Cathy L. Melvin, PhD. MPH, Associate Professor, Department of Public Health Sciences Co-Director, SCTR Community Engagement Program Team Lead, Dissemination and Implementation Science, Hollings Cancer Center Medical University of South Carolina

 Review Need and Rationale for Dissemination and Implementation (D & I) Research  Understand Definitions ◦ D & I ◦ D & I Research ◦ Expected Outcomes of D & I  Explore Models for D & I Research and Practice  Review Two D & I Models ◦ Consolidated Framework for Advancing Implementation (CFIR) ◦ Interactive Systems Framework (ISF) and its companion Quality Improvement Tool (QIT)  Illustrate application for an important public health issue

 Reason 1: Vast resources are invested in the development of interventions to prevent and treat disease; however, only a fraction of research products is translated to practice and policy in order to affect population health.

Publication Bibliographic databases Submission Reviews, guidelines, textbook Negative results variable 0.3 year years 50% 46% 18% 35% 0.6 year 0.5 year 9.3 years Dickersin, 1987 Koren, 1989 Balas, 1995 Poynard, 1985 Kumar, 1992 Poyer, 1982 Antman, 1992 Negative results Lack of numbers Expert opinion Inconsistent indexing It takes 17 years to turn 14 per cent of original research to the benefit of patient care 1 to the benefit of patient care 1 17:14 Original research Acceptance Implementation E.A. Balas, 2000

 Reason 2  Dissemination and implementation (D&I) science seeks to understand how to systematically facilitate deployment and utilization of evidence-based approaches to improve the quality and effectiveness of health promotion, health services, and health care. 2

 Classic diffusion of innovation is defined as the passive process by which a program or product is absorbed into more widespread use 2  Often the “default” approach to increasing widespread use  Dependent on a number of factors ◦ Characteristics of the innovation itself ◦ Properties of the communication channel through which the intervention is disseminated ◦ Time from no use of the intervention to full adoption across the population and the different activities that occur across time ◦ Characteristics of the social system in which the innovation is being disseminated

 Definition: the active approach of spreading evidence-based interventions to the target audience(s) via determined channels using planned strategies 2  Intention: to spread information and the associated evidence- based interventions to all appropriate audiences via credible, trusted communication channels  Outcomes: increased awareness of evidence, increased adoption and/or likelihood of adoption  Dissemination Research: addresses how information about health promotion and care interventions is created, packaged, transmitted, and interpreted among a variety of important stakeholder groups. 3

 Definition: the process of putting to use or integrating evidence-based interventions within a setting 2  Intention: to investigate and address major bottlenecks (e.g. social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact 3  Outcomes: use and/or integration of evidence in practice settings and communities  Implementation Research: study of methods to promote the integration of research findings and evidence into healthcare policy and practice. It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions 3

 Recent review identified 61 models (e.g. theories and frameworks) describing either dissemination and/or implementation models to guide research 3  Of the 61 identified models: ◦ 11 were Dissemination only (I) ◦ 16 were combined but mostly Dissemination (D>I) ◦ 17 were equally Dissemination and Implementation (D=I) ◦ 5 were combined but mostly Implementation (I>D) ◦ 12 were Implementation only (I)

 Prevention Synthesis and Translation System (PSTS) ◦ Entities that  synthesize evidence about effective prevention innovations and  translate evidence into accessible, user friendly formats adaptable to local circumstances and settings  Prevention Support System (PSS) ◦ Entities that support change in prevention practice via  innovation-specific capacity building and  general capacity building  Prevention Delivery System (PDS) ◦ Entities that carry out activities necessary to implement prevention interventions at the organizational, community, state, or national level

 Practical translation of the implementation science literature  Six components ◦ Develop an implementation team ◦ Foster supportive organizational/communitywide climate and conditions ◦ Develop an implementation plan ◦ Receive training and technical assistance ◦ Practitioner-developer collaboration in implementation ◦ Evaluate the effectiveness of the intervention 7

Consolidated Framework for Implementation Research (CFIR) 5 Source: 5

Five CFIR Domains “An overarching typology to promote implementation theory development” Combines 19 conceptual models in 5 Domains: Intervention characteristics Outer setting Inner setting Characteristics of the individuals involved Process of implementation

Uses of CFIR Formative stage: capacity and needs assessment to identify barriers and facilitators to implementation Implementation stage: to track key implementation processes Outcome and impact stage: to explore what factors influenced implementation and how implementation influenced intervention performance At macro level: to organize and synthesize findings across studies using common language and definitions

The ProblemMissed Opportunities  Despite availability and extensive marketing of the HPV vaccines—a cost effective and proven solution, vaccination rates remain low in the US: 33% for all 3 doses in 2012  Vaccination rates for 2 other vaccines given at the same time to adolescents are much higher

