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BackgroundAlthough healthcare is delivered in inherently multilevel contexts, implementation science has no widely endorsed methodological standards defining the characteristics of rigorous, multilevel implementation research. We identify and describe eight characteristics of high-quality, multilevel implementation research to encourage discussion, spur debate, and guide decision-making around study design and methodological issues.RecommendationsImplementation researchers who conduct rigorous multilevel implementation research demonstrate the following eight characteristics. First, they map and operationalize the specific multilevel context for defined populations and settings. Second, they define and state the level of each construct under study. Third, they describe how constructs relate to each other within and across levels. Fourth, they specify the temporal scope of each phenomenon at each relevant level. Fifth, they align measurement choices and construction of analytic variables with the levels of theories selected (and hypotheses generated, if applicable). Sixth, they use a sampling strategy consistent with the selected theories or research objectives and sufficiently large and variable to examine relationships at requisite levels. Seventh, they align analytic approaches with the chosen theories (and hypotheses, if applicable), ensuring that they account for measurement dependencies and nested data structures. Eighth, they ensure inferences are made at the appropriate level. To guide implementation researchers and encourage debate, we present the rationale for each characteristic, actionable recommendations for operationalizing the characteristics in implementation research, a range of examples, and references to make the characteristics more usable. Our recommendations apply to all types of multilevel implementation study designs and approaches, including randomized trials, quantitative and qualitative observational studies, and mixed methods.ConclusionThese eight characteristics provide benchmarks for evaluating the quality and replicability of multilevel implementation research and promote a common language and reference points. This, in turn, facilitates knowledge generation across diverse multilevel settings and ensures that implementation research is consistent with (and appropriately leverages) what has already been learned in allied multilevel sciences. When a shared and integrated description of what constitutes rigor is defined and broadly communicated, implementation science is better positioned to innovate both methodologically and theoretically.

BACKGROUND: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. METHODS: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). DISCUSSION: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

INTRODUCTION: Mechanisms explain how implementation strategies work. Implementation research requires careful operationalisation and empirical study of the causal pathway(s) by which strategies effect change, and factors that may amplify or weaken their effects. Understanding mechanisms is critically important to replicate findings, learn from negative studies or adapt an implementation strategy developed in one setting to another. Without understanding implementation mechanisms, it is difficult to design strategies to produce expected effects across contexts, which may have disproportionate effects on settings in which priority populations receive care. This manuscript outlines the protocol for an Agency for Healthcare Research and Quality-funded initiative to: (1) establish priorities for an agenda to guide research on implementation mechanisms in health and public health, and (2) disseminate the agenda to research, policy and practice audiences. METHODS AND ANALYSIS: A network of scientific experts will convene in Deep Dive meetings across 3 years. A research agenda will be generated through analysis and synthesis of information from six sources: (1) systematic reviews, (2) network members approaches to studying mechanisms, (3) new proposals presented in implementation proposal feedback sessions, (4) working group sessions conducted in a leading implementation research training institute, (5) breakout sessions at the Society for Implementation Research Collaborations (SIRC) 2019 conference and (6) SIRC conference abstracts. Two members will extract mechanism-relevant text segments from each data source and a third member will generate statements as an input for concept mapping. Concept mapping will generate unique clusters of challenges, and the network will engage in a nominal group process to identify priorities for the research agenda. ETHICS AND DISSEMINATION: This initiative will yield an actionable research agenda to guide research to identify and test mechanisms of change for implementation strategies. The agenda will be disseminated via multiple channels to solicit feedback and promote rigorous research on implementation mechanisms.

Primate inferotemporal cortex (ITC) neurons respond with declining strength to repeated presentations of large natural images. This phenomenon - repetition suppression - has been assumed to arise at the level of ITC because ITC neurons possess the large receptive fields and sophisticated selectivity to recognize images as repetitions. It was recently discovered that V2 neurons exhibit repetition suppression under identical conditions. How do V2 neurons, with classical receptive fields encompassing only a small fraction of the image, recognize it as a repetition? One possibility is that they are sensitive to repetition of content outside the classical receptive field, in the surround. To assess this, we recorded neuronal responses to displays while independently controlling repetition of elements in the classical receptive field and the surround. We found that content in the surround contributed to repetition suppression and that this occurred relatively late in the response, consistent with being mediated by feedback.

