[Show abstract][Hide abstract] ABSTRACT: Panel overview abstract Implementation research is the scientific study of methods that promote systematic uptake of research findings and other evidence-based practices into routine practice, thereby improving the quality and effectiveness of health services. As the field has progressed over the past decades , substantial advances continue in the development and application of implementation-related theories as well as innovative implementation strategies and methods. This session will provide three examples of implementation research studies that are designed to improve care through the use of evidence. The examples come from three health services areas: primary care, mental health, and HIV; from funded NIH and VA studies; and from community and hospital settings in rural and urban sites. Across the three examples, six different theories were used-providing ample examples of linking conceptual models and frameworks to study design, implementation strategies, and measurements. Each presentation will highlight the ways in which the conceptual theory was configured into the overall research design and evaluation , as well as common challenges and lessons learned while conducting implementation research. Blended facilitation to enhance PCMH program implementation: conceptual, design, and measurement considerations Integrated primary care mental health evidence-based programs improve care. The Department of Veterans Affairs mandated and provided limited national level implementation support for Primary Care-Mental Health Integration (PC-MHI) but VA facilities were slow to implement them. The Blended Facilitation study was funded by the VA to implement and evaluate an innovative implementation facilitation (IF) strategy that included a national external expert facilitator with expertise in implementation science and PC-MHI who mentored and worked with two internal regional facilita-tors to help clinics implement PC-MHI. According to the PARIHS framework, successful implementation is a function of the dynamic interaction between evidence, context and facilitation. This presentation will describe how PARIHS guided the application of the IF strategy and the study's design. For this quasi-experimental, Hybrid Type 3 study, we used mixed methods to test the effectiveness of the IF strategy and assess organizational context, perceptions of evidence, and facilitation activities. We used a consensus matching approach to select sixteen clinics that were unlikely to implement PC-MHI without assistance across four VA regions. The RE-AIM framework guided our test of IF's effectiveness using administrative data and program component interviews to measure RE-AIM dimensions. We conducted monthly debriefing interviews with and collected time data from facilitators and measured site level contextual and evidence factors through key informant interviews. We also conducted intensive case studies at four IF
[Show abstract][Hide abstract] ABSTRACT: Prior studies of mostly male U.S. service members suggest service characteristics such as deployment with combat exposure and lower rank may be a risk factor for alcohol misuse. However, these relationships have not been examined among servicewomen who may be at high risk for experiencing deployment-related stressors and associated health consequences. This cross-sectional report of US servicewomen in the Reserve or National Guard (RNG) and active component (AC) sought to examine these associations.
A Midwestern community sample of currently serving and veteran servicewomen (N=1339) completed structured telephone interviews. The Generalized Linear Model was used to examine associations between service characteristics, any binge drinking, and frequency of recent binge drinking after adjusting for demographics.
After adjusting for demographics, deployment to Iraq or Afghanistan was associated with greater odds of reporting a binge drinking episode, compared to no deployment, among servicewomen in the AC but not RNG. Deployment to Iraq or Afghanistan was also associated with more days binge drinking in both groups compared to servicewomen not deployed. Lower ranking servicewomen also reported higher odds of a binge drinking episode and higher frequency of binge drinking in both the RNG and AC.
Service characteristics including deployment to Iraq or Afghanistan (vs. those not deployed) and lower rank (vs. officers) may be a risk factor for recent binge drinking and higher frequency of binge drinking among servicewomen, after adjusting for demographic covariates. Public health and clinical implications are discussed.
Published by Elsevier Ireland Ltd.
Drug and alcohol dependence 06/2015; 153. DOI:10.1016/j.drugalcdep.2015.06.013 · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study qualitatively examines the religious and spiritual dimensions of cutting down and stopping cocaine use among African Americans in rural and urban areas of Arkansas. The analyses compare and contrast the narrative data of 28 current cocaine users living in communities where the Black church plays a fundamental role in the social and cultural lives of many African Americans, highlighting the ways that participants used religious symbols, idiomatic expression, and Biblical scriptures to interpret and make sense of their substance-use experiences. Participants drew on diverse religious and spiritual beliefs and practices, including participation in organized religion, reliance on a personal relationship with God, and God's will to cut down and stop cocaine use. Our findings suggest that culturally sensitive interventions addressing the influence of religion and spirituality in substance use are needed to reduce cocaine use and promote recovery in this at-risk, minority population.
