Barriers and Facilitators to the Implementation of the Pathways to Comorbidity Care (PCC) Training Package for the Management of Comorbid Mental Disorders in Drug and Alcohol Settings

Background: We have previously reported that the Pathways to Comorbidity Care (PCC) training program for alcohol and other drug (AOD) clinicians improved identification of comorbidity, self-efficacy, and attitudes toward screening and monitoring of comorbidity. We aimed to identify barriers and facilitators of implementation of the PCC training program in drug and alcohol settings.Methods: The PCC training program was implemented across 6 matched sites in Australia as per (1), and 20 clinicians received training. PCC training included seminar presentations, workshops conducted by local “clinical champions,” individual clinical supervision, and access to an online information portal. We examined barriers and facilitators of implementation according to the Consolidated Framework for Implementation Research.Results: Barriers included inner setting (e.g., allocated time for learning) and characteristics of individuals (e.g., resistance). Facilitators included intervention characteristics (e.g., credible sources), inner setting (e.g., leadership), and outer setting domains (e.g., patient needs). Clinical champions were identified as an important component of the implementation process.Conclusions: Barriers included limited specific allocated time for learning. A credible clinical supervisor, strong leadership engagement and an active clinical champion were found to be facilitators of the PCC training program.

Implementation, interrupted: Identifying and leveraging factors that sustain after a program interruption

BackgroundMany implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform targeted re-implementation strategies.MethodsThis study took place in two public health centers with tuberculosis (TB) units in Uganda that previously implemented diabetes mellitus (DM) screening in 2017. In 2019, we conducted interviews with clinic staff to determine current DM practices. We mapped themes identified in the interviews to a Social Ecological Model with three levels: outer setting, inner setting, and individuals.ResultsWe conducted nine interviews with clinic staff. Respondents explained that DM screening ceased due to disruptions in the supply chain for glucose test strips. This outer setting interruption had cascading effects on the inner setting and individuals. The lack of screening supplies limited the staff’s opportunities to perform DM screening within the inner setting level, which was associated with diminished self-efficacy within the individual level. However, culture, compatibility and individual beliefs about DM screening sustained throughout the interruption.ConclusionsWe identified factors that diminished and sustained within and between ecological levels during a program interruption. Using this approach, other programs facing interruptions can identify factors and cascading effects of the interruption to target them for re-implementation.

Identifying and understanding the contextual factors that shaped mid-implementation outcomes during the COVID-19 pandemic in organizations implementing mental health recovery innovations into services

Background Seven housing and health services organizations were guided through a process of translating Chapter Six of the Canadian Guidelines for Recovery-Oriented Practice into a recovery-oriented innovation and plan for its implementation. At the time of the COVID-19 outbreak and lockdown measures, six of the seven organizations had begun implementing their chosen innovation (peer workers, wellness recovery action planning facilitator training, staff training and a family support group). This mid-implementation study used the Consolidated Framework for Implementation Research (CFIR) to identify contextual factors that influenced organizations to continue or postpone implementation of recovery-oriented innovations in the early months of the COVID-19 pandemic. Methods Twenty-seven semi-structured 45-min interviews were conducted between May and June 2020 (21 implementation team members and six providers of the innovation (trainers, facilitators, peer workers). Interview guides and analysis were based on the CFIR. Content analysis combined deductive and inductive approaches. Summaries of coded data were given ratings based on strength and valence of the construct’s impact on implementation. Ratings were visualized by mid-implementation outcome and recovery innovation to identify constructs which appear to distinguish between sites with a more or less favorable mid-implementation outcomes. Results Four mid-implementation outcomes were observed at this snapshot in time (from most to least positive): continued implementation with adaptation (one site), postponement with adaptation and estimated relaunch date (four sites), indefinite postponement with no decision on relaunch date (one site), and no implementation of innovation yet (one site). Two constructs had either a negative influence (external policies and incentives—renamed COVID-19-related external policy for this study) or a positive influence (leadership engagement), regardless of implementation outcome. Four factors appeared to distinguish between more or less positive mid-implementation outcome: adaptability, implementation climate and relative priority, available resources, and formally appointed internal implementation leaders (renamed “engaging implementation teams during the COVID-19 pandemic” for this study). Conclusions The COVID-19 pandemic is an unprecedented outer setting factor. Studies that use the CFIR at the mid-implementation stage are rare, as are studies focusing on the outer setting. Through robust qualitative analysis, we identify the key factors that shaped the course of implementation of recovery innovations over this turbulent time.