Stimulus recency has a strong effect on both behavior andneural responses. Its effects on neural responses have beenmost closely studied in the visual system in inferotemporalcortex (IT) in which recency gives rise to suppressedresponses by a phenomenon known as repetition suppression.This observation has led to many possible explanations ofhow repetition suppression arises in the visual system. Here,we explore three of them: (1) top-down, (2) bottom-up and (3)independently in each brain region. Each of these accountsmakes different predictions about the pattern of effects atdifferent stages in visual processing for cases in which thestimulus either is or is not a match for the location or theidentity of the preceding stimulus. We tested these predictionsby recording from neurons in IT and V2, two separate stagesof processing, while monkeys viewed displays of repeatedand non-repeated image sequences.

Schools play a major role in delivering behavioral health services to autistic youth. School culture and climate are strong predictors of the extent to which these services incorporate evidence-based practices; however, little is known about how school leaders shape culture and climate. Drawing on the concept of culture and climate embedding mechanisms, we conducted a qualitative study to understand the ways in which school principals embed cultures and climates that support effective implementation of evidence-based practices for youth with autism. Semi-structured interviews with 32 teachers in schools that implemented three closely related evidence-based practices for youth with autism (discrete trial training, pivotal response training, and visual schedules) explored teachers' experiences regarding (a) implementation of the three evidence-based practices, (b) perceptions of school culture and climate, and (c) principals' behaviors, practices, and decisions that supported or detracted from the aspects of culture and climate that supported successful implementation. Thematic analysis detailed seven mechanisms that principals used to embed cultures and climates that shaped evidence-based practice implementation. These mechanisms represent actionable targets for school leaders and inform strategies to improve the implementation of evidence-based practices for youth with autism in schools.

BACKGROUND: Implementation researchers have typically studied organizational culture and climate by testing whether individual dimensions are linked to the implementation of evidence-based practices (EBPs) rather than examining how the overarching social context influences implementation. This approach may limit implementation theory and strategy development to the extent that individual dimensions of culture and climate interact, mutually reinforce or counteract one another, or exhibit non-linear relationships. This study tests whether empirically identifiable culture and climate profiles emerge in a sample of organizations and examines how these profiles relate to EBP fidelity and work attitudes that support EBP sustainment, focusing on three EBPs for youth with autism delivered in schools as an example. METHODS: The study included 65 elementary schools in the U.S. that implemented three EBPs-discrete trial training, pivotal response training, and visual schedules-for youth with autism. Organizational culture and climate and work attitudes were assessed using the Organizational Social Context measure at the beginning of the school year. Observations of EBP fidelity occurred mid school-year. We used bias-adjusted stepwise latent profile modeling to (1) identify subpopulations of schools that share similar culture and climate profiles, and (2) test for mean differences across profiles in observed EBP fidelity and teacher and staff work attitudes. RESULTS: Controlling for region, four profiles best characterized the organizational cultures and climates of schools. Teachers and staff in schools with a comprehensive profile (high proficiency culture, positive climate) exhibited higher fidelity to two of three EBPs (ds = .95 to 1.64) and reported superior work attitudes (ds = .71 to 1.93) than teachers and staff in all other schools. Teachers and staff in supportive schools (low rigidity culture, positive climate) had better work attitudes, but not better fidelity, than those in schools with indifferent (low culture/climate, elevated stress) and constrained (high rigidity and resistance, high stress) profiles. CONCLUSIONS: Organizational culture and climate profiles are a strong predictor of EBP fidelity and work attitudes that support EBP sustainment, highlighting the importance of an organizations overarching social context when developing implementation theory and strategies. Strategies that foster a comprehensive profile may improve EBP implementation.

