Traumatic brain injury (TBI) is common among individuals seeking treatment for substance use disorders in behavioral healthcare settings, but evidence-based TBI screening methods are underutilized. We investigated provider perceptions of the acceptability, feasibility, and appropriateness of TBI screening, and whether these perceptions influenced the relationships between screening intentions and behaviors. Understanding how these implementation outcomes are interrelated can help clarify the temporal sequencing of implementation processes and lead to more precise and cost-effective dissemination and implementation (D&I) strategies. In Phase 1 of this explanatory sequential mixed methods study, 215 behavioral healthcare providers completed an electronic survey assessing their intentions to screen for TBI using the Ohio State University TBI Identification Method (OSU TBI-ID). After 1-month, a second survey assessed the number of screens conducted, and perceptions of the acceptability, feasibility, and appropriateness of the OSU TBI-ID. Binary logistic regressions were used to examine whether acceptability, feasibility, and appropriateness moderated the relationship between screening intentions and behaviors. In Phase 2, 20 providers participated in an interview to contextualize the quantitative results. Qualitative data were analyzed thematically and integrated with the quantitative results. The mean acceptability, feasibility, and appropriateness scores were 4.12, 4.02, and 3.69, respectively. Acceptability (OR = 0.80, p = .29), feasibility (OR = 0.93, p = .88), and appropriateness (OR = 0.97, p = .65) of TBI screening did not moderate the relationship between intentions and behaviors. Providers endorsed the OSU TBI-ID as easy to use and integrate into practice, relevant to clients, and helpful in guiding referrals and treatment decision-making. Positive perceptions of an intervention are important but insufficient for shaping the transition from intentions to behavior. This study begins to disentangle interrelationships between early-phase implementation outcomes, which can help guide more precise D&I strategy development to enhance implementation efficiency and effectiveness.

De-implementing non-effective or even harmful practices in healthcare is sometimes necessary, as has been the case with opioid prescribing in dentistry over the past decade. One approach to practice transformation is to deploy clinical decision support (CDS) tools. This qualitative study examined barriers to CDS use as part of a cluster randomized trial that aimed to decrease opioid prescribing for pain management following tooth extractions across a large dental practice. Twenty dental providers who took part in the larger randomized trial were purposively selected to complete a semi-structured qualitative interview. Participants represented a broad range in terms of years of practice, dental specialization, and CDS use patterns. Interviews were conducted via Zoom, audio recorded, transcribed, and analyzed using a content analysis approach in ATLAS.ti following participation in the cluster randomized trial. Reasons for not using the CDS fell generally into two broad categories: unintentional (i.e., forgetting to use the CDS) and intentional. Providers who forgot to use the CDS after training and implementation either were not sure where to look for the alert on the screen or did not remember to look for it because its use was never incorporated into their workflow. Reasons for deciding not to use the CDS included feeling that it slowed down their workflow, thinking that the information it provided would not be useful, and not trusting the functionality of the system. There were numerous, interdependent human, organizational, and technological factors that influenced the intentionally and unintentionally low CDS use rates observed in the study. Findings highlight issues to be aware of and address in future implementation efforts that utilize CDS. Clinicaltrials.gov NCT03584789.

BackgroundIn South Africa, rates of HIV and alcohol use are among the highest globally, with a detrimental synergistic relationship. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, cost-effective approach to identifying people at risk of alcohol-related problems to deliver early intervention. We developed and deployed a cascading train-the-trainer model to promote SBIRT implementation in a large nongovernmental organization offering HIV services across South Africa.MethodBetween 2021 and 2022, we completed preparatory activities including designing scalable training resources prior to rolling out the train-the-trainer model across two South African provinces. We conducted a comprehensive assessment of outcomes at the trainer- (knowledge, fidelity), provider- (attitudes, confidence, perceived implementation potential, adoption), and client-encounter (reach) levels over approximately one year.ResultsWe trained 12 novice trainers who then trained 206 providers to implement SBIRT. Trainer SBIRT knowledge increased pre- to posttraining, and fidelity of training delivery was high (99.0% of elements covered across sessions). Provider attitudes, confidence, and perceived implementation potential increased over time, and 64% of providers adopted SBIRT. Reach of the model varied by component, with 41,793 clients screened by trained providers. Of those screening positive for risky alcohol use, 86% received brief intervention (BI) and 53% received referral to treatment (RT). Additionally, 15,353 clients who did not screen as having risky alcohol use received BI and 1,122 received RT.ConclusionResults indicated that the cascading training model was delivered with high fidelity, associated with improvements in all provider outcomes, and reached high numbers of clients for the screening component of the model. Rates of BI and RT delivery were moderate to high, though data suggested over-application of these elements with some clients, highlighting the tension between reach and fidelity. Lessons learned will inform future scale-out of this model in HIV service settings in low- and middle-income countries.