Journal of drug issues 11/2014; 44(1):94-113. DOI:10.1177/0022042613491108 · 0.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND
Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise for addressing these challenges.
Our aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care–Mental Health Integration (PC-MHI).
This was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites.
Patients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study.
We used a highly partnered IF strategy incorporating evidence-based implementation interventions.
We evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods.
Evaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93, p
Journal of General Internal Medicine 10/2014; 20(4). DOI:10.1007/s11606-014-3027-2 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To encourage access, policy makers and providers need information about variations in drug users’ treatment preferences. This study examined how rural/urban residence, stigma surrounding drug use, and perceived treatment availability and effectiveness are associated with African American cocaine users’ preferences for the site of treatment (local, or in one’s home town; nearby, or in a town nearby; and distant, or in a town farther away). Two hundred rural and 200 urban cocaine users were recruited using Respondent-Driven Sampling and completed in-person interviews. Multinomial logit regression analyses were conducted to estimate the relative odds of preferring local vs. nearby and local vs. distant treatment. Rural cocaine users preferred distant (58%) and urban users preferred local (57%) treatment. Rural residence and a lifetime history of treatment were associated with higher odds of preferring nearby vs. local treatment; older age and greater perceived local treatment effectiveness were associated with lower odds of preferring nearby vs. local treatment. Rural residence, access to an automobile, higher rejection/discrimination stigma scores, and higher Brief Symptom Inventory-Global Severity Index scores were associated with higher odds of preferring distant vs. local treatment; older age, lower educational attainment, and greater perceived discrimination after treatment were associated with lower odds of preferring distant vs. local treatment. The findings from this study suggest that a regional approach to organizing drug use treatment services could better satisfy the preferences of rural African American cocaine users, whereas local treatment services should be expanded to meet the needs of urban cocaine users.
[Show abstract][Hide abstract] ABSTRACT: Objective
To examine how rural/urban residence, perceived access, and other factors impede or facilitate perceived need for drug use treatment, a concept closely linked to treatment utilization.Study DesignTwo hundred rural and 200 urban African American cocaine users who were not receiving treatment were recruited via Respondent-Driven Sampling and completed a structured in-person interview. Bivariate and multivariate analyses were conducted to test the associations between perceived need and rural/urban residence, perceived access, and other predisposing (eg, demographics), enabling (eg, insurance), and health factors (eg, psychiatric distress).Principal FindingsIn bivariate analyses, rural relative to urban cocaine users reported lower perceived treatment need (37% vs 48%), availability, affordability, overall ease of access, and effectiveness, as well as lower perceived acceptability of residential, outpatient, self-help, and hospital-based services. In multivariate analyses, there was a significant interaction between rural/urban residence and the acceptability of religious counseling. At the highest level of acceptability, rural users had lower odds of perceived need (OR = 0.21); at the lowest level, rural users had higher odds of perceived need (OR = 3.97) than urban users. Among rural users, the acceptability of religious counseling was negatively associated with perceived need (OR = 0.65). Ease of access was negatively associated (OR = 0.71) whereas local treatment effectiveness (OR = 1.47) and the acceptability of hospital-based treatment (OR = 1.29) were positively associated with perceived need among all users.Conclusions
Our findings suggest rural/urban disparities in perceived need and access to drug use treatment. Among rural and urban cocaine users, improving perceptions of treatment effectiveness and expanding hospital-based services could promote treatment seeking.
The Journal of Rural Health 09/2014; 31(1). DOI:10.1111/jrh.12092 · 1.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
The Theory of Planned Behavior (TPB) can provide insights into perceived need for cocaine treatment among African American cocaine users.
