Evaluation of a breastmilk hand expression toolkit: the M.I.L.K survey study

Background Breastmilk hand expression (BMHE) is recommended to promote lactation, relieve breast engorgement, and collect milk for future infant feedings. Resources to teach this skill are limited and infrequently developed in partnership with the obstetrical population. In collaboration with maternity care experts and individuals with recent breastfeeding experience, we designed a one-page toolkit that describes the process of BMHE and includes step-by-step instructions and images to illustrate the technique. This study aimed to evaluate the readability, clarity of content, layout, and informational value of this BMHE toolkit. Methods Individuals who intended to breastfeed, were currently breastfeeding, or had recently breastfed were electronically surveyed and completed a two-part survey that consisted of radio, multi-select, Likert scale, and open-ended questions. Part one captured sociodemographic factors, obstetrical history, and breastfeeding practices. Part two collected feedback on the BMHE toolkit. Participants were recruited electronically through social media and posters were circulated in antenatal and postnatal care settings in Ottawa, Canada between November 2020 and February 2021. Results Of the 123 participants, 117 (95.1%) had heard of hand expression prior to reviewing the toolkit and 99 (80.5%) had hand expressed before. Among the 48 participants who were no longer exclusively breastfeeding at the time of the survey, 22 (45.8%) had exclusively breastfed their infant for at least six months and 7 (14.6%) had discontinued exclusive breastfeeding within the first month. When asked about the BMHE toolkit, 118 (95.9%) participants said it was informative, 115 (93.5%) said it was easy to understand, and 114 (92.7%) said it was well laid-out. When asked about information seeking behaviours, participants indicated a preference for online resources (58.5%) and video resources (22.0%). Conclusions The BMHE toolkit was well received by participants and the feedback was favourable overall. The survey feedback will be used to create a revised version of the toolkit that has been validated by the obstetrical patient population. Future research should focus on identifying implementation strategies to optimize the use of the toolkit and increase its effectiveness as an educational resource to teach participants correctly BMHE.

Conceptualising Four Categories of Behaviours: Implications for Implementation Strategies to Achieve Behaviour Change

Background: Effectiveness of implementation strategies is influenced by the extent to which they are based on appropriate theories concerning the behaviours that the strategies intend to impact. Effectiveness may be limited simply because the strategies are based on theories that are limited in scope or are derived from partially inaccurate assumptions about the behaviours in question. It may therefore be important to combine insights from various theories to cover the range of influences on the behaviours that will be changed.Aim: This article aims to explore concepts, theories and empirical findings from different disciplines to categorise four types of behaviours and discuss the implications for implementation strategies attempting to change these behaviours.Influences on behaviours: Multilevel influences on behaviours are dichotomized into individual-level and collective-level influences, and behaviours that are guided by conscious cognitive processes are distinguished from those that rely on non-conscious processing. Combining the two dimensions (levels and cognitive modes) creates a 2 x 2 conceptual map consisting of four categories of behaviours. Explicitly conceptualising the levels and cognitive modes is crucial because different implementation strategies are required depending on the characteristics of the behaviours involved in the practise that needs to be changed.Conclusion: The 2 x 2 conceptual map can be used to consider and reflect on the nature of the behaviours that need to be changed, thus providing guidance on the type of theory, model or framework that might be most relevant for understanding and facilitating behaviour change.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews

The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers’ and consumers’ knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.

PATHWEIGH, pragmatic weight management in adult patients in primary care in Colorado, USA: study protocol for a stepped wedge cluster randomized trial

Background Despite the overwhelming prevalence and health implications of obesity, it is rarely adequately addressed in a health care setting. PATHWEIGH is a pragmatic approach to weight management that uses tools built into the electronic medical record to overcome barriers and guide care. Implementation strategies are employed to facilitate adoption and use of the PATHWEIGH tools and processes. The current study will compare the effectiveness of PATHWEIGH versus standard of care (SOC) on patient weight loss in primary care and explore factors for its successful implementation. Methods A stepped wedge cluster randomized trial design will be used within an effectiveness-implementation hybrid study. Adult patient weight loss and weight loss maintenance will be compared in PATHWEIGH versus SOC in 57 family and internal medicine clinics in a large health system in Colorado, USA. Effectiveness will be evaluated using generalized linear mixed models to determine statistical differences in weight loss and weight loss maintenance at 6, 12, and 18 months. Patient-, provider-, and clinic-level predictors will be identified using mediator and moderator analyses. Conceptually guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), a mixed methods approach including quantitative (practice surveys, use tracking) and qualitative (interviews, observations) data collection will be used to determine factors impeding and facilitating adoption, implementation, and maintenance of PATHWEIGH and evaluate specified implementation strategies. A cost analysis of the practice and system costs and resources required by PATHWEIGH relative to the reimbursement collected will be performed. Discussion The effectiveness and implementation of PATHWEIGH, and their interrelatedness, for patient weight loss are collectively the focus of the current trial. Findings from this study are expected to serve as a blueprint for available and effective weight management in primary care medical practice. Trial registration ClinicalTrials.govNCT04678752. Registered on December 21, 2020.