Preventing and treating mental health and substance use problems requires effective, affordable, scalable, and efficient interventions. The multiphase optimization strategy (MOST) framework guides researchers through a phased and systematic process of developing optimized interventions. However, new methods of systematically incorporating information about implementation constraints across MOST phases are needed. We propose that early and sustained integration of community-engaged methods within MOST is a promising strategy for enhancing an optimized intervention's potential for implementation. In this article, we outline the advantages of using community-engaged methods throughout the intervention optimization process, with a focus on the Preparation and Optimization Phases of MOST. We discuss the role of experimental designs in optimization research and highlight potential challenges in conducting rigorous experiments in community settings. We then demonstrate how relying on the resource management principle to select experimental designs across MOST phases is a promising strategy for maintaining both experimental rigor and community responsiveness. We end with an applied example illustrating a community-engaged approach to optimize an intervention to reduce the risk for mental health problems and substance use problems among children with incarcerated parents.

BackgroundAs the opioid crisis continues to affect communities across the United States, new interventions for screening and prevention are needed to mitigate its impact. Mental health diagnoses have been identified as a risk factor for opioid misuse, and surgical populations and injury survivors are at high risk for prolonged opioid use and misuse. This study investigated the implementation of a novel opioid risk screening tool that incorporated putative risk factors from a recent study in four trauma units across Wisconsin.MethodThe screening tool was implemented across a 6-month period at four sites. Data was collected via monthly meeting notes and “Plan, Do, Study, Act” (PDSA) forms. Following implementation, focus groups reflected on the facilitators and barriers to implementation. Meeting notes, PDSA forms, and focus group data were analyzed using the consolidated framework for implementation research, followed by thematic analyses, to generate themes surrounding the facilitators and barriers to implementing an opioid misuse screener.ResultsImplementation facilitators included ensuring patient understanding of the screener, minimizing staff burden from screening, and educating staff to encourage engagement. Barriers included infrastructure limitations that prevented seamless administration of the screener within current workflows, overlap of the screener with existing measures, and lack of guidance surrounding treatment options corresponding to risk. Recommended solutions to address barriers include careful timing of screener administration, accommodating workflows, integration of the screening tool within the electronic health record, and evidence-based interventions guided by screener results.ConclusionFour trauma centers across Wisconsin successfully implemented a pilot opioid misuse screening tool. Trauma providers and unit staff members believe that this tool would be a beneficial addition to their repertoire if their recommendations were adopted. Future research should refine opioid misuse risk factors and ensure screening items are well-validated with psychometric research supporting treatment responses to screener-indicated risk categories.

