Search

BACKGROUND: Goals of care conversations explore seriously ill patients values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations. METHODS: We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders. CONCLUSION: This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

BackgroundColorectal cancer (CRC) screening is underused, particularly among low-income and minoritized populations, for whom the coronavirus disease 2019 (COVID-19) pandemic has challenged progress in achieving equity.MethodsA hub-and-spoke model was used. The hub was a nonacademic organization and the spokes were three community health center (CHC) systems overseeing numerous clinic sites. Via a cluster-randomized trial design, nine clinic sites were randomized to intervention and 16 clinic sites were randomized to usual care. Patient-level interventions included invitation letters, mailed fecal immunochemical tests (FITs), and call/text-based reminders. Year 1 intervention impact, which took place during the COVID-19 pandemic, was assessed as the proportion completing screening among individuals not up to date at baseline, which compared intervention and nonintervention clinics accounting for intraclinic cluster variation; confidence intervals (CIs) around differences not including 0 were interpreted as statistically significant.ResultsAmong 26,736 patients who met eligibility criteria, approximately 58% were female, 55% were Hispanic individuals, and 44% were Spanish speaking. The proportion completing screening was 11.5 percentage points (ppts) (95% CI, 6.1-16.9 ppts) higher in intervention versus usual care clinics. Variation in differences between intervention and usual care clinics was observed by sex (12.6 ppts [95% CI, 7.2-18.0 ppts] for females; 8.8 ppts [95% CI, 4.7-13.9 ppts] for males) and by racial and ethnic group (13.8 ppts [95% CI, 7.0-20.6 ppts] for Hispanic individuals; 13.0 ppts [95% CI, 3.6-22.4 ppts] for Asian individuals; 11.3 ppts [95% CI, 5.8-16.8 ppts] for non-Hispanic White individuals; 6.1 ppts [95% CI, 0.8-10.4 ppts] for Black individuals).ConclusionsA regional mailed FIT intervention was effective for increasing CRC screening rates across CHC systems serving diverse, low-income populations.

BACKGROUND: Patient participation in treatment decision making is a pillar of recovery-oriented care and is associated with improvements in empowerment and well-being. Although demand for increased involvement in treatment decision-making is high among veterans with serious mental illness, rates of involvement are low. Collaborative decision skills training (CDST) is a recovery-oriented, skills-based intervention designed to support meaningful patient participation in treatment decision making. An open trial among veterans with psychosis supported CDSTs feasibility and demonstrated preliminary indications of effectiveness. A randomized control trial (RCT) is needed to test CDSTs effectiveness in comparison with an active control and further evaluate implementation feasibility. METHODS: The planned RCT is a hybrid type 1 trial, which will use mixed methods to systematically evaluate the effectiveness and implementation feasibility of CDST among veterans participating in a VA Psychosocial Rehabilitation and Recovery Center (PRRC) in Southern California. The first aim is to assess the effectiveness of CDST in comparison with the active control via the primary outcome, collaborative decision-making behavior during usual care appointments between veterans and their VA mental health clinicians, and secondary outcomes (i.e., treatment engagement, satisfaction, and outcome). The second aim is to characterize the implementation feasibility of CDST within the VA PRRC using the Practical Robust Implementation and Sustainability Model framework, including barriers and facilitators within the PRRC context to support future implementation. DISCUSSION: If CDST is found to be effective and feasible, implementation determinants gathered throughout the study can be used to ensure sustained and successful implementation at this PRRC and other PRRCs and similar settings nationally. TRIAL REGISTRATION: ClinicalTrials.gov NCT04324944. Registered on March 27, 2020. Trial registration data can be found in Appendix 1.

BACKGROUND: Subjective cognitive concerns (SCCs) entail perceived difficulties in thinking or memory, often reported without substantial objective evidence of cognitive impairment. These concerns are prevalent among individuals with a history of brain injuries, neurological conditions, or chronic illnesses, contributing to both psychological distress and functional limitations. They are increasingly considered to be a risk factor for future objective decline. A considerable number of individuals reporting SCCs also exhibit mental health symptoms, such as a history of trauma, depression, or anxiety. Interventions that address modifiable emotional and cognitive factors related to SCC could improve functioning and quality of life. Therefore, the use of emotion regulation strategies, especially those directed at minimizing rumination, could serve as a promising focus for interventions aimed at mitigating subjective cognitive concerns in veteran populations. OBJECTIVE: This pilot study explored the feasibility, acceptability, and preliminary efficacy of a brief, 1-session emotion regulation intervention called Worry Less, Remember More. The Worry Less, Remember More intervention was designed to reduce rumination and improve subjective cognitive functioning in veterans with subjective cognitive changes (N=15). METHODS: We randomized 15 veterans to either the active telehealth condition or waitlist control and completed the intervention. Participants were aged between 31 and 67 (mean 49.5, SD 10.1) years, and the sample was primarily male (12/15, 83%) and White (10/15, 67%). The most common diagnoses were posttraumatic stress disorder and depression. Following the intervention, veteran input was sought through semistructured interviews with a subset of 12 participants, examining feasibility, acceptability, and perceived efficacy. Preliminary efficacy was also measured using pre- and postintervention self-report measures. RESULTS: Veterans reported that this intervention was acceptable, with 92% (11/12) of the sample reporting that they benefited from the intervention and would recommend the intervention to others with similar difficulties. Semistructured interviews revealed difficulties with feasibility, including problems with the remote consenting process, forgetting appointments, and needing additional strategies to remember to consistently use the interventions. The intervention improved self-reported cognitive symptoms on quantitative measures but did not improve self-reported rumination. CONCLUSIONS: This pilot study establishes the preliminary feasibility, acceptability, and efficacy of the Worry Less, Remember More intervention for veterans with subjective cognitive symptoms. Future iterations of the intervention may benefit from simplifying the electronic consent process, providing reminders for appointments, and incorporating compensatory cognitive strategies to assist with using the telehealth system, as well as applying the strategies learned in the intervention. While future research is needed with larger samples, including nonveteran populations, the intervention may also be a useful clinical tool to bridge care between neuropsychology clinics and mental health treatment.