Conducting a Community Engagement Studio to Adapt Enhanced Milieu Teaching

Purpose: Barriers to implementing evidence-based practices occur at various levels. Stakeholder input is required to identify challenges specific to clinical practice settings, client populations, and service delivery approaches. The purpose of this project was to solicit feedback from stakeholders on the telepractice service delivery and implementation strategies proposed for a future study of enhanced milieu teaching (EMT) in rural counties. Method: A Community Engagement Studio was conducted with 11 caregivers of children with language delays living in rural counties. Caregivers and the researchers discussed early intervention service delivery for children with language delays in rural Oregon and the proposed telepractice EMT procedures. Researchers gathered feedback on three intervention components: session frequency and schedule, implementation strategies to encourage caregivers' use of EMT, and performance feedback techniques to teach caregivers. Results: Findings from the Community Engagement Studio led to four primary modifications to the telepractice EMT study protocol. The principal investigator increased available days and times for intervention sessions and added text-message reminders for parents. A survey was also added for caregivers to identify their preferences for additional implementation strategies (e.g., tip sheets, checklist, e-mailed session summaries) and graphic representations of performance feedback (e.g., bar graph, radial graph, mountain climber infographic). Conclusion: Community Engagement Studios are a promising method for increasing community engagement in clinical research and soliciting stakeholder feedback on evidence-based intervention adaptations. Supplemental Material: https://doi.org/10.23641/asha.17774819

Costs of an Alcohol Measurement Intervention in Three Latin American Countries

Alcohol measurement in health care settings is an effective intervention for reducing alcohol-related harm. However, in many countries, costs related to alcohol measurement have not yet been transparently assessed, which may hinder its adoption and implementation. Costs of an alcohol measurement programme in three upper-middle-income Latin American countries were assessed via questionnaires and compared, as part of the quasi-experimental SCALA study. Additional to the intervention costs, the costs of three implementation strategies: standard training and clinical package, intensive training and clinical package, and community support, were assessed and subsequently translated into costs per additional alcohol measurement session. Results demonstrated that costs for one alcohol measurement session ranged between Int$ 0.67 and Int$ 1.23 in Colombia, Int$ 1.19 and Int$ 2.57 in Mexico, and Int$ 1.11 and Int$ 2.14 in Peru. Costs were mainly driven by the salaries of the health professionals. Implementation strategies costs per additional alcohol measurement session ranged between Int$ 1.24 and Int$ 6.17. In all three countries, standard training and a clinical package may be a promising implementation strategy with a relatively low cost per additional alcohol measurement session.

Six Moments of Infection Prevention in Injection Drug Use: An Educational Toolkit for Clinicians

Background Injection drug use-associated bacterial and viral infections are increasing. Expanding access to harm reduction services, such as safe injection education, are effective prevention strategies. However, these strategies have had limited uptake. New tools are needed to improve provider capacity to facilitate dissemination of these evidence-based interventions. Methods The “Six Moments of Harm Reduction” provider educational tool was developed using a global, rather than pathogen-specific, infection prevention framework, highlighting the prevention of invasive bacterial and fungal infections in additional to viral pathogens. The tool’s effectiveness was tested using a short, paired pre/post survey that assessed provider knowledge and attitudes about harm reduction. Results N=75 respondents completed the paired surveys. At baseline, 17 respondents (22.6%) indicated that they had received no prior training in harm reduction and 28 (37.3%) reported discomfort counseling patients who inject drugs (PWID). 60 respondents (80.0%) reported they had never referred a patient to a syringe service program (SSP) and, of those, 73.3% cited lack of knowledge regarding locations of SSPs and 40.0% reported not knowing where to access information regarding SSPs. After the training, 66 (88.0%) reported that they felt more comfortable educating PWID (p<0.0001), 65 respondents (86.6%) reported they planned to use the “Six Moments” model in their own practice, and 100% said they would consider referring patients to a SSP in the future. Conclusions The “Six Moments” model emphasizes the importance of a global approach to infection prevention and harm reduction. This educational intervention can be used as part of a bundle of implementation strategies to reduce morbidity and mortality in PWID.

Translating Medicaid policy into practice: policy implementation strategies from three US states’ experiences enhancing substance use disorder treatment

Background Despite the important upstream impact policy has on population health outcomes, few studies in implementation science in health have examined implementation processes and strategies used to translate state and federal policies into accessible services in the community. This study examines the policy implementation strategies and experiences of Medicaid programs in three US states that responded to a federal prompt to improve access to evidence-based practice (EBP) substance use disorder (SUD) treatment. Methods Three US state Medicaid programs implementing American Society of Addiction Medicine (ASAM) Criteria-driven SUD services under Section 1115 waiver authority were used as cases. We conducted 44 semi-structured interviews with Medicaid staff, providers and health systems partners in California, Virginia, and West Virginia. Interviews were triangulated with document review of state readiness and implementation plans. The Exploration, Preparation, Implementation, Sustainment Framework (EPIS) guided qualitative theme analysis. The Expert Recommendations for Implementing Change and Specify It criteria were used to create a taxonomy of policy implementation strategies used by policymakers to promote providers’ uptake of statewide EBP SUD care continuums. Results Four themes describe states’ experiences and outcomes implementing a complex EBP SUD treatment policy directive: (1) Medicaid agencies adapted their inner/outer contexts to align with EBPs and adapted EBPs to fit their local context; (2) enhanced financial reimbursement arrangements were inadequate bridging factors to achieve statewide adoption of new SUD services; (3) despite trainings, service providers and managed care organizations demonstrated poor fidelity to the ASAM Criteria; and (4) successful policy adoption at the state level did not guarantee service providers’ uptake of EBPs. States used 29 implementation strategies to implement EBP SUD care continuums. Implementation strategies were used in the Exploration (n=6), Preparation (n=10), Implementation (n=19), and Sustainment (n=6) phases, and primarily focused on developing stakeholder interrelationships, evaluative and iterative approaches, and financing. Conclusions This study enhances our understanding of statewide policy implementation outcomes in low-resource, public healthcare settings. Themes highlight the need for additional pre-implementation and sustainment focused implementation strategies. The taxonomy of detailed policy implementation strategies employed by policymakers across states should be tested in future policy implementation research.