.
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http://dx.doi.org/10.1186/s13012-020-01016-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364639PMC
July 2020

Contracting as a bridging factor linking outer and inner contexts during EBP implementation and sustainment: a prospective study across multiple U.S. public sector service systems.

Implement Sci 2020 06 11;15(1):43. Epub 2020 Jun 11.

Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.

Background: Bridging factors are relational ties (e.g. partnerships), formal arrangements (e.g. contracts or polices) and processes (e.g. data sharing agreements) linking outer and inner contexts and are a recent evolution of the Exploration-Preparation-Implementation-Sustainment (EPIS) framework. Bridging factor research can elucidate ways that service systems may influence and/or be influenced by organizations providing health services. This study used the EPIS framework and open systems and resource dependence theoretical approaches to examine contracting arrangements in U.S. public sector systems. Contracting arrangements function as bridging factors through which systems communicate, interact, and exchange resources with the organizations operating within them.

Methods: The sample included 17 community-based organizations in eight service systems. Longitudinal data is derived from 113 contract documents and 88 qualitative interviews and focus groups involving system and organizational stakeholders. Analyses consisted of a document review using content analysis and focused coding of transcripts from the interviews and focus groups. A multiple case study analysis was conducted to identify patterns across service systems and organizations. The dataset represented service systems that had sustained the same EBP for between 2 and 10 years, which allowed for observation of bridging factors and outer-inner context interactions over time.

Results: Service systems and organizations influenced each other in a number of ways through contracting arrangements. Service systems influenced organizations when contracting arrangements resulted in changes to organizational functioning, required organizational responses to insufficient funding, and altered interorganizational network relationships. Organizations influenced service systems when contract arrangements prompted organization-driven contract negotiation/tailoring, changes to system-level processes, and interorganizational collaboration. Service systems and organizations were dependent on each other as implementation progressed. Resources beyond funding emerged, including adequate numbers of eligible clients, expertise in the evidence-based practice, and training and coaching capacity.

Conclusion: This study advances implementation science by expanding the range and definition of bridging factors and illustrating specific bi-directional influences between outer context service systems and inner context organizations. This study also identifies bi-directional dependencies over the course of implementation and sustainment. An analysis of influence, dependencies, and resources exchanged through bridging factors has direct implications for selecting and tailoring implementation strategies, especially those that require system-level coordination and change.
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http://dx.doi.org/10.1186/s13012-020-00999-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288508PMC
June 2020

The Development of a Brief Version of the Insomnia Severity Index (ISI-3) in Older Adult Veterans with Posttraumatic Stress Disorder.

Behav Sleep Med 2021 May-Jun;19(3):352-362. Epub 2020 Jun 1.

Child and Adolescent Services Research Center, San Diego, California.

: The Insomnia Severity Index (ISI) is an insomnia self-report measure used to identify individuals at risk for insomnia disorder. Although the full ISI is only seven questions, a briefer version would allow more efficient and pragmatic administration in routine practice settings. Reliable and valid brief measures can support measurement-based care. The present study was a proof-of-concept study that developed a brief version of the ISI, the ISI-3, in a sample of older adult veterans with posttraumatic stress disorder (PTSD), a group which is at increased risk for insomnia.: Participants included 86 older veterans with combat- or military-related PTSD. Veterans completed a clinician-administered PTSD diagnostic interview, self-report measures of insomnia and other psychosocial questionnaires, and two neuropsychological assessments. The factor structure of the ISI was examined to reduce the measure into a brief version. The reliability and validity of the ISI-3 were examined.: Principal axis factoring yielded a one-factor solution, which reproduced 59% of the item variance. Item reduction procedures resulted in three items, which best represented this factor ("Insomnia Impact;" ISI-3). For the ISI-3, internal consistency was good (α =.89). Convergent validity was demonstrated via moderate to high positive correlations between the ISI-3 and other measures of sleep disturbance. Divergent validity was demonstrated via non-significant correlations between the ISI-3 and unrelated measures and moderate correlations with self-reported depression.: The ISI-3 is a psychometrically valid brief version of the ISI. Clinicians can administer the ISI-3 to screen for insomnia and monitor changes in insomnia during treatment.
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http://dx.doi.org/10.1080/15402002.2020.1760278DOI Listing
September 2021

Improving the implementation and sustainment of evidence-based practices in community mental health organizations: a study protocol for a matched-pair cluster randomized pilot study of the Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS).

Implement Sci Commun 2020 25;1. Epub 2020 Feb 25.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Implementing and sustaining evidence-based programs with fidelity may require multiple implementation strategies tailored to address multi-level, context-specific barriers and facilitators. Ideally, selecting and tailoring implementation strategies should be guided by theory, evidence, and input from relevant stakeholders; however, methods to guide the selection and tailoring of strategies are not well-developed. There is a need for more rigorous methods for assessing and prioritizing implementation determinants (barriers and facilitators) and linking implementation strategies to determinants. The Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS) is an intervention designed to increase the effectiveness of evidence-based practice implementation and sustainment. COAST-IS will enable organizational leaders and clinicians to use Intervention Mapping to select and tailor implementation strategies to address their site-specific needs. Intervention Mapping is a multi-step process that incorporates theory, evidence, and stakeholder perspectives to ensure that implementation strategies effectively address key determinants of change.