There are numerous frameworks for implementing evidence-based practices (EBPs) in novel settings to achieve "fidelity." However, identifying appropriate referents for fidelity poses a challenge. The Core Functions and Forms paradigm offers a model that can inform adaptation decisions throughout all phases of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We applied the Core Functions-Forms paradigm throughout the Exploration and Preparation phases of EPIS in the design of two EBPs targeting family protective factors among Latinos in San Diego, as well as describe plans for its use in Implementation and Sustainment. We employed a distinct approach for each intervention element to contrast adaptation decisions that prioritize adherence to either form or function fidelity. We describe our application of the functions-forms paradigm within the EPIS framework, focusing on the Preparation phase. We also provide functions-forms matrices that map out the relationship between individual intervention components (forms) and the essential processes (functions) by which components are theorized to exert their impact. This case study of how the core functions-forms framework can be mapped onto EPIS can support a conceptual shift from prioritizing form fidelity to also focusing on function fidelity. This might allow interventionists to target appropriate fidelity referents when adapting an EBP, rather than defaulting to maintaining fidelity to forms as described in the protocol. We see great promise for using this framework for guiding actions throughout all EPIS phases and informing future applications of this paradigm to foster more robust fidelity to function.

IntroductionMeaningful engagement of partners in co-creating and refining health-related programs can increase the initial uptake, sustained implementation, broad reach, and effectiveness of these programs. This is especially important for underserved communities where resources are limited and need to be prioritized. Brainwriting premortem is a novel qualitative approach to partner engagement that combines the strengths of individual idea generation with the concept of premortem exercise that addresses failure points prior to the implementation of new programs.MethodsAn adapted form of brainwriting premortem was used to inform iterative refinements to a COVID-19 testing program at a Federally Qualified Health Center (FQHC) in San Diego. Patients and providers from the FQHC participated in interviews at two time points (early- and mid-implementation of the program). Interview data were transcribed, translated, and analyzed using a rapid qualitative approach. Key themes and sub-themes were identified and used to inform refinements to the program.ResultsA total of 11 patients (7 Spanish- and 4 English-speaking) and 8 providers participated in the brainwriting premortem interviews. Key themes related to possible reasons for COVID-19 testing program failure: advertising/sharing information; access to testing; handling of test results; staff and patient safety; patient beliefs and views regarding the SARS-CoV-2 virus; and COVID-19 testing options offered. Proposed solutions were offered for the key failures except for patient beliefs and views regarding the SARS-CoV-2 virus. Additional solutions offered were related to education, physical operations, and recruitment strategies. Real-time changes to the program flow and components were made in response to 7 suggestions from patients and 11 from providers. Changes related to the process of returning results were the most common, and included sending results via email with distinct workflows based on the test result.ConclusionThe implementation of the adapted brainwriting premortem technique allowed us to incorporate the perspective of key partners in the delivery and iterative refinement of the COVID-19 testing program. This was an effective tool in the context of an FQHC and can be a promising and approach to incorporate iterative input from patients and providers to ensure successful program implementation. Future studies, particularly those requiring rapid response to public health emergencies, should consider the use of this technique.

BackgroundGuidelines recommend screening for colorectal cancer (CRC), but participation and abnormal test follow up rates are suboptimal, with disparities by demography. Evidence-based interventions exist to promote screening, but community adoption and implementation are limited.MethodsThe San Diego Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) program is an academic-community partnership testing regional implementation of a Hub-and-Spoke model for increasing CRC screening and follow-up. The "hub" is a non-academic, non-profit organization that includes 17 community health center (CHC) systems, serving over 190 rural and urban clinic sites. The "spokes" are 3 CHC systems that oversee 11-28 clinics each, totaling over 60 clinics. Using a cluster-randomized trial design, 9 clinics were randomized to intervention and 16 to usual care. Within intervention clinics, approximately 5000 eligible patients not up-to-date with CRC screening per year were identified for intervention. Interventions include an invitation primer, a mailed fecal immunochemical test with completion instructions, and phone and text-based reminders (hub) and patient navigation protocol to promote colonoscopy completion after abnormal FIT (spoke). Outcomes include: 1) proportion of patients up-to-date with screening after three years in intervention versus non-intervention clinics; 2) proportion of patients with abnormal FIT completing colonoscopy within six months of the abnormal result. Implementation science measures are collected to assess acceptability, intervention and usual care adaptations, and sustainability of the intervention strategies.ConclusionThis large-scale, regional cluster randomized trial among CHCs serving diverse populations is anticipated to accelerate progress in CRC prevention in underserved populations.Trial registrationNCT04941300.