Operational Challenges That May Affect Implementation of Evidence-based Interventions at Mobile Produce Markets

Introduction: Mobile produce markets are becoming an increasingly prevalent, accepted, and effective strategy for improving fruit and vegetable (F&V) access and consumption across underserved and lower-income communities. However, there is limited published research on mobile market operations. The goal of this research is to identify the challenges mobile markets face and ways to potentially mitigate those challenges. We will also discuss implications of our findings on implementation of evidence-based interventions for mobile produce markets.Methods: We conducted 21 semi-structured key informant (KI) interviews to assess common practices of mobile market organizations that had been operating for 2 + years. We asked KIs about their organizational structure, operations, procurement and logistics, evaluation efforts, marketing and community engagement, success and challenges. All interviews were recorded, transcribed, and analyzed by two independent coders using ATLAS.ti 8.0 qualitative software. A secondary qualitative analysis identified subthemes related to common challenges and remedial practices. An inductive coding process was applied to match identified challenges to the appropriate Consolidated Framework for Implementation Research (CFIR).Results: The leading challenges cited by KIs correspond to the CFIR domains of inner setting (e.g., funding and resources), outer setting (e.g., navigating regulations), and process (e.g. engaging community partnership). Practices that may mitigate challenges include maximizing ancillary services, adopting innovative volunteer and staffing structures, and formalizing agreements with community partners.Conclusion: Common and persistent challenges ought to be addressed to ensure and enhance the positive public health impacts of mobile produce markets. Contextual factors, particularly organizational factors, that impact implementation should also be considered when implementing an evidence-based-intervention at a mobile market. Further research is needed to determine which innovative solutions are the most effective in mitigating challenges, improving implementation, and enhancing sustainability of mobile markets.

Operational Challenges that May Affect Implementation of Evidence-Based Interventions at Mobile Produce Markets

Introduction: Mobile produce markets are becoming an increasingly prevalent, accepted, and effective strategy for improving fruit and vegetable (F&V) access and consumption across underserved and lower-income communities. However, there is limited published research on mobile market operations. The goal of this research is to identify the challenges mobile markets face and ways to potentially mitigate those challenges. We will also discuss implications of our findings on implementation of evidence-based interventions for mobile produce markets. Methods: We conducted 21 semi-structured key informant (KI) interviews to assess common practices of mobile market organizations that had been operating for 2 + years. We asked KIs about their organizational structure, operations, procurement and logistics, evaluation efforts, marketing and community engagement, success and challenges. All interviews were recorded, transcribed, and analyzed by two independent coders using ATLAS.ti 8.0 qualitative software. A secondary qualitative analysis identified subthemes related to common challenges and remedial practices. An inductive coding process was applied to match identified challenges to the appropriate Consolidated Framework for Implementation Research (CFIR). Results: The leading challenges cited by KIs correspond to the CFIR domains of inner setting (e.g., funding and resources), outer setting (e.g., navigating regulations), and process (e.g. engaging community partnership). Practices that may mitigate challenges include maximizing ancillary services, adopting innovative volunteer and staffing structures, and formalizing agreements with community partners. Conclusion: Common and persistent challenges ought to be addressed to ensure and enhance the positive public health impacts of mobile produce markets. Contextual factors, particularly organizational factors, that impact implementation should also be considered when implementing an evidence-based-intervention at a mobile market. Further research is needed to determine which innovative solutions are the most effective in mitigating challenges, improving implementation, and enhancing sustainability of mobile markets.

Implementing at-birth, point-of-care HIV testing in Kenya: a qualitative study using the Consolidated Framework for Implementation Research

Background At-birth and point-of-care (POC) testing can expedite early infant diagnosis of HIV and improve infant outcomes. Guided by the Consolidated Framework for Implementation Research (CFIR), this study describes the implementation of an at-birth POC testing pilot from the perspective of implementing providers and identifies the factors that might support and hinder the scale up of these promising interventions. Methods We conducted 28 focus group discussions (FGDs) with 48 providers across 4 study sites throughout the course of a pilot study assessing the feasibility and impact of at-birth POC testing. FGDs were audio-recorded, transcribed, and analyzed for a priori themes related to CFIR constructs. This qualitative study was nested within a larger study to pilot and evaluate at-birth and POC HIV testing. Results Out of the 39 CFIR constructs, 30 were addressed in the FGDs. While all five domains were represented, major themes revolved around constructs related to intervention characteristics, inner setting, and outer setting. Regarding intervention characteristics, the advantages of at-birth POC (rapid turnaround time resulting in improved patient management and enhanced patient motivation) were significant enough to encourage provider uptake and enthusiasm. Challenges at the intervention level (machine breakdown, processing errors), inner settings (workload, limited leadership engagement, challenges with access to information), and outer setting (patient-level challenges, limited engagement with outer setting stakeholders) hindered implementation, frustrated providers, and resulted in missed opportunities for testing. Providers discussed how throughout the course of the study adaptations to implementation (improved channels of communication, modified implementation logistics) were made to overcome some of these challenges. To improve implementation, providers cited the need for enhanced training and for greater involvement among stakeholders outside of the implementing team (i.e., other clinicians, hospital administrators and implementing partners, county and national health officials). Despite provider enthusiasm for the intervention, providers felt that the lack of engagement from leadership within the hospital and in the outer setting would preclude sustained implementation outside of a research setting. Conclusion Despite demonstrated feasibility and enthusiasm among implementing providers, the lack of outer setting support makes sustained implementation of at-birth POC testing unlikely at this time. The findings highlight the multi-dimensional aspect of implementation and the need to consider facilitators and barriers within each of the five CFIR domains. Trial registration ClinicalTrials.gov, NCT03435887. Retrospectively registered on 19 February 2020