A cross-sectional community sample of 400 (50% rural) not-in-treatment African-American cocaine users was identified through respondent-driven sampling in one urban and two rural counties in Arkansas. Measures included self-reports of attitudes and beliefs about cocaine treatment, perceived need and perceived effectiveness of treatment, and positive and negative cocaine expectancies. Normative beliefs were measured by perceived stigma and consequences of stigma regarding drug use and drug treatment. Perceived control was measured by readiness for treatment, prior drug treatment, and perceived ability to cut down on cocaine use without treatment.
Multiple regression analysis found that older age (standardized regression coefficient β=0.15, P<0.001), rural residence (β=-0.09, P=0.025), effectiveness of treatment (β=0.39, P<0.001), negative cocaine expectancies (β=0.138, P=0.003), experiences of rejection (β=0.18, P<0.001), need for secrecy (β=0.12, P=0.002), and readiness for treatment (β=0.15, P<0.001) were independently associated with perceived need for cocaine treatment.
TPB is a relevant model for understanding perceived need for treatment among African-American cocaine users. Research has shown perceived need to be a major correlate of treatment participation. Study results should be applicable for designing interventions to encourage treatment participation.
[Show abstract][Hide abstract] ABSTRACT: In this article, we show that the Veterans Health Administration (VA), similar to military organizations, is a gendered organization where women Veterans’ experiences are embedded in and shaped by gender inequalities and structures of power. Based on an in-depth analysis of women Veterans’ substance use histories and VA treatment seeking experiences, we illustrate how gender power dynamics are (re)produced and maintained through everyday social interactions and organizational practices and processes that render women Veterans both visible and invisible: visible as sexual objects and invisible as suffering subjects. By retelling the illness and treatment experiences of women Veterans with trauma histories and co-occurring substance use and mental health disorders—a highly stigmatized population of Veterans—we highlight the importance of giving voice to their concerns when developing policies and programs to address the unique health care needs of women Veterans.
[Show abstract][Hide abstract] ABSTRACT: Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing for rural drug users. Yet few outpatient substance abuse treatment facilities in the United States provide HIV testing. The purpose of this study was to identify barriers to incorporating HIV testing with substance use treatment from the perspectives of treatment and testing providers in Arkansas.
We used purposive sampling from state directories to recruit providers at state, organization, and individual levels to participate in this exploratory study. Using an interview guide, the first and second authors conducted semistructured individual interviews in each provider's office or by telephone. All interviews were recorded, transcribed verbatim, and entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used constant comparison and content analysis techniques to identify codes, categories, and primary patterns in the data.
The sample consisted of 28 providers throughout the state, 18 from the substance use system and 10 from the public/ community health system. We identified 7 categories of barriers: environmental constraints, policy constraints, funding constraints, organizational structure, limited inter- and intra-agency communication, burden of responsibility, and client fragility.
This study presents the practice-based realities of barriers to integrating HIV testing with substance use treatment in a small, largely rural state. Some system and/or organization leaders were either unaware of or not actively pursuing external funds available to them specifically for engaging substance users in HIV testing. However, funding does not address the system-level need for coordination of resources and services at the state level.
The Journal of Rural Health 09/2013; 29(4):420-431. DOI:10.1111/jrh.12021 · 1.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This qualitative study is about barriers to the utilization of HIV testing as perceived by African Americans who have recently used cocaine and who live in the rural Delta region of Arkansas. Affordability, physical accessibility, and geographic availability were not perceived as barriers to HIV testing in this sample, yet acceptability was still perceived as poor. Acceptability due to social mores and norms was a major barrier. Many said testing was unacceptable because of fear of social costs. Many were confident of being HIV-negative based on risky assumptions about testing and the notification process. Small-town social and sexual networks added to concerns about reputation and risk. System approaches may fail if they focus solely on improving access to HIV services but do not take into consideration deeply internalized experiences of rural African Americans as well as involvement of the community in developing programs and services.
