From single to multiple behaviour change approaches in implementation science

Justin Presseau, PhD
University of Ottawa

ABSTRACT:
Behaviour change theory-informed implementation intervention development and evaluation often focuses on improving sub-optimally performed clinical practice, redressing variations in care, or de-implementing lower-value care. In many instances, such approaches focus on a given clinical action as the target for change. However, the professional context of those delivering healthcare and the lived experience of those receiving healthcare are characterised by navigating contexts involving engaging in multiple behaviours; where engaging in a given action may impact on other competing demands and/or the actions of others. Predominant methodological approaches and theoretical lenses used in implementation science may not yet be accounting for this system of multiple behaviours. This talk will explore the challenges and opportunities of shifting from a single behaviour to a multiple behaviour approach in implementation science. With examples of implementation research across a variety of chronic disease topic areas, this talk will explore the implications and opportunities for shifting to a multiple behaviour change approach for: identifying gaps in care and selecting focal behaviour(s), identifying theory-informed barriers/enablers to change, selecting intervention strategies and change techniques, and evaluating implementation strategies.

The Stanford Lightning Report: An Implementation Science Rapid Qualitative Approach for Formative Evaluation

Catherine Brown Johnson, PhD
Stanford School of Medicine

Steve Asch, MD, MPH
Stanford School of Medicine

ABSTRACT:
The Stanford Lightning Report is a structured but flexible rapid qualitative approach used to increase the pace of learning in healthcare implementation. Supporting Learning Health System goals as well as large-scale research agendas, it can be applied across settings, from quality improvement and to randomized trials, ensuring more successful implementation. This talk includes examples of Lightning Report use in addiction settings (e-cigarettes and opioid use), step-by-step instructions on how to employ the approach, and hands-on just-in-time consultation on how to incorporate the Lightning Report into your projects.

Designing for Dissemination and Sustainability: Methods, Frameworks, Tools, and a Diabetes Case Example

Bethany M. Kwan, PhD, MSPH, FSBM
University of Colorado School of Medicine

ABSTRACT:
Designing for dissemination and sustainability (D4DS) refers to the process of ensuring that the products of research are likely to be adopted, implemented, and sustained in the context of intended use. D4DS involves use of methods such as participatory co-design, active dissemination planning, and pragmatic trial designs to develop evidence that “fits the context” and can be readily adopted in real-world settings. This presentation will provide an overview of the rationale, principles, methods, and frameworks for D4DS. The Fit to Context Framework for D4DS is a novel process framework to guide planning, conduct, and dissemination of research, based on a narrative review of the literature on D4DS. Tools to support application of the Fit to Context Framework, including https://dicemethods.org/ and https://app.d4dsplanner.com/, will be demonstrated. A case example will describe D4DS applications in the Invested in Diabetes study, a pragmatic, type II hybrid implementation-effectiveness trial of two models of diabetes shared medical appointments.

Peer-delivered Intervention to Improve Retention and Polysubstance Use in Mobile Telemedicine in Rural Maryland

Jessica Magidson, PhD
University of Maryland

Sarah Kattakuzhy, MD, MPH
University of Maryland

ABSTRACT:
There is a severe shortage of providers to treat opioid use disorder (OUD), which is further exacerbated in rural areas. Similar to the shortage of prescribers, there is also a severe shortage of trained behavioral health providers to meet the needs of patients with OUD. This talk will provide an overview of a newly launched NIDA-funded R01 trial “Peer Recovery to Improve Polysubstance Use and Mobile Telemedicine Retention” (PRISM)--a randomized Type 1 hybrid effectiveness-implementation trial (n=180) to examine a peer recovery specialist-delivered behavioral intervention to improve retention and polysubstance use on a mobile telemedicine treatment unit in rural Maryland. We will describe a novel telemedicine mobile treatment unit approach to expand access to OUD treatment in hard hit rural areas, as well as how our team is integrating an evidence-based, peer-delivered behavioral activation intervention to support retention and polysubstance use outcomes.

Adapting to the Fentanyl Epidemic: Implications for translation of a multi-component intervention and RCT in the Emergency Department and real world lessons from an implementation practitioner 

Lauren K. Whiteside, MD, MS
University of Washington

ABSTRACT:
The opioid epidemic is rapidly evolving with the proliferation of nonpharmaceutical fentanyl. Simultaneously, researchers, public health officials, and clinicians are working to develop and implement interventions to improve clinical care for patients with opioid use disorder (OUD). The Emergency Department Longitudinal Integrated Care (ED-LINC) randomized clinical trial harnesses the Collaborative Care model to reduce illicit opioid use and improve initiation and retention of evidence-based medications for opioid use disorder (MOUD) for patients that visit the ED with OUD. The original ED-LINC intervention was developed and pilot-tested prior to the overwhelming availability of fentanyl in our community.  We present information on a systematic rapid qualitative approach leveraging real-time clinical observations related to fentanyl use among the initial n=30 ED-LINC intervention participants.  This method was used to systematically produce and document protocol modifications and intervention adaptations required to ensure successful implementation of an intervention that is relevant to the target population amidst the rapidly intensifying fentanyl epidemic. As an implementation practitioner, there is an unavoidable urgency in treating patients with OUD due to fentanyl now and it is crucial that research does not lag behind the current state given the rapidly evolving epidemic. 

