Getting a Clinical Innovation into Practice: An Introduction to Implementation Strategies
Just as there is a robust science that supports development and rigorous testing of clinical innovations, the emerging field of implementation science is developing new theory-based knowledge regarding a growing portfolio of meticulously tested implementation strategies that seek to improve uptake of evidence-based practices by targeting barriers at multiple levels within health care settings. Studying and documenting implementation strategies associated with uptake during the development and trial of a clinical innovation could subsequently position the researcher for a more seamless transition and handoff of the innovation to clinical and operational leaders.The objective of this manuscript is to introduce the concept of implementation strategies: what they are; the rigor with which they are defined and applied to address barriers to clinical innovation adoption; how strategy selection may vary based on contextual, innovation, and recipient factors; how to document the application of strategies over the course of an implementation study; and how testing their effectiveness is the focus of implementation research trials.
Adherence to Cervical Cancer Screening in Korean American Immigrant Women: Identifying Malleable Variables for Intervention Development
Despite Korean American women having a high incidence rate of cervical cancer, many are unaware of the significance of Pap test. The purpose of this research was to examine the rates of Pap test receipt and factors associated with the uptake. The study was guided by Andersen’s Model of Health Service Use and used a cross-sectional research design. A sample of 230 women residing in metro-Atlanta, Georgia, participated in this study. Results. Slightly more than half (55.7%) had lifetime Pap tests while less than half (45.7%) had it within the last 3 years. Binary logistic regression indicated that marital status, monthly income, and annual checkups were significantly correlated with receiving Pap tests. Special attention is needed for women who are unmarried and have low income to increase Pap test receipt. Suggested intervention programs include better communication strategies, extended Medicare coverage, and outreach programs within Korean American community.
Assessing trustworthiness: Marginalized youth and the central relational paradox in treatment
Marginalized youth are at elevated risk for mental health difficulties, yet they encounter numerous barriers to engagement with mental health services. Past negative experiences with family, social workers, and systems of care contribute to distrust of service providers and ambivalence about engaging in trusting relationships with adults. This longitudinal qualitative study explored how marginalized youth living with mental health conditions make decisions about trust in their relationships with helping professionals. Semi-structured, open-ended in-depth interviews were conducted with 13 young women living with a mood or anxiety disorder, exploring trust, mutuality, and disconnection in relationships between marginalized youth and helping professionals. Eleven of the participants also participated in a second interview, 3 months later, that explored participants’ relationships with friends and family. Transcripts were analyzed using thematic analysis and interpreted through the lens of relational-cultural theory. Results indicated that the majority of interview participants described feeling unseen, judged, or invalidated in their relationships with family members. Four themes emerged as factors in the assessment of the trustworthiness of service providers: genuine caring; understanding; non-judgmental acceptance; and adult respect for youth agency. Concerns about confidentiality and mandated reporting informed participants’ decisions about disclosure in these relationships. Analysis of findings reveals evidence of the central relational paradox in these descriptions of helping relationships, reflecting the simultaneous appeal and peril of vulnerability in relationships, especially relationships characterized by power differentials. Findings suggest that practitioners working with marginalized youth can expect both openness and guardedness in the treatment relationship.
The Effect of Mentoring on School Attendance and Academic Outcomes: A Randomized Evaluation of the Check & Connect Program
Chronic absenteeism in early grades has been found to be predictive of high school dropout, but little is known about effective solutions to reduce absenteeism. Researchers conducted a randomized evaluation of Check & Connect (C&C), a school-based mentoring program, to evaluate its impact on school attendance and academic outcomes. The study was conducted in Chicago Public Schools (CPS) from 2011-2015. For students who began the program in grades 5-7, the program decreased student absences and caused participating students to fail fewer courses. However, there were no measurable effects of participating in the program for students who began the program in grades 1-4.