BACKGROUND: There continues to be a need for COVID-19 testing that is pragmatic, community-centered, and sustainable. This study will refine and test implementation strategies prioritized by community partners: (1) walk-up no-cost testing, (2) community health worker (promotores)-facilitated testing and preventive care counseling, (3) vending machines that dispense no-cost, self-testing kits. METHODS: A co-designed Theory of Change from an earlier study phase and the Practical, Robust Implementation and Sustainment Model (PRISM) will guide the study design, measures selection, and evaluation. The first aim is to refine and operationalize a multi-component implementation strategy bundle and outcome measures for COVID-19 testing. A Community and Scientific Advisory Board (CSAB) will be established and include community members, clinical providers/staff from the partnering Federally Qualified Health Center (FQHC), public health researchers, policymakers, and a county health department ambassador. Engagement of CSAB members will be assessed through structured ethnography and a survey about the quality and quantity of engagement practices. The second aim is to implement and evaluate the impact of the implementation strategy bundle to optimize COVID-19 testing in communities using a roll-out implementation optimization (ROIO) design. Seven thousand and five hundred community members will be enrolled across four FQHC clinics over 18 months. Participants will be invited to complete an electronic survey about their demographics, health, and COVID-19 testing results and experiences. CSAB members and clinic partners will participate in PRISM fit and determinant assessments prior to each clinic rollout and post-trial. Interviews will be conducted with 60 community participants and 12 providers/staff following a 3-month rollout period at each clinic, inquiring about their experiences with the implementation strategies. Quantitative data will be analyzed using hierarchical multilevel models to determine the impact of implementation strategies. Qualitative data will be analyzed using rapid qualitative approaches to summarize implementation experiences and identify necessary changes prior to subsequent rollouts. A matrix approach will be used to triangulate data from quantitative and qualitative sources based on PRISM domains. DISCUSSION: This is one of the first pragmatic implementation trials to use a ROIO design and aims to co-create a sustainable and equitable COVID-19 testing program. Findings are likely to generalize to other public health prevention efforts. TRIAL REGISTRATION: NCT05894655 March 2, 2023.

Introduction: This mixed methods study describes processes to actively engage underserved, immigrant, and refugee communities in COVID-19 vaccine efforts to co-create culturally relevant resources and dissemination.Methods: A survey on health care characteristics and COVID-19 attitudes was deployed between March-November 2021 followed by listening sessions conducted in December 2021. All participants were recruited through the project's Community Advisory Board. The survey, completed by 77 adults, was available in English, Spanish, Burmese, Kizigua, and Karen. Listening sessions were led by trained, multilingual, and multicultural interviewers.Results: Doctors/healthcare providers were rated as the most trusted messengers of COVID-19 information, however, trusted sources varied across communities. Data from three listening sessions (with a total of 14 participants) expanded survey findings with a focus on trusted sources of COVID-19 communication.Conclusions: This study confirmed the importance of healthcare professionals as trusted messengers for COVID-19 information among underserved communities. Qualitative data highlighted the importance of schools, ethnically-based community organizations, and friends/family with health and English literacy skills for immigrant and refugee communities. Findings suggest opportunities for collaboration with specific trusted sources for future public health dissemination efforts.Trial registration: not applicable.

Racial and ethnic disparities in COVID-19 incidence are pronounced in underserved U.S./Mexico border communities. Working and living environments in these communities can lead to increased risk of COVID-19 infection and transmission, and this increased risk is exacerbated by lack of access to testing. As part of designing a community and culturally tailored COVID-19 testing program, we surveyed community members in the San Ysidro border region. The purpose of our study was to characterize knowledge, attitudes, and beliefs of prenatal patients, prenatal caregivers, and pediatric caregivers at a Federally Qualified Health Center (FHQC) in the San Ysidro region regarding perceived risk of COVID-19 infection and access to testing. A cross-sectional survey was used to collect information on experiences accessing COVID-19 testing and perceived risk of COVID-19 infection within San Ysidro between December 29, 2020 and April 2, 2021. A total of 179 surveys were analyzed. Most participants identified as female (85%) and as Mexican/Mexican American (75%). Over half (56%) were between the age of 25 and 34 years old. Perceived Risk: 37% reported moderate to high risk of COVID-19 infection, whereas 50% reported their risk low to none. Testing Experience: Approximately 68% reported previously being tested for COVID-19. Among those tested, 97% reported having very easy or easy access to testing. Reasons for not testing included limited appointment availability, cost, not feeling sick, and concern about risk of infection while at a testing facility. This study is an important first step to understand the COVID-19 risk perceptions and testing access among patients and community members living near the U.S./Mexico border in San Ysidro, California.

BackgroundResearch centers and programs focused on dissemination and implementation science (DIS) training, mentorship, and capacity building have proliferated in recent years. There has yet to be a comprehensive inventory of DIS capacity building program (CBP) cataloging information about activities, infrastructure, and priorities as well as opportunities for shared resources, collaboration, and growth. The purpose of this systematic review is to provide the first inventory of DIS CBPs and describe their key features and offerings.MethodsWe defined DIS CBPs as organizations or groups with an explicit focus on building practical knowledge and skills to conduct DIS for health promotion. CBPs were included if they had at least one capacity building activity other than educational coursework or training alone. A multi-method strategy was used to identify DIS CBPs. Data about the characteristics of DIS CBPs were abstracted from each program's website. In addition, a survey instrument was developed and fielded to gather in-depth information about the structure, activities, and resources of each CBP.ResultsIn total, 165 DIS CBPs met our inclusion criteria and were included in the final CBP inventory. Of these, 68% are affiliated with a United States (US) institution and 32% are internationally based. There was one CBP identified in a low- and middle-income country (LMIC). Of the US-affiliated CBPs, 55% are embedded within a Clinical and Translational Science Award program. Eighty-seven CBPs (53%) responded to a follow-up survey. Of those who completed a survey, the majority used multiple DIS capacity building activities with the most popular being Training and Education (n=69, 79%) followed by Mentorship (n=58, 67%), provision of DIS Resources and Tools (n=57, 66%), Consultation (n=58, 67%), Professional Networking (n=54, 62%), Technical Assistance (n=46, 52%), and Grant Development Support (n=45, 52%).ConclusionsTo our knowledge, this is the first study to catalog DIS programs and synthesize learnings into a set of priorities and sustainment strategies to support DIS capacity building efforts. There is a need for formal certification, accessible options for learners in LMICs, opportunities for practitioners, and opportunities for mid/later stage researchers. Similarly, harmonized measures of reporting and evaluation would facilitate targeted cross-program comparison and collaboration.