Understanding and Reducing Inequities in Substance Use Treatment Access and Utilization

Lesia Ruglass, PhD
City College of New York

ABSTRACT:
Data from the United States National Survey on Drug Use and Health (NSDUH, 2021) indicate that while certain racial/ethnic minoritized populations may have equivalent or lower rates of substance use disorders (SUD) compared to White people, evidence suggests that once developed, and given structural inequities and barriers, racial/ethnic minoritized people may suffer more deleterious consequences (i.e., health, criminal justice system involvement etc.) related to SUD than their White counterparts. In tandem, racial/ethnic minoritized people are less likely to access, utilize, and receive quality evidence-based SUD treatment than their White counterparts, which may further contribute to worsening of their SUD over time. This presentation will review research findings on some of the key factors (individual, interpersonal, community, and social) associated with inequities in treatment access and outcomes for racial/ethnic minoritized populations. Recommendations for research, clinical, and community/societal changes to advance health equity for racial/ethnic minoritized populations with SUD will be discussed.

Adjunctive Interventions in Implementation Research:​ One “thing”? Two things? Old thing? New thing?

Nanette Benbow, MA
Northwestern University

Dennis Li, MPH, PhD
Northwestern University

James Merle, PhD
University of Utah

ABSTRACT:
Implementation science currently groups change methods into two categories: (1) clinical, behavioral, or biomedical interventions targeting recipients’ health outcomes, and (2) implementation strategies—actions taken to improve system-level delivery of an intervention. Differentiating interventions from strategies based on their intended functions is critical to accurately attributing the effects of each change method on its respective health or implementation outcomes. However, in our work coordinating 200+ HIV implementation research projects and conducting systematic reviews of HIV intervention implementation, we identified change methods that had characteristics of both interventions and strategies and were inconsistently classified. To alleviate confusion and improve change method specification, we propose that implementation science should adopt the term adjunctive interventions to classify change methods that fall into this gray area. Adjunctive interventions are distinguished from other change methods by their intended targets, desired outcomes, and theory of action and causal processes. Whereas health interventions target recipients and have a direct, causal effect on the health outcome, adjunctive interventions enhance recipients’ motivation, self-efficacy, or capacity for initiating, adhering to, or engaging with the health intervention and thus have an indirect causal link to the health outcome via increasing the probability of recipients’ utilization of the health intervention. Adjunctive interventions are incapable of directly producing the health outcome and require additional implementation strategies to deliver alongside the health intervention. We will discuss case examples, logic modeling, and considerations for adjunctive intervention research. Conceptualizing adjunctive interventions as a separate type of change method will advance implementation research by improving tests of effectiveness and the specification of mechanisms and outcomes, which will accelerate research evidence to achieve public health impact.

Proposing and Applying the Observational-Implementation Hybrid Approach

Justin Knox, PhD, MPH
Columbia University

ABSTRACT:
We recently proposed the observational-implementation hybrid approach, or the incorporation of implementation science elements into observational studies in order to collect information that will allow for anticipation, estimation, and/or inference about the effects of interventions and implementation strategies. We describe this approach, including examples of how we are applying it to an ongoing observational study among n=600 Black sexual minority (SMM) men in order to collect relevant implementation data regarding the use of evidence-based practices to support drinking reductions. An initial step for employing an observational-implementation hybrid approach is knowing about the state of the research on relevant interventions or policies that aim to address the modifiable constructs relevant to the research questions of the study, including their implementation. Evidence-based practices that have been shown to help individuals reduce their alcohol use that we will focus on include: electronic screening and brief intervention, motivational interviewing, HealthCall (an mHealth intervention for people living with HIV), and naltrexone. We will employ various approaches to collect information on how to deliver these alcohol interventions to Black SMM. We are using survey measures to collect factors related to transportability of the alcohol interventions that we selected (e.g., access to a primary care physician, insurance status, treatment-seeking). We are conducting a discrete choice experiment among n=240 participants who report heavy drinking (AUDIT-C score >4) in order to collect preference data on the delivery of the alcohol interventions. Among a HIV-status neutral sub-sample of participants who report heavy drinking (n=30), we are using a human-centered design approach to collect journey maps of their experiences accessing HIV prevention and care service in clinical settings that will identify opportunities for co-delivery of alcohol interventions in these settings. Lastly, we are conducting in-depth interviews with n=10 HIV prevention and care service providers to collect input on implementation factors related to co-locating alcohol interventions into HIV prevention and care services. Applying this observational-implementation hybrid approach provides an opportunity to conduct observational research in ways that will allow it to achieve more rapid translational gains in terms of understanding how to deliver evidence-based practices to support reductions in alcohol use among Black SMM.