BackgroundReporting on strategies to advance implementation outcomes is imperative. The current study reports descriptive information about external implementation support (EIS) provided over 5 years to 13 regions in North Carolina and South Carolina scaling an evidence-based system of parenting and family supports. Regional support teams operating through the Implementation Capacity for Triple P (ICTP) projects employed core practice components (CPCs) for EIS as proposed by Aldridge et al. and further operationalized by members of The Impact Center at FPG Child Development Institute, UNC-Chapel Hill.MethodPractice activities associated with CPCs were developed and iteratively refined across the study period. ICTP regional support teams systematically tracked their use of CPCs and related activities following each substantive support interaction. Tracking included the duration of time a CPC was employed and the use of specific practice activities associated with that CPC. Data were aggregated by month of the relationship to account for differential start dates across regions.ResultsFrom November 2016 through December 2021, ICTP support teams tracked 749 support interactions with Triple P regions in North Carolina and South Carolina. Monthly support decreased year over year, though dose varied considerably. Patterns of CPC use indicated a high dose of “foundational” and “co-design” CPCs early, followed by a blended and more diverse use thereafter, with some notable trends. Practice activities considered essential to influencing intended practice outcomes were characterized by higher rates of use. Like CPCs, practice activities were used dynamically across the study period.ConclusionsThis descriptive study offers a case study for how EIS might be operationalized, tracked, and employed. Findings suggest several interpretations that might refine our understanding and use of EIS. Although the nature of this practical report precludes generalizability of findings, directions for future research and practice are discussed.

BackgroundEmerging research has demonstrated that organizational efforts at becoming secondary traumatic stress (STS)-informed can improve the overall well-being of the workforce, especially when implementation activity by a champion team is high. Questions remain, however, regarding the mechanisms that enable these improvements.MethodThis study uses configurational analysis to determine necessary and sufficient conditions to produce reductions in STS symptoms in workers as well as organizational improvements toward being more STS-informed in a cohort survey of 6,033 professionals working with individuals exposed to trauma representing 52 organizations. The Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) was used to measure professional's perceptions of how well the unit addressed secondary trauma in the workplace, and the Secondary Traumatic Stress Scale (STSS) assessed traumatic stress symptoms in respondents. Champions' activity was scored using the categories suggested by Shea.ResultsFor the STSS outcome, either a STSI-OA positive increase of 10 or more points or high levels of champion problem-solving were independently sufficient for an improvement in the outcome. The STSI-OA model had two pathways: high levels of peer engagement via the scaling up of innovations using PDSAs or the combination of facilitation of peer knowledge and skills together with working in a child welfare organization. Either pathway was sufficient by itself to yield the STSI-OA outcome.ConclusionsIdentifying and cultivating the champions' use of problem-solving and peer engagement strategies can transform the threat posed by indirect trauma exposure into an opportunity for shared experience and healing.Plain Language SummaryOrganizational champions are individuals or teams that strive to promote change within their workplace. These champions are integral to spreading innovative ideas and strategies and creating organization-wide changes (Powell et al., 2015). However, little is known about the processes or specific strategies that make champions successful. One area in which champions are needed is in improving organizations' response to and understanding of secondary traumatic stress (STS), among those in helping professions that are indirectly exposed to trauma through the traumatic stories of those they work with. In fact, research has shown that organizational efforts to address STS improve the well-being of individual professionals within that organization (Sprang et al., 2021). The present study sought to better understand what champion-related processes or conditions led to organizational change in addressing the effects of indirect exposure and improving symptoms related to STS. Results showed that organizational change in addressing STS and champions' problem-solving strategies resulted in reductions in individual professionals' STS symptoms. Furthermore, champions' use of peer engagement or sharing of knowledge among peers in child welfare settings led to improvements at an organizational level. These results show that organization-level change can have a direct impact on individual well-being and there are specific champion activities that can promote this change. Specifically, results demonstrate a need to identify and support champions' use of problem-solving and peer engagement strategies to turn the individual and organizational threat posed by indirect trauma into an opportunity for shared healing.

There is a priority need to make community-based care widely available for people living with schizophrenia (PLwS) in low- and middle-income countries. An innovative approach for increasing access could be to integrate clinical services available in tertiary care hospitals with community-based care through a task-sharing approach. We describe such an integrated intervention that was implemented at Tezpur in northeast India in collaboration with the Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH). The objectives of the study were to illustrate the feasibility of integrating and implementing the intervention and to describe its individual, systemic, and public health impacts. Due to the limited resources available, we conducted a pragmatic single-arm longitudinal evaluation of the intervention cohort over 24 months. Of the 239 PLwS enrolled in the intervention, 198 (83%) were followed up for 24 months, with nearly three-quarters reporting a >70% reduction in disabilities, most notably between 6 and 18 months. There was a marked reduction in unmet needs across multiple domains, and at 24 months, 62% of the cohort was engaged in individual jobs or other market-linked livelihood opportunities. There was greater uptake and retention with outpatient contacts at the LGBRIMH, and PLwS experienced a marked (82%) reduction in inpatient admissions rates, as compared to before enrolment. Over a period of 24 months, primary caregivers reported that their families experienced significantly fewer social difficulties such as unemployment, interpersonal conflicts, and social isolation. The intervention had a significant public health impact, with an estimated 51.8% effective treatment coverage rate for the integrated intervention. Our findings provide preliminary evidence of the feasibility of implementing the integrated intervention and its effectiveness. We believe that there is merit in further in-depth refinement and exploration of this implementation-related research and cost analysis while replicating the intervention in other tertiary care institutions.