BackgroundThe existing grant review criteria do not consider unique methods and priorities of Dissemination and Implementation Science (DIS). The ImplemeNtation and Improvement Science Proposals Evaluation CriTeria (INSPECT) scoring system includes 10 criteria based on Proctor et al.'s "ten key ingredients" and was developed to support the assessment of DIS research proposals. We describe how we adapted INSPECT and used it in combination with the NIH scoring system to evaluate pilot DIS study proposals through our DIS Center.MethodsWe adapted INSPECT to broaden considerations for diverse DIS settings and concepts (e.g., explicitly including dissemination and implementation methods). Five PhD-level researchers with intermediate to advanced DIS knowledge were trained to conduct reviews of seven grant applications using both the INSPECT and NIH criteria. The INSPECT overall scores range from 0 to 30 (higher scores are better), and the NIH overall scores range from 1 to 9 (lower scores are better). Each grant was independently reviewed by two reviewers, then discussed in a group meeting to compare the experiences using both criteria to evaluate the proposal and to finalize scoring decisions. A follow-up survey was sent to grant reviewers to solicit further reflections on each scoring criterion.ResultsAveraged across reviewers, the INSPECT overall scores ranged from 13 to 24, while the NIH overall scores ranged from 2 to 5. Reviewer reflections highlighted the unique value and utility for each scoring criterion. The NIH criteria had a broad scientific purview and were better suited to evaluate more effectiveness-focused and pre-implementation proposals not testing implementation strategies. The INSPECT criteria were easier to rate in terms of the quality of integrating DIS considerations into the proposal and to assess the potential for generalizability, real-world feasibility, and impact. Overall, reviewers noted that INSPECT was a helpful tool to guide DIS research proposal writing.ConclusionsWe confirmed complementarity in using both scoring criteria in our pilot study grant proposal review and highlighted the utility of INSPECT as a potential DIS resource for training and capacity building. Possible refinements to INSPECT include more explicit reviewer guidance on assessing pre-implementation proposals, providing reviewers with the opportunity to submit written commentary with each numerical rating, and greater clarity on rating criteria with overlapping descriptions.

The UC San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center (DISC) launched in 2020 to provide dissemination and implementation science (DIS) training, technical assistance, community engagement, and research advancement. DISC developed a program-wide logic model to inform a process evaluation of member engagement and impact related to DISC services. The DISC Logic Model (DLM) served as the framework for a process evaluation capturing quantitative and qualitative information about scientific activities, outputs, and outcomes. The evaluation involved a multimethod approach with surveys, attendance tracking, feedback forms, documentation of grant outcomes, and promotions metrics (e.g., Twitter engagement). There were 540 DISC Members at the end of year 2 of the DISC. Engagement in the DISC was high with nearly all members endorsing at least one scientific activity. Technical assistance offerings such as DISC Journal Club and consultation were most frequently used. The most common scientific outputs were grant submission (65, 39%), formal mentoring for career award (40, 24%), and paper submission (34, 21%). The DLM facilitated a comprehensive process evaluation of our center. Actionable steps include prioritizing technical assistance, strengthening networking opportunities, identifying streamlined approaches to facilitate DIS grant writing through writing workshops, as well as office hours or organized writing leagues.

BackgroundCOVID-19 vaccine uptake has been uneven, particularly across racial/ethnic and age groups. This study seeks to understand factors associated with COVID-19 vaccine uptake in a large cross-sectional sample of predominantly Latinos/Latinas individuals living near the US/Mexico border.MethodsData are extracted from a 176-item survey conducted as part of a parent study focused on the co-creation of a COVID-19 testing program for underserved communities developed through a partnership between an academic institution and a Federally Qualified Health Center. The following participant variables were examined: health history, COVID-19 symptoms, COVID-19 testing and vaccine experiences, and perceptions of sources of health information. Participant characteristics were compared using chi-square tests. Multivariate logistic regressions were used for the final statistical model.ResultsFrom 1 May 2021 to 30 April 2022, 4,964 adults, 66% of whom were identified as women, completed the survey. Approximately 80% of participants reported having received at least one COVID-19 vaccine. Female sex, older age, Hispanic/Latino(a) ethnicity, previous influenza vaccination, advanced education, and perceived elevated risk of COVID-19 were significantly (p < 0.05) associated with having received a COVID-19 vaccine. Regarding sources of health information, individuals who indicated they trust their doctor, healthcare provider, or the US government "a great deal" were more likely to have received a COVID-19 vaccine compared to individuals who indicated that they trusted these sources "not at all." In contrast, those who reported having "a great deal" of trust in their faith leader or their social media contacts were significantly less likely to have received a COVID-19 vaccine than those who reported that they trusted these sources "not at all."ConclusionSex, education, past influenza vaccination, perceived risk of COVID-19 infection, and trust in specific sources of information were correlated with the uptake of COVID-19 vaccination. Additional research is needed to better understand why this confluence of factors, particularly the unique findings about trusted sources of information, are associated with vaccine uptake. Understanding these associations, specifically within underserved, Latino/Hispanic communities, is an important first step to inform efforts aimed at increasing and sustaining COVID-19 vaccine uptake and adoption of other public health interventions.