Journal of drug issues 07/2013; 43(3):314-334. DOI:10.1177/0022042613476260 · 0.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Examined the direct and interactive relationships between personality and environment as predictive of problem drug use. In the 13-yr longitudinal study, 1,201 adolescents provided self-report data concerning problem drug use, social environment, and the 4 personality constructs of disinhibition, experience seeking, depressive tendencies, and hostility. Results show that environmental and personality risk factors were predictive only when they were concurrent with problem drug abuse. Depression and hostility predicted the presence of hard drug use only within a problem drug-using network. It is concluded that social learning models based on the co-occurrence of personality and environmental influences are most predictive of concurrent use behaviors, that such models are appropriate for both cross-sectional and longitudinal prediction, and that pathways to problem use vary from substance to substance. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Journal of drug issues 10/2012; 30(2):375-405. · 0.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mental health and substance abuse are among the most commonly reported reasons for visits to Federally Qualified Health Centers (CHCs), yet only 6.5% of encounters are with on-site behavioral health specialists. Rural CHCs are significantly less likely to have on-site behavioral specialists than urban CHCs. Because of this lack of mental health specialists in rural areas, the most promising approach to improving mental health outcomes is to help rural primary care (PC) providers deliver evidence-based practices (EBPs). Despite the scope of these problems, no research has developed an effective implementation strategy for facilitating the adoption of mental health EBPs for rural CHCs. We sought to describe the conceptual components of an implementation partnership that focuses on the adaption and adoption of mental health EBPs by rural CHCs in Arkansas.
We present a conceptual model that integrates seven separate frameworks: (1) Jones and Wells' Evidence-Based Community Partnership Model, (2) Kitson's Promoting Action on Research Implementation in Health Services (PARiHS) implementation framework, (3) Sackett's definition of evidence-based medicine, (4) Glisson's organizational social context model, (5) Rubenstein's Evidence-Based Quality Improvement (EBQI) facilitation process, (6) Glasgow's RE-AIM evaluation approach, and (7) Naylor's concept of shared decision making.
By integrating these frameworks into a meaningful conceptual model, we hope to develop a successful implementation partnership between an academic health center and small rural CHCs to improve mental health outcomes. Findings from this implementation partnership should have relevance to hundreds of clinics and millions of patients, and could help promote the sustained adoption of EBPs across rural America.
Progress in community health partnerships: research, education, and action 09/2012; 6(3):389-98. DOI:10.1353/cpr.2012.0039
[Show abstract][Hide abstract] ABSTRACT: This study investigates the associations of recent criminal justice involvement with perceived need for alcohol treatment and alcohol treatment utilization, adjusting for demographic and clinical characteristics. We examined a national sample of adults with alcohol use disorders (N=4390) from the 2006 National Survey on Drug Use and Health. Almost 15% reported criminal justice involvement in the past year. Generalized logit models regressed perceived need for alcohol or drug treatment and past year treatment utilization (versus neither) on past year legal involvement, demographic, and clinical information. In general, results found stronger associations between frequency of criminal justice involvement for treatment utilization compared to perceived need for treatment alone. Treatment utilization was also associated with being on probation, arrests for drug possession/sale and driving under the influence but perceived need was not. Study results suggest opportunities for interventions to increase treatment rates or treatment need, a major correlate of treatment utilization.
[Show abstract][Hide abstract] ABSTRACT: We examined whether motivation to change mediated the relationships between gender and baseline alcohol severity with drinking outcome at 12-month follow-up in a longitudinal community sample.
Data were from baseline and 12-month interviews from the Rural Alcohol Study, a probability sample of rural and urban at-risk drinkers (N = 733) from six southern states. At-risk drinkers were identified through a telephone-screening interview. Measures of motivation (problem recognition and taking action) were the resultant two factors derived from the Stages of Change Readiness and Treatment Eagerness Scale. Items on social consequences of drinking measured alcohol severity. Structural equation models examined relationships between baseline alcohol severity and motivation with drinks per drinking day at 12 months.