Mixed-Methods Randomized Evaluation of FAMS: A Mobile Phone-Delivered Intervention to Improve Family/Friend Involvement in Adults’ Type 2 Diabetes Self-Care
Family and friends have both helpful and harmful effects on adults’ diabetes self-management. Family-focused Add-on to Motivate Self-care (FAMS) is a mobile phone-delivered intervention designed to improve family/friend involvement, self-efficacy, and self-care via monthly phone coaching, texts tailored to goals, and the option to invite a support person to receive texts. We sought to evaluate how FAMS was received by a diverse group of adults with Type 2 diabetes and if FAMS improved diabetes-specific family/friend involvement (increased helpful and reduced harmful), diabetes self-efficacy, and self-care (diet and physical activity). We also assessed if improvements in family/friend involvement mediated improvements in self-efficacy and self-care. Methods Participants were prospectively assigned to enhanced treatment as usual (control), an individualized text messaging intervention alone, or the individualized text messaging intervention plus FAMS for 6 months. Participants completed surveys at baseline, 3 and 6 months, and postintervention interviews. Between-group and multiple mediator analyses followed intention-to-treat principles. Retention, engagement, and fidelity were high. FAMS was well received and helped participants realize the value of involving family/friends in their care. Relative to control, FAMS participants had improved family/friend involvement, self-efficacy, and diet (but not physical activity) at 3 and 6 months (all ps < .05). Improvements in family/friend involvement mediated effects on self-efficacy and diet for FAMS participants but not for the individualized intervention group. The promise of effectively engaging patients’ family and friends lies in sustained long-term behavior change. This work represents a first step toward this goal by demonstrating how content targeting helpful and harmful family/friend involvement can drive short-term effects.
Can Center-Based Care Reduce Summer Slowdown Prior to Kindergarten? Exploring Variation by Family Income, Race/Ethnicity, and Dual Language Learner Status
This study examines growth in language and math skills during the summer before kindergarten; considers variation by family income, race/ethnicity, and dual language learner status; and tests whether summer center-based care sustains preschool gains. Growth in skills slowed during summer for all children, but the patterns varied by domain and group. Non-White and dual language learner students showed the largest drop-off in language skills during summer. Lower-income students demonstrated slower summer growth in math skills than their higher-income peers. Students enrolled in summer center-based care had faster growth in math skills than those who did not attend care. Yet lower-income students who attended center-based care showed slower growth in language skills during summer than similar nonattenders. Implications are discussed.
On the Front Lines of the COVID-19 Pandemic: Occupational Experiences of the Intimate Partner Violence and Sexual Assault Workforce
In the face of increasing risk for intimate partner violence (IPV) and sexual assault during the COVID-19 pandemic, there is an urgent need to understand the experiences of the workforce providing support to survivors, as well as the evolving service delivery methods, shifting safety planning approaches, and occupational stress of frontline workers. We addressed this gap by conducting an online survey of members of IPV and sexual assault workforce using a broad, web-based recruitment strategy. In total, 352 staff from 24 states participated. We collaborated with practitioner networks and anti-violence coalitions to develop the brief survey, which included questions about work and health, safety planning, and stress. We used chi-square, t-test, and ANOVA analysis techniques to analyze differences within position and demographic variables. For qualitative data, we used thematic analysis to analyze responses from four open-ended questions. The sample was majority female-identified (93.7%) and essential workers in dual IPV and sexual assault programs (80.7%). Findings demonstrated that since the pandemic began, IPV and sexual assault staff are experiencing more personal and professional stressors, perceive a decrease in client safety, and lack resources needed to help survivors and themselves. Common problems included a lack of food or supplies at home and work and housing and financial support for survivors. There was a 51% increase in the use of video conference for work, which contributed to workforce strain. Reductions in overall service capacity and a shift to remote service provision have implications for both survivors and staff. These findings suggest a critical need for additional training, infrastructure, and support for the IPV and sexual assault workforce. There is an urgent need to classify IPV and sexual assault staff as first responders and address the occupational stress associated with the COVID-19 pandemic.