BackgroundCommunity Advisory Boards (CABs) have been frequently used to engage diverse partners to inform research projects. Yet, evaluating the quality of engagement has not been routine. We describe a multi-method ethnographic approach documenting and assessing partner engagement in two "virtual" CABs, for which we conducted all meetings remotely.MethodsTwo research projects for increasing equitable COVID-19 testing, vaccination, and clinical trial participation for underserved communities involved remote CAB meetings. Thirty-three partners representing 17 community groups participated in 15 sessions across the two CABs facilitated by a social change organization. We developed ethnographic documentation forms to assess multiple aspects of CAB member engagement (e.g., time spent speaking, modality used, types of interactions). Documenters were trained to observe CAB sub-groups via virtual sessions. Debriefing with the documentation team after CAB meetings supported quality assurance and process refinement. CAB members completed a brief validated survey after each meeting to assess the quality and frequency of engagement. Content and rapid thematic analysis were used to analyze documentation data. Quantitative data were summarized as frequencies and means. Qualitative and quantitative findings were triangulated.ResultsA total of 4,540 interactions were identified across 15 meetings. The most frequent interaction was providing information (44%), followed by responding (37-38%). The quality and frequency of stakeholder engagement were rated favorably (average 4.7 of 5). Most CAB members (96%) reported good/excellent engagement. Specific comments included appreciation for the diversity of perspectives represented by the CAB members and suggestions for improved live interpretation. Debriefing sessions led to several methodological refinements for the documentation process and forms.ConclusionWe highlight key strategies for documenting and assessing community engagement. Our methods allowed for rich ethnographic data collection that refined our work with community partners. We recommend ongoing trainings, including debriefing sessions and routinely reviewed assessment of data to strengthen meaningful community engagement.

Abstract Background Community Advisory Boards (CABs) have been frequently used to engage diverse partners to inform research projects. Yet, evaluating the quality of engagement has not been routine. We describe a multi-method ethnographic approach documenting and assessing partner engagement in two “virtual” CABs, for which we conducted all meetings remotely.Methods Two research projects for increasing equitable COVID-19 testing, vaccination, and clinical trial participation for underserved communities involved remote CAB meetings. Thirty-three partners representing 17 community groups participated in 15 sessions across the two CABs facilitated by a social change organization. We developed ethnographic documentation forms to assess multiple aspects of CAB member engagement (e.g., time spent speaking, modality used, types of interactions). Documenters were trained to observe CAB sub-groups via virtual sessions. Debriefing with the documentation team after CAB meetings supported quality assurance and process refinement. CAB members completed a brief validated survey after each meeting to assess the quality and frequency of engagement. Content and rapid thematic analysis were used to analyze documentation data. Quantitative data were summarized as frequencies and means. Qualitative and quantitative findings were triangulated.Results A total of 4,540 interactions were identified across 15 meetings. The most frequent interaction was providing information (44%), followed by responding (37–38%). The quality and frequency of stakeholder engagement were rated favorably (average 4.7 of 5). Most CAB members (96%) reported good/excellent engagement. Specific comments included appreciation for the diversity of perspectives represented by the CAB members and suggestions for improved live interpretation. Debriefing sessions led to several methodological refinements for the documentation process and forms.Conclusions We highlight key strategies for documenting and assessing community engagement. Our methods allowed for rich ethnographic data collection that refined our work with community partners. We recommend ongoing trainings, including debriefing sessions and routinely reviewed assessment of data to strengthen meaningful community engagement.

ObjectivesTo describe the use of a Theory of Change to meaningfully engage community members from or support underserved communities in two National Institutes of Health-funded implementation science projects aimed at promoting equitable access to COVID-19 testing and vaccination for underserved communities.Study settingBoth projects focused on Latino, Black, and immigrant and refugee communities in South/Central San Diego and/or individuals accessing care at a federally qualified health center near the US/Mexico border during December 2020-April 2021.Study designBy using a participatory action research design, Community Advisory Boards (CABs) were established for each project with 11 and 22 members. CAB members included community organizers, promotores de salud (community health workers), clinic providers and administrators, and public health researchers. The CABs were guided through a seven-session Theory of Change process, focused on identifying necessary conditions that must exist to eliminate COVID-19 disparities along with specified actions to create those conditions and a blueprint for assessing the impact of those actions.Data collectionEach session lasted 2 h hosted virtually and was augmented by interactive web-based activities. There was a live interpreter who facilitated the participation of Spanish-speaking CAB members. A Theory of Change for each project was completed in approximately 4 months.Principal findingsNine necessary conditions were identified related to (1) accessible and available services; (2) culturally and linguistically competent programming; (3) investment in trusted community and faith leaders; (4) social safety nets to provide ancillary services. Corresponding actions to create these conditions and measures to indicate success in creating these conditions were operationalized by the CAB.ConclusionsWhile resource-intensive, a CAB-led Theory of Change process yielded a rich opportunity to engage diverse groups that typically are not invited to inform these processes.

BackgroundAdaptation of interventions is inevitable during translation to new populations or settings. Systematic approach to adaptation can ensure that fidelity to core functions of the intervention are preserved while optimizing implementation feasibility and effectiveness for the local context. In this study, we used an iterative, mixed methods, and stakeholder-engaged process to systematically adapt Collaborative Decision Skills Training for Veterans with psychosis currently participating in VA Psychosocial Rehabilitation and Recovery Centers.MethodsA modified approach to Intervention Mapping (IM-Adapt) guided the adaptation process. An Adaptation Resource Team of five Veterans, two VA clinicians, and four researchers was formed. The Adaptation Resource Team engaged in an iterative process of identifying and completing adaptations including individual qualitative interviews, group meetings, and post-meeting surveys. Qualitative interviews were analyzed using rapid matrix analysis. We used the modified, RE-AIM enriched expanded Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) to document adaptations. Additional constructs included adaptation size and scope; implementation of planned adaptation (yes-no); rationale for non-implementation; and tailoring of adaptation for a specific population (e.g., Veterans).ResultsRapid matrix analysis of individual qualitative interviews resulted in 510 qualitative codes. Veterans and clinicians reported that the intervention was a generally good fit for VA Psychosocial Rehabilitation and Recovery Centers and for Veterans. Following group meetings to reach adaptation consensus, 158 adaptations were completed. Most commonly, adaptations added or extended a component; were small in size and scope; intended to improve the effectiveness of the intervention, and based on experience as a patient or working with patients. Few adaptations were targeted towards a specific group, including Veterans. Veteran and clinician stakeholders reported that these adaptations were important and would benefit Veterans, and that they felt heard and understood during the adaptation process.ConclusionsA stakeholder-engaged, iterative, and mixed methods approach was successful for adapting Collaborative Decision Skills Training for immediate clinical application to Veterans in a psychosocial rehabilitation center. The ongoing interactions among multiple stakeholders resulted in high quality, tailored adaptations which are likely to be generalizable to other populations or settings. We recommend the use of this stakeholder-engaged, iterative approach to guide adaptations.