Understanding the need for a whole-of-society approach in school nutrition policy implementation: a qualitative analysis

Background Only three of twenty Caribbean Community (CARCICOM) countries have mandatory school nutrition policies despite one third of the region’s children being overweight or obese. In Barbados, there are nutrition guidelines which lack the legal mandate of a formal policy. We aim to assess the comprehensiveness of current national nutrition guidelines and to understand the factors operating in the inner and outer school setting that may influence the implementation of a mandatory school nutrition policy from the perspectives of school administrators. Methods A documentary analysis of existing nutritional guidelines was conducted along with qualitative semi-structured interviews in primary (elementary) and secondary (high) schools in Barbados. We purposively sampled six primary and four secondary school administrators (principals, deputy principals or senior teachers) to explore their knowledge and views on the National School Nutrition Guidelines. The deterministic implementation paradigm, Consolidated Framework for Implementation (CFIR), was used to explore the complexities within the inner and outer settings of schools. Documentary analysis used a theory-based framework informed by the Wellness School Assessment Tool—school policy analysis questionnaire. Interview transcripts were team coded using thematic analysis with constant comparison facilitated by NVIVO software version12. Results School administrators were unaware of the existing National School Nutrition Guidelines which documentary analysis found to be restrictive and weak for implementation. Administrators envisioned a government-led (outer setting), whole of society approach as the most effective strategy for the development and implementation of a proposed mandatory school nutrition policy. School administrators identified lack of financial and human resources as barriers to nutrition policy implementation. Formal and informal food vendors are institutionalized in schools and are influential determinants of the school food environment. Schools have individually reached into the outer setting to work with civil society organizations and private individuals to provide financial support and nutrition expertise to their institutions. Mass media campaigns in the outer setting may influence child and parental food choices. Conclusion School administrators describe that government-led, CSO supported policy development using a whole-of-society approach has implications for improving nutrition policy implementation. Our findings demonstrate the use of a deterministic implementation framework in the pre-implementation phase of school nutrition policy development.

Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol

Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs.Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations).Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs.Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.

The Implementation of an Interpersonal Violence Screening Program in Primary Care Settings: Lessons Learned

Background Interpersonal violence (IPV) is a public health issue that disproportionately affects women. IPV screening improves likelihood of survivor disclosure and access to additional support. To enhance primary care IPV screening, Technology Enhanced Screening and Supportive Assistance (TESSA) uses integrated technological systems to deliver bidirectional, evidence-informed health navigation, health management, and safety interventions. This study evaluates TESSA implementation in primary care clinics using the Consolidated Framework for Implementation Research (CFIR). Method CFIR is a metatheoretical framework used for evaluating clinical intervention implementation. Salient constructs within CFIR’s five domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) were identified (23 constructs), and pertinent implementation details were examined. Results Key lessons learned included intervention characteristic constructs like intervention source (e.g., selecting tablets that can screen for items integral to the program’s aims) and adaptability (e.g., ensuring tablets worked with electronic medical records for each clinic), process constructs like engaging champions (e.g., garnering buy-in from key clinic stakeholders and staff), outer setting constructs like patient needs and resources (e.g., addressing pertinent patient resource needs) and external policies and incentives (e.g., incentivizing clinics by addressing clinic needs), and inner setting constructs like leadership engagement (e.g., ensuring buy-in from organizational leaders as leadership changed frequently). Conclusions CFIR identifies important implementation factors for programs like TESSA that screen for high-risk populations and implement in primary care settings. The TESSA program implementation permits increased IPV screening among primary health care populations, thus promoting access to resources for otherwise hard-to-reach populations.

Application of the Consolidated Framework for Implementation Research to Facilitate Delivery of Trauma-Informed HIV Care

Background: The high prevalence of trau­ma and its negative impact on health among people living with HIV underscore the need for adopting trauma-informed care (TIC), an evidence-based approach to address trauma and its physical and mental sequelae. However, virtually nothing is known about factors internal and external to the clinical environment that might influence adoption of TIC in HIV primary care clinics.Methods: We conducted a pre-implemen­tation assessment consisting of in-depth interviews with 23 providers, staff, and ad­ministrators at a large urban HIV care center serving an un-/under-insured population in the southern United States. We used the Consolidated Framework for Implementa­tion Research (CFIR) to guide qualitative coding to ascertain factors related to TIC adoption.Results: Inner setting factors perceived as impacting TIC adoption within HIV primary care included relative priority, compatibility, available resources, access to knowledge and information (ie, training), and networks and communications. Relevant outer setting factors included patient needs/resources and cosmopolitanism (ie, connections to external organizations). Overall, the HIV care center exhibited high priority and compatibility for TIC adoption but displayed a need for system strengthening with regard to available resources, training, communica­tions, cosmopolitanism, and patient needs/ resources.Conclusions: Through identification of CFIR inner and outer setting factors that might influence adoption of TIC within an HIV primary care clinic, our findings begin to fill key knowledge gaps in understand­ing barriers and facilitators for adopting TIC in HIV primary care settings and highlight implementation strategies that could be employed to support successful TIC imple­mentation. Ethn Dis. 2021;31(1):109-118; doi:10.18865/ed.31.1.109