Developing Metrics to Improve Equitable Implementation of HIV Prevention

Moira McNulty, MD
University of Chicago

Maria Pyra, MEd, MPH, PhD
Northwestern University

ABSTRACT:
A daily pill, PrEP, has changed HIV prevention and could help end the HIV epidemic in the U.S. Thus far, use of PrEP has not been evenly or effectively distributed. Much of the focus to date on PrEP delivery has been on linkage and initiation of PrEP. We know that effectiveness of PrEP depends not only on initiation, but also on adherence, which typically requires retention in care for ongoing monitoring and prescriptions per the CDC guidelines; i.e., persistence on PrEP. While the annual number of PrEP users has been increasing, improvement in retention and adherence has lagged, with many individuals who initiate PrEP no longer adherent or retained at 6 months, despite the likelihood that risk of exposure to HIV continues. Furthermore, some of the most vulnerable populations such as young Black MSM are more likely to fall out of PrEP care than their non-Black peers. Yet, measuring persistence has been challenging, particularly in a way that is standardized and can be used across patient populations and PrEP programs. Dr. Moira McNulty, from the University of Chicago, and Dr. Maria Pyra, from Northwestern University, will present their work on PrEP metrics, particularly around persistence, and how these metrics can improve equitable implementation of PrEP.

Innovating Substance Use Disorder Treatment at Scale

Jeff DeFlavio, MD
Groups: Recover Together

ABSTRACT:
Across medicine clinical innovations take years to disseminate widely into practice, while some best practices in addiction medicine fail to ever gain widespread adoption. This presentation describes two private medical practices (Groups Recover Together and Affect Therapeutics) which have brought underutilized and evidence-based interventions to scale across the United States. The presentation will focus on the clinical models, patient outcomes, workforce considerations, revenue models and capital formation which was required to scale these effective care programs.

Supercharging implementation science with insights from behavioral economics

Rinad Beidas, MA, PhD
Northwestern University

ABSTRACT:
This presentation will describe efforts to apply the tools and insights from behavioral economics to improve upon implementation of evidence-based practices.

How to embed equity perspective in implementation studies – reflections from a learner

Ana Baumann, PhD
Washington University

ABSTRACT:
Equity continues to garner attention in the field of implementation science. Coming from a learner perspective, this presentation will offer some recommendations and suggestions as to how to embed equity in implementation studies, with a focus on processes and outcomes.

The Systems Analysis and Improvement Approach for Mental Health Systems Optimization in Mozambique (SAIA-MH)

Brad Wagenaar, PhD
University of Washington

ABSTRACT:
Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This talk will summarize our work on adapting, implementing, and now testing the effectiveness of the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) implementation strategy to optimize the primary mental healthcare treatment cascade in government health facilities in Mozambique.

Does evidence-based practice have any meaning for implementation science?  Rethinking the nature of evidence and purpose of research through an examination of sustainment and spread.

Brian Mittman, PhD
Kaiser Permanente

ABSTRACT:
Full realization of the societal benefits of our work in implementation science requires high levels of successful sustainment (maintenance) and scale-up/spread of our implementation strategies and the effective practices we strive to implement.  This presentation offers a series of questions we should ask, and recommendations for actions we can – and should – take, to enhance our societal contributions as implementation scientists.

A Proposed Framework for Designing Trials Evaluating the Effectiveness and Implementation of Digital Interventions for Substance Use

Theresa Matson, PhD
Kaiser Permanente Washington Health Research Institute

Joseph Glass, PhD
Kaiser Permanente Washington Health Research Institute

ABSTRACT:
Background: Clinicians and community health workers may wish to use digital interventions to reach more patients with unhealthy substance use, optimize costs of care, and improve outcomes. However, digital interventions have unique implementation considerations (e.g., technology infrastructure, digital literacy, monitoring and follow-up) and may not fit traditional care pathways. Effectiveness and implementation trials are needed to understand how well digital interventions work and how to best deploy them in the real-world. This presentation presents a framework to help researchers design their trials in such a way that maximizes scientific understanding.