Remotely sensed nighttime light data have become vital for electrification mapping in data-scarce regions. However, uncertainty persists regarding the veracity of these electrification maps. This study investigates how characteristics of electrified areas influence their detectability using nighttime lights. Utilizing a dataset comprising the locations, installation date, and electricity purchase history of thousands of electric meters and transformers from utilities in Rwanda and Kenya, we present a systematic error assessment of electrification maps produced with nighttime lights. Descriptive analysis is employed to offer empirical evidence that the likelihood of successfully identifying an electrified nighttime light pixel increases as characteristics including the time since electrification, the number of meters within a pixel, and the total annual electricity purchase of meters in a pixel increase. The performance of models trained on various temporal aggregations of nighttime light data (annual, quarterly, monthly, and daily) was compared, and it was determined that aggregation at the monthly level yielded the best results. Additionally, we investigate the transferability of electrification models across locations. Our findings reveal that models trained on data from Rwanda demonstrate strong transferability to Kenya, and vice versa, as indicated by balanced accuracies differing by less than 5% when additional data from the test location are included in the training set. Also, models developed with data from the centralized grid in East Africa were found to be useful for detecting areas electrified with off-grid systems in West Africa. This research provides valuable insight into the characterization of sources of nighttime lights and their utility for mapping electrification. [ABSTRACT FROM AUTHOR]

This study examines how the introduction of TeachTown:Basics, a computer-assisted intervention for students with autism spectrum disorder, influenced teachers' use of other evidence-based practices. In a randomized controlled trial that enrolled 73 teachers nested within 58 schools, we used three-level hierarchical linear models to evaluate changes in teachers' use of evidence-based practices across the school year for those who received TeachTown:Basics versus those assigned to control. Both groups received training and implementation support to deliver three well-established evidence-based practices for autism spectrum disorder. Qualitative interviews were conducted with 25 teachers who used TeachTown:Basics to better understand their experience. Compared with teachers in the control group, teachers in the TeachTown:Basics group reported significantly less growth over the 9-month period in their use of evidence-based practices that require one-to-one instruction (ps < 0.05), but no difference in their reported use of evidence-based practices that do not involve one-to-one instruction (p = 0.637). Qualitative interviews indicated that teachers viewed TeachTown:Basics as an effective substitute for one-to-one instruction because it was less burdensome, despite the lack of support for TeachTown:Basics' effectiveness. Before introducing new practices, education leaders should carefully consider both evidence of effectiveness and the potential impact on the use of other evidence-based practices.

BACKGROUND: Behavioral health organizations are characterized by multiple organizational climates, including molar climate, which encompasses clinicians shared perceptions of how the work environment impacts their personal well-being, and strategic implementation climate, which includes clinicians shared perceptions of the extent to which evidence-based practice implementation is expected, supported, and rewarded by the organization. Theory suggests these climates have joint, cross-level effects on clinicians implementation of evidence-based practice and that these effects may be long term (i.e., up to 2 years); however, no empirical studies have tested these relationships. We hypothesize that molar climate moderates implementation climates concurrent and long-term relationships with clinicians use of evidence-based practice such that strategic implementation climate will have its most positive effects when it is accompanied by a positive molar climate. METHODS: Hypotheses were tested using data collected from 235 clinicians in 20 behavioral health organizations. At baseline, clinicians reported on molar climate and implementation climate. At baseline and at a 2-year follow-up, all clinicians who were present in the organizations reported on their use of cognitive-behavioral psychotherapy techniques, an evidence-based practice for youth psychiatric disorders. Two-level mixed-effects regression models tested whether baseline molar climate and implementation climate interacted in predicting clinicians evidence-based practice use at baseline and at 2-year follow-up. RESULTS: In organizations with more positive molar climates at baseline, higher levels of implementation climate predicted increased evidence-based practice use among clinicians who were present at baseline and among clinicians who were present in the organizations at 2-year follow-up; however, in organizations with less positive molar climates, implementation climate was not related to clinicians use of evidence-based practice at either time point. CONCLUSIONS: Optimizing clinicians implementation of evidence-based practice in behavioral health requires attention to both molar climate and strategic implementation climate. Strategies that focus exclusively on implementation climate may not be effective levers for behavior change if the organization does not also engender a positive molar climate. These findings have implications for the development of implementation theory and effective implementation strategies.