“Problem Children” and “Children with Problems”: Discipline and Innocence in a Gentrifying Elementary School
This article examines the ways Hazel, a white girl entering kindergarten, became known as a child with a problem rather than a problem child in her gentrifying school. Building on a year of classroom observations and interviews with students, school staff, and parents, author Alexandra Freidus identifies the role of racialized discourses related to disposition, medicalization, family, and community in shaping Hazel’s reputation and contrasts Hazel’s reputation with that of Marquise, a Black boy in her class. Hazel’s and Marquise’s storylines teach us that to fully understand and address the differences in how Black and white children are disciplined, we need to look closely at the allowances and affordances we make for some students, as well as how we disproportionately punish others. By examining the ways educators in a gentrifying school construct white innocence and Black culpability, this study illustrates the relational nature of the “school discipline gap” and helps us understand how and why some children are disproportionately subject to surveillance and exclusion and others are not.
A Meta-Analysis of Acculturation and Enculturation: Bilinear, Multidimensional, and Context-Dependent Processes
Acculturation and enculturation are currently conceptualized as bilinear, multidimensional, and context-dependent cultural socialization processes (Yoon et al., 2013). Yet, this conceptualization requires further specification and empirical evidence. Our work is timely given the downward shift in productivity of traditional acculturation research and the need for a new direction. We examined the constructs and processes of acculturation and enculturation by meta-analytically synthesizing the findings of 255 publications (343 independent samples). In support of a bilinear (vs. unilinear) conceptualization, we found that acculturation and enculturation were only slightly associated with each other, r = −.18. In support of multidimensionality and context-dependency, their relationship varied by dimension (e.g., nonsignificant association of mainstream and ethnic identities vs. significant associations in other dimensions), geographic region, and race. Additionally, acculturation and enculturation rates/patterns varied by dimension; extrinsic changes (e.g., behavior) proceeded faster than intrinsic changes (e.g., values, identity). We discuss a direction for future research and implications for practice, advocacy, and education/training.
“Gambling Can’t Be Positive, Can it?”: Gambling Beliefs and Behaviors Among Older Korean Immigrants
After migrating to the United States, older Korean immigrants may increase their gambling participation and be at higher risk for problem gambling. However, not much is known about their experiences and beliefs on gambling. The purpose of the present study was to explore gambling behaviors and shared beliefs about gambling among older Korean immigrants residing in New York City. A total of 20 semi-structured in-depth interviews (10 men and 10 women) were conducted in Korean. Interviews were transcribed verbatim and analyzed using a thematic analysis approach. The findings revealed three major categories among older Korean immigrants. The first category, cultural beliefs, has three subcategories (i.e., gambling is unethical, fear of addiction, and losing everything) and refers to negative beliefs about gambling. The second category, adaptation, refers to positive attitudes they acquired as they adjusted to the new gambling environment (i.e., harmless leisure, coping strategies, and excitement in life). Last, they revealed ambivalence about gambling (i.e., changes in gambling environment, ‘my gambling’ is different, and gambling in secrecy). Overall, older Korean immigrants have retained their cultural beliefs about gambling, even as they have embraced the legalized gambling environment and changed social norms of the U.S. However, they have trouble reconciling the differences between their beliefs, behaviors, values, and newly acquired norms. Findings point to a need for healthy and affordable leisure pursuits, and for culturally appropriate intervention programs to help problem gamblers.
Male service members’ and civilian wives’ perceptions of partner connection regarding deployment and PTSD symptoms
In general, a sense of understanding and connection is an important aspect of marital relationships. In the context of military couples in which a service member may have symptoms of posttraumatic stress disorder (PTSD), spouses’ understanding of the nature and causes of service member PTSD symptoms may be protective for both partners’ marital satisfaction. However, partners may vary in the degree to which they understand and connect around (a) historical experiences of combat and deployment versus understanding and connecting around (b) any ongoing manifestation of PTSD symptoms post deployment. In a sample of 58 male Army service members and their civilian wives drawn from a larger study of military couple functioning, we found that a measure of “Combat/Deployment connection” and a measure of “PTSD connection” were strongly correlated with each other yet not isomorphic. Both Combat/Deployment connection and PTSD connection had unique predictive effects for marital satisfaction. Both husbands and wives reported higher levels of PTSD connection relative to Combat/Deployment connection. At low or average levels of Combat/Deployment connection, higher levels of PTSD symptoms were associated with lower levels of marital satisfaction, whereas at high levels of Combat/Deployment connection, this association was no longer signiﬁcant. No such moderation effects were found for PTSD connection. The utility of distinguishing these two domains of potential connection for military couples is discussed.