ObjectiveTo describe the early activities and lessons of the Share, Trust, Organize, Partner COVID-19 California Alliance (STOP COVID-19 CA), the California awardee of the NIH-funded multi-state Community Engagement Alliance (CEAL) against COVID-19. The Alliance was established to ensure equity in Coronavirus-19 disease (COVID-19) research, clinical practice, and public health for communities most impacted by the COVID-19 pandemic.Study settingThe STOP COVID-19 CA Alliance network of 11 universities and affiliated partner community-based organizations (CBOs) across California.Study designMixed methods evaluation consisting of an analysis of activity (August 2020 to December 2021) detailed in reports submitted by community-academic teams and a survey (August 2021) of academic investigators and affiliated community-based organization (CBO) partners.Data collectionWe summarized activities from the 11 community-academic teams' progress reports and described results from an online survey of academic investigators and CBO partners in the California Alliance.Principal findingsA review of progress reports (n = 256) showed that teams fielded surveys to 11,000 Californians, conducted 133 focus groups, partnered with 29 vaccine/therapeutics clinical trials, and led more than 300 town halls and vaccine events that reached Californians from communities disproportionately impacted by COVID-19. Survey responses from academic investigators and CBO partners emphasized the importance of learning from the successes and challenges of the California Alliance teams' COVID-19 initiatives. Both academic and CBO respondents highlighted the need for streamlined federal and institutional administrative policies, and fiscal practices to promote more effective and timely operations of teams in their efforts to address the numerous underlying health and social disparities that predispose their communities to higher rates of, and poor outcomes from, COVID-19.ConclusionsSTOP COVID-19 CA represents a new and potentially sustainable statewide community engagement model for addressing health disparities in multiethnic/multicultural and geographically dispersed communities.

Cognitive Symptom Management and Rehabilitation Training (CogSMART) and Compensatory Cognitive Training (CCT) are evidence-based compensatory cognitive training interventions that improve cognition in persons with a history of traumatic brain injury or other neuropsychiatric disorders. Despite demonstrated efficacy, use and effectiveness of CogSMART/CCT in real-world settings is not known.We used a multi-method design to collect and analyze quantitative and qualitative survey data from several domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to gather information about use of CogSMART/CCT in real-world settings from provider and patient perspectives. Surveys were sent to email addresses from persons who registered on the CogSMART website seeking access to training manuals and other resources. Descriptive statistics were generated, and we used Natural Language Processing methods to study the self-report free responses. Using n-gram analysis, we identified the most frequently reported responses.We found CogSMART/CCT was broadly used in real-world settings and delivered by a variety of providers for several patient groups with high attendance and overall high satisfaction. CogSMART/CCT seemed to be offered in VA- or university-related clinics more than in private practice or rehabilitation centers. The diversity of providers and variety of formats by which to deliver CogSMART/CCT (i.e., individual, group, telehealth) seemed to play a role in its widespread implementation, as did its adaptability. Most providers made adaptations to the intervention that reduced the length or number of sessions. These changes were most likely to be based on client characteristics. The low rates of formal training, however, may have contributed to lower levels of perceived helpfulness among patients.Reach and Adoption of a cognitive rehabilitation intervention improved by increasing access to the manuals. Attention to characteristics of dissemination and implementation in the design of an intervention may enhance its use in real-world settings. The relevant outcomes, easy access to training manuals, and adaptability of CogSMART/CCT seem to have been important factors in its use in a variety of settings and for several disorders with cognitive impairment. The adoption of CogSMART/CCT by a variety of providers other than neuropsychologists suggests its use may be broadened to other healthcare providers, if adequately trained, to increase access to an intervention with demonstrated efficacy for cognitive rehabilitation for several neuropsychiatric disorders.

BackgroundThe Practical, Robust Implementation and Sustainability Model (PRISM) was developed in 2008 as a contextually expanded version of the broadly used Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. PRISM provides researchers a pragmatic and intuitive model to improve translation of research interventions into clinical and community practice. Since 2008, the use of PRISM increased across diverse topics, populations, and settings. This citation analysis and scoping systematic review aimed to assess the use of the PRISM framework and to make recommendations for future research.MethodsA literature search was conducted using three databases (PubMed, Web of Science, Scopus) for the period of 2008 and September 2020. After exclusion, reverse citation searches and invitations to experts in the field were used to identify and obtain recommendations for additional articles not identified in the original search. Studies that integrated PRISM into their study design were selected for full abstraction. Unique research studies were abstracted for information on study characteristics (e.g., setting/population, design), PRISM contextual domains, and RE-AIM outcomes.ResultsA total of 180 articles were identified to include PRISM to some degree. Thirty-two articles representing 23 unique studies integrated PRISM within their study design. Study characteristics varied widely and included studies conducted in diverse contexts, but predominately in high-income countries and in clinical out-patient settings. With regards to use, 19 used PRISM for evaluation, 10 for planning/development, 10 for implementation, four for sustainment, and one for dissemination. There was substantial variation across studies in how and to what degree PRISM contextual domains and RE-AIM outcomes were operationalized and connected. Only two studies directly connected individual PRISM context domains with RE-AIM outcomes, and another four included RE-AIM outcomes without direct connection to PRISM domains.ConclusionsThis is the first systematic review of the use of PRISM in various contexts. While there were low levels of 'integrated' use of PRISM and few reports on linkage to RE-AIM outcomes, most studies included important context domains of implementation and sustainability infrastructure and external environment. Recommendations are provided for more consistent and comprehensive use of and reporting on PRISM to inform both research and practice on contextual factors in implementation.