We identified significant, direct paths between drinking at 12 months and alcohol severity and taking action with an unstandardized estimate of 0.116 (p < .05), alcohol severity and problem recognition (0.423, p < .01), and each of the two "motivation" latent constructs-problem recognition (1.846, p < .01) and taking action (-0.660, p < .01). Finally, the combined direct and negative effect of gender on alcohol consumption at 12-month follow-up was statistically significant, with an unstandardized estimate of -0.970 (p < .01).
The current study offers evidence for motivation to change as a viable mechanism through which alcohol severity is associated with subsequent drinking outcomes. More research is needed to further explore the persistence of motivation to change on drinking outcomes over time.
Journal of studies on alcohol and drugs 05/2012; 73(3):504-13. DOI:10.15288/jsad.2012.73.504 · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) ) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed?
Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes.
Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS.
The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.
[Show abstract][Hide abstract] ABSTRACT: This study proposes methods for blending design components of clinical effectiveness and implementation research. Such blending can provide benefits over pursuing these lines of research independently; for example, more rapid translational gains, more effective implementation strategies, and more useful information for decision makers. This study proposes a "hybrid effectiveness-implementation" typology, describes a rationale for their use, outlines the design decisions that must be faced, and provides several real-world examples.
An effectiveness-implementation hybrid design is one that takes a dual focus a priori in assessing clinical effectiveness and implementation. We propose 3 hybrid types: (1) testing effects of a clinical intervention on relevant outcomes while observing and gathering information on implementation; (2) dual testing of clinical and implementation interventions/strategies; and (3) testing of an implementation strategy while observing and gathering information on the clinical intervention's impact on relevant outcomes.
The hybrid typology proposed herein must be considered a construct still in evolution. Although traditional clinical effectiveness and implementation trials are likely to remain the most common approach to moving a clinical intervention through from efficacy research to public health impact, judicious use of the proposed hybrid designs could speed the translation of research findings into routine practice.
Medical care 03/2012; 50(3):217-26. DOI:10.1097/MLR.0b013e3182408812 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examined substance abuse and mental health service utilization during a three-year period among stimulant users living in rural areas.
Participants (N=710) were interviewed at baseline and every six months for 36 months. One-step transition probabilities were constructed between the two types of service use for each consecutive pair of interviews to examine the resulting steady-state probabilities among multiple one-step transition matrices.
Most participants received no substance abuse or mental health services. On average, the probabilities of reporting use of the same types of services during the 36-month follow-up were 82% for receiving neither service, 9% for receiving only mental health treatment, 6% for receiving only substance abuse treatment, and 2% for receiving both services.
Further study is needed to determine factors that affect the decision to seek mental health or substance abuse treatment among residents of rural communities.
[Show abstract][Hide abstract] ABSTRACT: We sought to develop and implement collaborative depression care in human immunodeficiency virus (HIV) clinics in a project called HIV Translating Initiatives for Depression into Effective Solutions (HITIDES). Here we describe: (i) the formative evaluation (FE) conducted prior to implementation; (ii) the process used to adapt the primary care collaborative care model for depression to specialty HIV clinics; and (iii) the intervention itself. The overall design of HITIDES was a multi-site randomized trial in United States Department of Veterans Affairs (VA) HIV clinics comparing the depression collaborative care intervention to usual depression care. Qualitative methods were used for the FEs and informed the evidence-based quality improvement (EBQI) methods that were used for adapting and implementing the intervention. Baseline assessments were completed by 249 depressed HIV participants. Summaries of respective key informant interviews with eight HIV patients who were receiving depression treatment and 25 HIV or mental health (MH) providers were presented to each site. EBQI methods were used to tailor the HITIDES intervention to each site while maintaining true to the evidence base for depression collaborative care. EBQI methods provided a useful framework for intervention adaptation and implementation. The HITIDES study provides the opportunity to evaluate collaborative depression care in a specialty physical health clinic setting with a population that has a high prevalence of depression and MH comorbidity.
AIDS Care 06/2011; 23(12):1626-36. DOI:10.1080/09540121.2011.579943 · 1.60 Impact Factor