Modeling Implementation

1. Modeling Implementation Sara Ackerman, PhD, MPH Epi 245 May 3, 2012

2. Objectives • Explain the rational for implementation frameworks and models 2. Describe three models/frameworks: - Precede/Proceed (intervention design) - PARiHS (implementation) - CFIR (implementation) 3. Discuss models in action: - youth mental health community awareness campaign in urban Australia (Precede) - improving inpatient care in rural Kenya(CFIR)

3. Theory “theory without empirical research is empty; empirical research without theory is blind” - Immanuel Kant

4. What is the purpose of theoretical models and frameworks? Pragmatic guide to action? Represent/shape knowledge? • UNICEF: http://helid.digicollection.org/en/d/Jh0226e/3.2.2.html

5. “All models are wrong, but some are useful” – George Box • thinking “inside the box” • models are indicators of phenomena, but they are not the phenomena themselves

6. Choosing a Framework • Interventionimplementation • Place existing evidence-based intervention in new setting(s) • focus on context, process, fit between intervention and setting • Interventiondevelopment and testing • understand problem • understand context of problem • select intervention tools • test intervention

7. precede-proceed Planning Model • helps identify determinants and context of problem in order to develop and test intervention • “blueprint” for intervention development • emphasizes multiple, interacting determinants of health

8. Predisposing, • Reinforcing, & • Enabling • Constructs in • Educational/Ecological • Diagnosis & • Evaluation • Policy, • Regulatory & • Organizational • Constructs in • Educational & • Environmental • Development Phase 3 Educational & ecological assessment Predisposing Phase 1 Social assessment Reinforcing Quality of life Health Enabling PRECEDE-PROCEED Phase 2 Epidemiological Assessment Phase 4a Intervention Alignment Health Program Genetics Phase 4b Educational strategies Administrative & policy assessment Behavior Policy regulation organization Environment Phase 5 Implementation Phase 6 Process evaluation Phase 7 Impact & Outcome evaluation Green & Kreuter, Health Program Planning, 4th ed., NY, London: McGraw-Hill, 2005.

9. precede-proceed • Phase 3: Educational and ecological assessment • PREDISPOSING FACTORS: • motivations subject to change through direct communication or education • e.g. • ENABLING FACTORS: • make it possible for people to change their behavior or environment • e.g. • REINFORCING FACTORS: • reward or reinforce desired behavior change • e.g.

10. Applying Precede-Proceed to Youth Mental Health in Australia • The Compass Strategy- Wright et al. 2006 • Aim: improve mental health literacy among young people • Outcomes: increased awareness, help-seeking

12. From evidence to practice. http://proteme.org/blog/2010/the-knowledge-last-mile-problem/

14. Peering into “the gap” Implementation context process fit

15. Implementation science “Successful implementation will not be achieved by doing more or better research on interventions.” - 2011 GlobalImplementation Conference “Implementation science is the study of what happens after adoption, especially in organizational settings.” - Dearing & Kee, Historical Roots of Dissemination & Implementation Science, Chapter 3, D&I Science in Health: Translating Science to Practice

16. Implementation Frameworks • Select interventions • Understand setting/context • Determine “fit” between intervention and setting • Develop plan for evaluations: formative, process, outcome • Guide interpretation of implementation activities • Identify concepts for analysis: qualitative and quantitative

17. Context John Ovretveit on the importance of context: http://www.implementationconference.org/articles/7541

18. Evidence “the evidence base for particular technologies and practices is often ambiguous and contested and must be continually interpreted and reframed in accordance with the local context and priorities” - Greenhalgh et al., 2004, Diffusion of Innovations in Service Organizations: A Systematic Review and Recommendations

19. PARIS?

20. PARIHS Theoretical Framework Kitson, A.L. et al. 2008

21. PARIHS Framework EVIDENCE: - research - clinical experience - patient preferences & experiences - local data (QI & project evaluations) - characteristics of evidence- based practice/ intervention • CONTEXT: • - receptivity to intervention • - culture • - leadership support • - evaluation • FACILITATION: • - expectations & activities • - purpose/role • - skills & attributes

22. PARIHS Framework

23. PARIHS Framework • Strengths • - promotes diagnostic analysis • - helps select implementation strategy • - emphasizes successful implementation Weaknesses • - lack of conceptual clarity & specificity • - difficult to operationalize • - how to define successful implementation?

24. Revised PARIHS Framework • Task-oriented implementation • vs. • Organizational implementation

25. CFIR: Consolidated Framework for implementation Research “Meta-theory”w/ common constructs from multiple implementation theories Why are there so many implementation theories?

26. CFIR: Consolidated Framework for implementation Research GOALS • promote verification of what works where and why across multiple contexts • provide consistent taxonomy, terminology, definitions

27. CFIR: Consolidated Framework for implementation Research Researchers/QI practitioners can select relevant constructs and use them to: • guide assessments of implementation context (formative evaluation) • evaluate implementation progress • explain findings

28. CFIR: Consolidated Framework for implementation Research Outer Setting

29. CFIR: Consolidated Framework for implementation Research Outer Setting Inner Setting

30. CFIR: Consolidated Framework for implementation Research Outer Setting Intervention (unadapted) Inner Setting Adaptable Periphery Core Components

31. CFIR: Consolidated Framework for implementation Research Intervention (adapted) Outer Setting Intervention (unadapted) Inner Setting Core Components Adaptable Periphery Adaptable Periphery Core Components

32. CFIR: Consolidated Framework for implementation Research Intervention (adapted) Outer Setting Intervention (unadapted) Inner Setting Core Components Adaptable Periphery Core Components People Involved Process

33. Applying CFIR to improve inpatient care in Kenya Parallel studies: • cluster randomized trial of rural Kenyan hospitals to evaluate effects of multifaceted intervention to introduce care based on best-practice guidelines • qualitative studies of context, process, health worker motivation

34. Applying CFIR to improve inpatient care in Kenya Aims: • Map findings against CFIR constructs • provide insight into how intervention works • explain variability in effects between sites Outcomes: • positive relationship between CFIR construct and implementation success for 23 constructs

35. Applying CFIR to improve inpatient care in Kenya Insights into the value of: • multi-disciplinary evaluations of complex interventions • mixed methods studies with integrated analyses

36. CFIR: Consolidated Framework for implementation Research Strengths - most comprehensive implementation model to date - helps guide evaluations at all stages - helps track key implementation processes Weaknesses - how to decide whether/at what level to apply constructs

37. Applying CFIR to improve inpatient care in Kenya “frameworks are good for guiding thinking but getting really immersed in the problems and contexts is essential” - Mike English