Evidence-based interventions (EBIs) seldom fit seamlessly into a setting and are often adapted. The literature identifies practitioners' management of fidelity and adaptations as problematic but offers little guidance. This study aimed to investigate practitioners' perceptions of the feasibility and usability of an intervention aimed to support them in fidelity and adaptation management when working with EBIs. The intervention, the adaptation and fidelity tool (A-FiT), was developed based on the literature, along with input from social service practitioners and social services' Research and Development units' personnel. The intervention consisted of two workshops where the participants were guided through a five-step process to manage fidelity and adaptations. It was tested in a longitudinal mixed-method intervention study with 103 practitioners from 19 social service units in Stockholm, Sweden. A multimethod data collection was employed, which included interviews at follow-up, questionnaires at baseline and follow-up (readiness for change and self-rated knowledge), workshop evaluation questionnaires (usability and feasibility) after each workshop, and documentation (participants' notes on worksheets). To analyze the data, qualitative content analysis, Kruskal-Wallis tests, and Wilcoxon rank-sum tests were performed. Overall, the practitioners had a positive perception of the intervention and perceived it as relevant for fidelity and adaptation management (mean ratings over 7.0 on usability and feasibility). The workshops also provided new knowledge and skills to manage fidelity and adaptations. Furthermore, the intervention provided insights into the practitioners' understanding about adaptation and fidelity through a more reflective approach. Practical tools are needed to guide professionals not only to adhere to intervention core elements but also to help them to manage fidelity and adaptation. The proposed A-FiT intervention for practitioners' management of both fidelity and adaptation is a novel contribution to the implementation literature. Potentially, the next step is an evaluation of the intervention's impact in an experimental design.

Implementation climate is an organizational construct theorized to facilitate the adoption and delivery of evidence-based practices. Within schools, teachers often are tasked with implementing universal prevention programs. Therefore, they are ideal informants when assessing school implementation climate for initial and continuous implementation improvement efforts. The purpose of this study was to examine the construct validity (i.e., factor structure and convergent/divergent validity) of a school-adapted measure of strategic implementation climate called the School Implementation Climate Scale (SICS). Confirmatory factor analyses of SICS data, collected from 441 teachers in 52 schools, were used to compare uncorrelated and correlated first-order factor models and a second-order hierarchical model. Correlations with other school measures were examined to assess SICS convergent and divergent validities. Results demonstrated acceptable internal consistency for each SICS subscale (αs > 0.80 for all subscales) and construct validity of the hypothesized factor structure of the SICS with three new scales. The hierarchical second-order factor structure with eight first-order factors was found to best model the SICS data. Correlations with other school measures were in the expected direction and magnitude. Results from this study provide psychometric evidence that supports the use of the SICS to inform the implementation research and practice in schools. Schools are busy trying to implement various universal programs and systems to help support kids in their growth. Beginning and sustaining these efforts is quite challenging, and there is need for tools and ideas to help those implementation efforts. One concept is implementation climate, which is broadly the school staff's perception of the implementation support for a given practice. However, no measure currently exists to help schools assess their implementation climate. The goal of our study was to adapt a measure of implementation climate used in other settings to the school environment. We used feedback from educational experts to make changes and used various analyses to determine if the newly adapted measure was psychometrically sound. Findings suggest the new measure is usable to guide implementation efforts in schools.