Methods: This framework draws from the literature on trial design, expert perspectives on the use of digital interventions, and lessons learned from implementation science research programs. It outlines three major steps for designing trials of digital interventions: 1) framing the research question; 2) delineating components of the intervention, implementation strategy, and delivery approach; and 3) specifying the experiment and other elements of trial design.

Results: In Step 1 of this framework, researchers frame the research question in terms of the goals or activities to be tested (i.e., features of the digital intervention itself, specific implementation strategies, or level of clinical support). In Step 2, researchers define and delineate each study component as actor, activity, action target, or outcome to maximize inference and reproducibility across studies. Steps 1 and 2 inform Step 3, in which researchers specify features of the trial design (i.e., experimental/comparator selection, outcome selection, and design classification). To illustrate the utility of this framework, we compare and contrast implementation and effectiveness studies of digital interventions for substance use.

Conclusion: The proposed framework provides a foundation for designing trials of digital interventions for substance use in healthcare and community settings. This framework can help researchers decide on appropriate methodology and help decision-makers understand how to apply findings.

From Rhetoric to Implementation: Stigma Reduction Efforts in New York City Utilizing Implementation Science and Structural Approaches

Cristina Rodriguez-Hart, PhD, MPH
New York City Department of Health and Mental Hygiene

ABSTRACT:
Although widely declared to be a priority for ending the US HIV epidemic, stigma reduction remains siloed, unstructured, and lacking in standard frameworks and methodologies. Much of what has been learned about stigma reduction comes from the global context and focuses on individual and interpersonal-level approaches. What works in high-income, high-burden contexts is still an open question. I will provide an overview of several structural-level stigma reduction efforts in New York City utilizing implementation science, community-planning processes, funding mechanisms, and quality improvement.

Intervention Optimization: Integrations with Implementation Science and Decision Science

Kate Guastaferro, PhD
New York University

Jillian Strayhorn, PhD
New York University

ABSTRACT:
For behavioral and biobehavioral interventions to be capable of meaningful public health impact, they must be not only effective but also readily implementable. In this presentation, we discuss this idea of ready implementability, and we show how intervention optimization using the multiphase optimization strategy (MOST) can be applied to arrive at interventions that achieve a strategic balance of effectiveness and ready implementability. We also highlight new advances in MOST that are rooted in the fields of (i) implementation science and (ii) decision science.

Application of a Race(ism)-Conscious Adaptation of the Consolidated Framework for Intervention Research to a School-Connectedness Intervention

Michele Allen, MD
University of Minnesota

April Wilhelm, MD, MPH
University of Minnesota

Luis Enrique Ortega, MEd
University of Minnesota

ABSTRACT:
The Consolidated Framework for Implementation Research (CFIR) facilitates understanding of intervention implementation, but deployment of CFIR as a presumptively race(ism) neutral tool may obscure the influences of racism-sensitive barriers and facilitators to intervention uptake, particularly for interventions aiming to address health disparities. We describe our use of CFIR, adapted through Public Health Critical Race Praxis, to understand facilitators and barriers to uptake of Project TRUST (Training for Resiliency in Urban Students and Teachers). Project TRUST was a community-based participatory intervention focused on BIPOC student-school connectedness. Our community-academic team analyzed qualitative observational field notes, youth and parent researcher reflections, and semi-structured interviews with community-academic researchers and school-based partners within CFIR constructs based on adapted framing questions. Within many CFIR constructs and sub-constructs, we identified barriers to implementation uptake either not previously recognized or differently contextualized than when we used standard racism-neutral definitions.  We conclude that a race(ism) conscious application of CFIR results in a more robust understanding of intervention uptake in equity-oriented interventions.

C-DIAS, the Center for Dissemination & Implementation At Stanford: A new NIDA P50 Center of Excellence

Mark McGovern, PhD
Stanford University School of Medicine

Helene Chokron Garneau, PhD, MPH
Stanford University School of Medicine

ABSTRACT:
This presentation will introduce the new Center for Dissemination and Implementation At Stanford (C-DIAS), a NIDA P50 Center of Excellence. C-DIAS’ overarching mission is to expand equitable access to the most effective treatments available for addiction. It unites experts from implementation science and addiction treatment services research, and hosts three innovative, synergistic research projects at the PREPARATION, IMPLEMENTATION and SUSTAINMENT phases of the implementation process. In addition, C-DIAS aims to increase the expert capacity of D&I science in addiction, and will offer a stratified range of education, training and mentoring opportunities based on need. Audience will learn how to access C-DIAS open resources and programs, and understand how research findings can be integrated across the 3 C-DIAS research projects, as well as other D&I investigations with an addiction content focus.