Perceived Discrimination as a Mediator of ACEs and Psychological Distress
The authors investigated the role of perceived discrimination in the association between adverse childhood experiences and psychological distress in adulthood in a sample of individuals (n = 125) at a university-based couple and family therapy clinic. Results showed that a majority had experienced four or more adverse experiences, indicating a high risk of negative health outcomes. A significant indirect effect of adverse experiences through perceived discrimination on psychological distress, even with gender, race/ethnicity, and household income as covariates, was noted. Findings underscore the importance of incorporating assessment of perceived discrimination in therapy with clients presenting with childhood adversity and psychological distress.
The role of maternal psychosocial perceptions in parent-training programs: a preliminary randomized controlled trial
Parent-child interaction is critical for early language and literacy development. Parent training programs have proliferated to support early interactions. However, many environmental and psychosocial factors can impact the quality of parent-child language and literacy interactions as well as training program outcomes. This preliminary randomized controlled trial examined maternal perceived self-efficacy and locus of control during a language and literacy parent training program. Thirty mother-child dyads (mother age 21-40; children 2;6-4;0) were assigned in parallel to the training or control group. The training was efficacious for mothers and children – training-group dyads made significantly greater gains in maternal strategy use, responsivity, and child print awareness than the control group. Gains were maintained one month post-training. Children whose mothers had more external baseline control perceptions identified significantly fewer print targets at baseline and made greater gains than those with more internal control perceptions. Future directions and implications are discussed.
Inequality in Isolation:: Educating Students with Disabilities during COVID-19
Effects of homophobic name‐calling and verbal sexual harassment on substance use among young adults
Verbal aggression victimization, such as homophobic name‐calling, has been linked to heavier substance use among young people, but little longitudinal research has examined how different types of victimization may affect substance use or whether certain psychosocial factors moderate these risks. In a diverse cohort (N = 2,663), latent transition analysis was used to model heterogeneity in victimization (age 19) and substance use (age 20). Four victimization (high victimization, homophobic name‐calling only, verbal sexual harassment only, and low victimization) and three substance use (poly‐substance use, alcohol, and cannabis only, low all) classes were identified. The high victimization and homophobic name‐calling only classes had the highest probabilities of transitioning into the poly‐substance use class, and the high victimization class had the highest probability of transitioning into the alcohol and cannabis only class. The probability of transitioning into the low all substance use class was highest in the low victimization class and lowest in the high victimization class. For the high victimization class, greater depressive symptoms increased the odds, and better peer relationship quality decreased the odds, of transitioning into the poly‐substance use and alcohol and cannabis only classes. For the homophobic name‐calling only class, greater depressive symptoms increased the odds of transitioning into the poly‐substance use class. Homophobic name‐calling, alone or in combination with verbal sexual harassment, is a risk factor for escalating substance use in young adulthood, especially among victims with depressive symptoms.
Defining Patient Engagement in Research: Results of a Systematic Review and Analysis: Report of the ISPOR Patient-Centered Special Interest Group
Objectives: Lack of clarity on the definition of “patient engagement” has been highlighted as a barrier to fully implementing patient engagement in research. This study identified themes within existing definitions related to patient engagement and proposes a consensus definition of “patient engagement in research.” Methods: A systematic review was conducted to identify definitions of patient engagement and related terms in published literature (2006-2018). Definitions were extracted and qualitatively analyzed to identify themes and characteristics. A multistakeholder approach, including academia, industry, and patient representation, was taken at all stages. A proposed definition is offered based on a synthesis of the findings. Results: Of 1821 abstracts identified and screened for eligibility, 317 were selected for full-text review. Of these, 169 articles met inclusion criteria, from which 244 distinct definitions were extracted for analysis. The most frequently defined terms were: “patient-centered” (30.5%), “patient engagement” (15.5%), and “patient participation” (13.4%). The majority of definitions were specific to the healthcare delivery setting (70.5%); 11.9% were specific to research. Among the definitions of “patient engagement,” the most common themes were “active process,” “patient involvement,” and “patient as participant.” In the research setting, the top themes were “patient as partner,” “patient involvement,” and “active process”; these did not appear in the top 3 themes of nonresearch definitions. Conclusion: Distinct themes are associated with the term “patient engagement” and with engagement in the “research” setting. Based on an analysis of existing literature and review by patient, industry, and academic stakeholders, we propose a scalable consensus definition of “patient engagement in research.”