BackgroundThe Veterans Health Administration (VHA) developed a comprehensive mobile screening technology (eScreening) that provides customized and automated self-report health screening via mobile tablet for veterans seen in VHA settings. There is agreement about the value of health technology, but limited knowledge of how best to broadly implement and scale up health technologies. Quality improvement (QI) methods may offer solutions to overcome barriers related to broad scale implementation of technology in health systems. We aimed to develop a process guide for eScreening implementation in VHA clinics to automate self-report screening of mental health symptoms and psychosocial challenges.MethodsThis was a two-phase, mixed methods implementation project building on an adapted quality improvement method. In phase one, we adapted and conducted an RPIW to develop a generalizable process guide for eScreening implementation (eScreening Playbook). In phase two, we integrated the eScreening Playbook and RPIW with additional strategies of training and facilitation to create a multicomponent implementation strategy (MCIS) for eScreening. We then piloted the MCIS in two VHA sites. Quantitative eScreening pre-implementation survey data and qualitative implementation process "mini interviews" were collected from individuals at each of the two sites who participated in the implementation process. Survey data were characterized using descriptive statistics, and interview data were independently coded using a rapid qualitative analytic approach.ResultsPilot data showed overall satisfaction and usefulness of our MCIS approach and identified some challenges, solutions, and potential adaptations across sites. Both sites used the components of the MCIS, but site 2 elected not to include the RPIW. Survey data revealed positive responses related to eScreening from staff at both sites. Interview data exposed implementation challenges related to the technology, support, and education at both sites. Workflow and staffing resource challenges were only reported by site 2.ConclusionsOur use of RPIW and other QI methods to both develop a playbook and an implementation strategy for eScreening has created a testable implementation process to employ automated, patient-facing assessment. The efficient collection and communication of patient information have the potential to greatly improve access to and quality of healthcare.

The 2019 novel coronavirus disease (COVID-19) pandemic has dramatically impacted numerous health and economic fronts. Because of the stay-at-home mandate and practice of physical distancing, nearly all preventive care measures have been halted, including colorectal cancer (CRC) screening. The health consequences of this temporary suspension are of great concern, particularly for underserved populations, who experience substantial CRC-related disparities. In this commentary, we describe challenges and opportunities to deliver COVID-19-adapted CRC screening to medically underserved populations receiving care in community health centers (CHC). This perspective is based on key informant interviews with CHC medical directors, teleconference discussions, and strategic planning assessments. To address the unprecedented challenges created by the COVID-19 pandemic, we identify 2 broad calls to action: invest in CHCs now and support equitable and adaptable telehealth solutions now and in the future. We also recommend 4 CRC-specific calls to action: establish COVID-19-adapted best practices to implement mailed fecal immunochemical test programs, implement grassroots advocacy to identify community gastroenterologists who commit to performing colonoscopies for CHC patients, assess cancer prevention priorities among individuals in underserved communities, and assess regional CRC screening and follow-up barriers and solutions. The COVID-19 pandemic may further exacerbate existing CRC screening disparities in underserved individuals. This will likely lead to delayed diagnosis, a shift to later-stage disease, and increased CRC deaths. To prevent this from happening, we call for timely action and a commitment to address the current extraordinary CRC screening challenges for vulnerable populations.

BACKGROUND: Post-9/11 veterans who enroll in VA health care frequently present with suicidal ideation and/or recent suicidal behavior. Most of these veterans are not screened on their day of enrollment and their risk goes undetected. Screening for suicide risk, and associated mental health factors, can lead to early detection and referral to effective treatment, thereby decreasing suicide risk. eScreening is an innovative Gold Standard Practice with evidence to support its effectiveness and implementation potential in transition and care management (TCM) programs. We will evaluate the impact of eScreening to improve the rate and speed of suicide risk screening and referral to mental health care compared to current screening methods used by transition care managers. We will also evaluate the impact of an innovative, multicomponent implementation strategy (MCIS) on the reach, adoption, implementation, and sustained use of eScreening. METHODS: This is an eight-site 4-year, stepped-wedge, mixed-method, hybrid type-II implementation trial comparing eScreening to screening as usual while also evaluating the potential impact of the MCIS focusing on external facilitation and Lean/SixSigma rapid process improvement workshops in TCM. The aims will address: 1) whether using eScreening compared to oral and/or paper-based methods in TCM programs is associated with improved rates and speed of PTSD, depression, alcohol, and suicide screening & evaluation, and increased referral to mental health treatment; 2) whether and to what degree our MCIS is feasible, acceptable, and has the potential to impact adoption, implementation, and maintenance of eScreening; and 3) how contextual factors influence the implementation of eScreening between high- and low-eScreening adopting sites. We will use a mixed methods approach guided by the RE-AIM outcomes of the Practical Robust Implementation and Sustainability Model (PRISM). Data to address Aim 1 will be collected via medical record query while data for Aims 2 and 3 will be collected from TCM staff questionnaires and qualitative interviews. DISCUSSION: The results of this study will help identify best practices for screening in suicide prevention for Post-9/11 veterans enrolling in VA health care and will provide information on how best to implement technology-based screening into real-world clinical care programs. TRIAL REGISTRATION: ClinicalTrials.gov : NCT04506164; date registered: August 20, 2020; retrospectively registered.