Methods: COAST-IS will be piloted with community mental health organizations that are working to address the needs of children and youth who experience trauma-related emotional or behavioral difficulties by engaging in a learning collaborative to implement an evidence-based psychosocial intervention (trauma-focused cognitive behavioral therapy). Organizations will be matched and then randomized to participate in the learning collaborative only (control) or to receive additional support through COAST-IS. The primary aims of this study are to (1) assess the acceptability, appropriateness, feasibility, and perceived utility of COAST-IS; (2) evaluate the organizational stakeholders' fidelity to the core elements of COAST-IS; and (3) demonstrate the feasibility of testing COAST-IS in a larger effectiveness trial.

Discussion: COAST-IS is a systematic method that integrates theory, evidence, and stakeholder perspectives to improve the effectiveness and precision of implementation strategies. If effective, COAST-IS has the potential to improve the implementation and sustainment of a wide range of evidence-based practices in mental health and other sectors.

Trial Registration: This study was registered in ClinicalTrials.gov (NCT03799432) on January 10, 2019 (last updated August 5, 2019).
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http://dx.doi.org/10.1186/s43058-020-00009-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207049PMC
February 2020

A systematic review of empirical studies examining mechanisms of implementation in health.

Implement Sci 2020 04 16;15(1):21. Epub 2020 Apr 16.

Division of Cancer Control and Population Science, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA.

Background: Understanding the mechanisms of implementation strategies (i.e., the processes by which strategies produce desired effects) is important for research to understand why a strategy did or did not achieve its intended effect, and it is important for practice to ensure strategies are designed and selected to directly target determinants or barriers. This study is a systematic review to characterize how mechanisms are conceptualized and measured, how they are studied and evaluated, and how much evidence exists for specific mechanisms.

Methods: We systematically searched PubMed and CINAHL Plus for implementation studies published between January 1990 and August 2018 that included the terms "mechanism," "mediator," or "moderator." Two authors independently reviewed title and abstracts and then full texts for fit with our inclusion criteria of empirical studies of implementation in health care contexts. Authors extracted data regarding general study information, methods, results, and study design and mechanisms-specific information. Authors used the Mixed Methods Appraisal Tool to assess study quality.

Results: Search strategies produced 2277 articles, of which 183 were included for full text review. From these we included for data extraction 39 articles plus an additional seven articles were hand-entered from only other review of implementation mechanisms (total = 46 included articles). Most included studies employed quantitative methods (73.9%), while 10.9% were qualitative and 15.2% were mixed methods. Nine unique versions of models testing mechanisms emerged. Fifty-three percent of the studies met half or fewer of the quality indicators. The majority of studies (84.8%) only met three or fewer of the seven criteria stipulated for establishing mechanisms.

Conclusions: Researchers have undertaken a multitude of approaches to pursue mechanistic implementation research, but our review revealed substantive conceptual, methodological, and measurement issues that must be addressed in order to advance this critical research agenda. To move the field forward, there is need for greater precision to achieve conceptual clarity, attempts to generate testable hypotheses about how and why variables are related, and use of concrete behavioral indicators of proximal outcomes in the case of quantitative research and more directed inquiry in the case of qualitative research.
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http://dx.doi.org/10.1186/s13012-020-00983-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164241PMC
April 2020

Leveraging implementation science to reduce inequities in Children's mental health care: highlights from a multidisciplinary international colloquium.

BMC Proc 2020 6;14(Suppl 2). Epub 2020 Apr 6.

Child and Adolescent Services Research Center, San Diego, CA 92123 USA.

Background And Purpose: Access to evidence-based mental health care for children is an international priority. However, there are significant challenges to advancing this public health priority in an efficient and equitable manner. The purpose of this international colloquium was to convene a multidisciplinary group of health researchers to build an agenda for addressing disparities in mental health care access and treatment for children and families through collaboration among scholars from the United States and Europe engaged in innovative implementation science and mental health services research.

Key Highlights: Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, presentations related to inner, outer, and bridging context factors that impact the accessibility and quality of mental health evidence-based practices (EBPs) for children and families. Three common topics emerged from the presentations and discussions from colloquium participants, which included: 1) the impact of inner and outer context factors that limit accessibility to EBPs across countries, 2) strategies to adapt EBPs to improve their fit in different settings, 3) the potential for implementation science to address emerging clinical and public health concerns.

Implications: The common topics discussed underscored that disparities in access to evidence-based mental health care are prevalent across countries. Opportunities for cross-country and cross-discipline learnings and collaborations can help drive solutions to address these inequities, which relate to the availability of a trained and culturally appropriate workforce, insurance reimbursement policies, and designing interventions and implementation strategies to support sustained use of evidence-based practices.
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http://dx.doi.org/10.1186/s12919-020-00184-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132860PMC
April 2020
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