Psychometric properties of a measure to assess beliefs about modifiable behavior and emotional distress
Assessing beliefs about the helpfulness of modifiable behaviors related to mental health could inform public health efforts to prevent emotional distress. This study examined the psychometric properties of a measure to assess beliefs about the helpfulness of modifiable behaviors involved in the development of anxiety and depression. The relationship between beliefs about modifiable behaviors and actual engagement in modifiable behaviors was also examined. Item pool generation was based on a review of the literature. Experts (N = 10) and participants (N = 50) reviewed the items for content validity. An exploratory factor analysis was conducted on the resultant Beliefs about Behaviors and Emotional Distress Scale (BBEDS) for item reduction in a sample of MTurk participants (Study 1, N = 371). A confirmatory factor analysis was completed in a second MTurk sample (Study 2, N = 373). Construct validity was then examined in a sample of college students (Study 3, N = 215). The questionnaire included 16 items across four domains: health behavior (0.77 ≤ α ≤ 0.84), social support (0.72 ≤ α ≤ 0.76), substance use (0.75 ≤ α ≤ 0.76), and avoidance (0.81 ≤ α ≤ 0.83). The BBEDS had adequate psychometric properties supporting its use to assess beliefs about the helpfulness of modifiable behaviors related to the development of emotional distress. BBEDS scores were associated with engaging in some but not all modifiable behaviors. The BBEDS may be a useful instrument to assess beliefs about the helpfulness of modifiable behaviors implicated in the development of anxiety and depression.
Dignity at the end of life
Debt, Incarceration, and Re-entry: a Scoping Review
People involved with the criminal justice system in the United States are disproportionately low-income and indebted. The experience of incarceration intensifies financial hardship, including through worsening debt. Little is known about how people who are incarcerated and their families are impacted by debt and how it affects their reentry experience. We conducted a scoping review to identify what is known about the debt burden on those who have been incarcerated and their families and how this impacts their lives. We searched 14 data bases from 1990 to 2019 for all original research addressing financial debt held by those incarcerated in the United States, and screened articles for relevance and extracted data from pertinent studies. These 31 studies selected for inclusion showed that this population is heavily burdened by debt that was accumulated in three general categories: debt directly from criminal justice involvement such as LFOs, preexisting debt that compounded during incarceration, and debts accrued during reentry for everyday survival. Debt was generally shown to have a negative effect on financial well-being, reentry, family structure, and mental health. Debts from LFOs and child support is very common among the justice-involved population and are largely unpayable. Other forms of debt likely to burden this population remain largely understudied. Extensive reform is necessary to lessen the burden of debt on the criminal justice population in order to improve reentry outcomes and quality of life.
Literacy of Breast Cancer and Screening Guideline in an Immigrant Group: Importance of Health Accessibility
Little is known about predictors of breast cancer literacy among immigrant women. A cross-sectional survey investigated predisposing, enabling, and need factors of breast cancer literacy among 233 Korean American women living in a southeastern U.S. city. Breast cancer literacy was measured by questions that asked awareness of cancer screening methods and a 5-item questionnaire derived from the American Cancer Society’s breast cancer screening guidelines and risk factors. Annual checkup was an enabling factor of awareness of Clinical Breast Exam (CBE) and mammogram, and also for breast cancer literacy covering the knowledge of breast cancer screening guidelines and risk factors. Health status was a need factor of CBE awareness. Marital status was a predisposing factor of mammogram awareness, and age and years of residence in the US were predisposing factors of breast cancer literacy. The findings of the study illuminate probable avenues of intervention to promote breast health knowledge for Korean American women.