BACKGROUND: Collaborative decision-making is an innovative decision-making approach that assigns equal power and responsibility to patients and providers. Most veterans with serious mental illnesses like schizophrenia want a greater role in treatment decisions, but there are no interventions targeted for this population. A skills-based intervention is promising because it is well-aligned with the recovery model, uses similar mechanisms as other evidence-based interventions in this population, and generalizes across decisional contexts while empowering veterans to decide when to initiate collaborative decision-making. Collaborative Decision Skills Training (CDST) was developed in a civilian serious mental illness sample and may fill this gap but needs to undergo a systematic adaptation process to ensure fit for veterans. METHODS: In aim 1, the IM Adapt systematic process will be used to adapt CDST for veterans with serious mental illness. Veterans and Veterans Affairs (VA) staff will join an Adaptation Resource Team and complete qualitative interviews to identify how elements of CDST or service delivery may need to be adapted to optimize its effectiveness or viability for veterans and the VA context. During aim 2, an open trial will be conducted with veterans in a VA Psychosocial Rehabilitation and Recovery Center (PRRC) to assess additional adaptations, feasibility, and initial evidence of effectiveness. DISCUSSION: This study will be the first to evaluate a collaborative decision-making intervention among veterans with serious mental illness. It will also contribute to the fields understanding of perceptions of collaborative decision-making among veterans with serious mental illness and VA clinicians, and result in a service delivery manual that may be used to understand adaptation needs generally in VA PRRCs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04324944.

BackgroundEffective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.MethodsA systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1-5 scale).ResultsIn total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5).ConclusionThis systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.

BackgroundTechnology-based self-assessment (TB-SA) benefits patients and providers and has shown feasibility, ease of use, efficiency, and cost savings. A promising TB-SA, the VA eScreening program, has shown promise for the efficient and effective collection of mental and physical health information. To assist adoption of eScreening by healthcare providers, we assessed technology-related as well as individual- and system-level factors that might influence the implementation of eScreening in four diverse VA clinics.MethodsThis was a mixed-method, pre-post, quasi-experimental study originally designed as a quality improvement project. The clinics were selected to represent a range of environments that could potentially benefit from TB-SA and that made use of the variety eScreening functions. Because of limited resources, the implementation strategy consisted of staff education, training, and technical support as needed. Data was collected using pre- and post-implementation interviews or focus groups of leadership and clinical staff, eScreening usage data, and post-implementation surveys. Data was gathered on: 1) usability of eScreening; 2) knowledge about and acceptability and 3) facilitators and barriers to the successful implementation of eScreening.ResultsOverall, staff feedback about eScreening was positive. Knowledge about eScreening ranged widely between the clinics. Nearly all staff felt eScreening would fit well into their clinical setting at pre-implementation; however some felt it was a poor fit with emergent cases and older adults at post-implementation. Lack of adequate personnel support and perceived leadership support were barriers to implementation. Adequate training and technical assistance were cited as important facilitators. One clinic fully implemented eScreening, two partially implemented, and one clinic did not implement eScreening as part of normal practice after 6 months as measured by usage data and self-report. Organizational engagement survey scores were higher among clinics with full or partial implementation and low in the clinic that did not implement.ConclusionsDespite some added work load for some staff and perceived lack of leadership support, eScreening was at least partially implemented in three clinics. The technology itself posed no barriers in any of the settings. An implementation strategy that accounts for increased work burden and includes accountability may help in future eScreening implementation efforts. Note. This abstract was previously published (e.g., Annals of Behavioral Medicine 53: S1-S842, 2019).

Objective: To use a practical approach to examining the use of Expert Recommendations for Implementing Change (ERIC) strategies by Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE‐AIM) dimensions for rural health innovations using annual reports on a diverse array of initiatives. Data Sources and Study Setting: The Veterans Affairs (VA) Office of Rural Health (ORH) funds initiatives designed to support the implementation and spread of innovations and evidence‐based programs and practices to improve the health of rural Veterans. This study draws on the annual evaluation reports submitted for fiscal years 2020–2022 from 30 of these enterprise‐wide initiatives (EWIs). Study Design: Content analysis was guided by the RE‐AIM framework conducted by the Center for the Evaluation of Enterprise‐Wide Initiatives (CEEWI), a Quality Enhancement Research Initiative (QUERI)‐ORH partnered evaluation initiative. Data Collection and Extraction Methods: CEEWI analysts conducted a content analysis of EWI annual evaluation reports submitted to ORH. Analysis included cataloguing reported implementation strategies by Reach, Adoption, Implementation, and Maintenance (RE‐AIM) dimensions (i.e., identifying strategies that were used to support each dimension) and labeling strategies using ERIC taxonomy. Descriptive statistics were conducted to summarize data. Principal Findings: A total of 875 implementation strategies were catalogued in 73 reports. Across these strategies, 66 unique ERIC strategies were reported. EWIs applied an average of 12 implementation strategies (range 3–22). The top three ERIC clusters across all 3 years were Develop stakeholder relationships (21%), Use evaluative/iterative strategies (20%), and Train/educate stakeholders (19%). Most strategies were reported within the Implementation dimension. Strategy use among EWIs meeting the rurality benchmark were also compared. Conclusions: Combining the dimensions from the RE‐AIM framework and the ERIC strategies allows for understanding the use of implementation strategies across each RE‐AIM dimension. This analysis will support ORH efforts to spread and sustain rural health innovations and evidence‐based programs and practices through targeted implementation strategies. [ABSTRACT FROM AUTHOR]