ParentsProviders  Hesitancy/self-efficacy to discuss and promote the vaccine  Pediatric providers poorly motivated by distal disease consequences  Reluctance to frame HPV as routine and as a cancer prevention measure  Lack of awareness & information  Concerns about ◦ safety, ◦ duration of efficacy, and ◦ impact on sexual debut  Cost of vaccine and other barriers, especially for uninsured individuals

Dissemination Goal – Adoption by Practices Implementation Goal – HPV Vaccine Uptake & Reach  Focus on poorly performing practices  Conduct audience research with providers  Identify barriers/enablers  Develop tailored, evidence- based communication strategies, materials and products  Distribute through credible channels  Repeat exposure  Develop an implementation team in each practice  Foster supportive organizational/community- wide climate and conditions  Develop an implementation plan  Receive tailored training and technical assistance  Evaluate the effectiveness of the intervention ◦ Increased series completion ◦ Decreased missed opportunities

1. Conduct audience research with patients, providers and opinion leaders to 1.Identify preferred communication channels considered credible by audience members 2.Assess availability and use of existing educational materials and practice-based tools such as those available from CDC and professional associations 3.Identify practice-based tools and materials currently in use in each setting and for each audience 2. Customize and test prototypes of evidence-based products and dissemination strategies with all stakeholders 3. Develop dissemination plan for poorly performing practices 4. Collaborate with experts, community and academic partners to problem solve and examine factors affecting quality of dissemination

1. Form Implementation Team representing all stakeholders in each practice 2. Foster supportive climate and conditions by 1.Using champions 2.Developing policies 3.Communicating perceived need and benefit 4.Establishing practices to counterbalance stakeholder resistance to change 3. Develop practice-specific implementation plan 4. Receive training and technical assistance for specific needs 5. Evaluate the effectiveness of the implementation strategies 1.Fidelity 2.Dose and quality of training and technical assistance 3.Participation and participant responsiveness 4.Documentation of adaptations to original implementation plan

Dissemination Goal – Adoption by Practices Implementation Goal – HPV Vaccine Uptake & Reach  Development of tailored, evidence-based ◦ Communication and Dissemination Strategies ◦ Educational Materials and Products  Effectiveness of Dissemination Strategies ◦ Increased Awareness ◦ Intention to Adopt or Change Practice ◦ Use of Materials and Products ◦ Removal of Barriers ◦ Adoption via Policy or Protocol  Relative Value of Dissemination Strategies and Channels  Assessments of ◦ Intervention Fidelity ◦ Dose and Quality of Training and Technical Assistance ◦ Participation and Participant Responsiveness  Documentation of Adaptations to Original Implementation Plan  Increased series completion  Decrease missed opportunities

 Knowledge translation is a process: Involving a complex set of activities including a combination of face-to-face interaction, reading, reflection, and discussion Promoting a dynamic, iterative, and collaborative process Between diverse stakeholders: researchers, decision- makers and practitioners Resulting in mutual learning, synthesis of knowledge, problem-solving, planning and application of new learning based on quality research and the specific context leading to practice change.  How to promote knowledge translation? Create systematic opportunities for meaningful, focused interaction or exchange 8,9

1. Balas EA & Boren SA. (2000). Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, editors. Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2000: Glasgow, Russell E., et al. "Disseminating effective cancer screening interventions." Cancer 101.S5 (2004): Tabak RG, Khoong EC, Chamber D and Brownson RC. (2012) Bridging Research and Practice: Models for Dissemination and Implementation Research. Am J Prev Med 43(3): doi: /j.amepre [Internet] 4th Annual NIH Conference on the Science of Dissemination and Implementation: Policy and Practice4th Annual NIH Conference on the Science of Dissemination and Implementation: Policy and Practice 5. Damschroder LJ, Aron DC, Keith RE, et al. (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation. Implementation Science, 4:50 doi: / Wandersman A, Duffy J, Flaspohler P, et al. (2008) Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation. Am j Community Pyschol 41: Meyers DC, Katz J, Chien V, et al. (2012) Practical implementation science: developing and piloting the quality implementation tool. Am J Community Psychol 50: , doi /s y 8. Canadian Institutes of Health Research (CIHR) CIHR. (2004). Knowledge translation strategy 2004–2009: Innovation in action. Ottawa, ON: Canadian Institutes of Health Research. Retrieved from 9. Lowe, M, Rappolt, S, Jaglal, S., & Macdonald, G. (2007). The role of reflection in implementing learning from continuing education to practice. Journal of Continuing Education in Health Care Practice, 27,

 Trans-NIH Dissemination and Implementation Program Announcement ◦ The targeted distribution of information and intervention materials to a specific public health or clinical practice audience with the intent of spreading knowledge and the associated evidence-based interventions 3  CDC Program Announcement ◦ The systematic study of how the targeted distribution of information and intervention materials to a specific health audience can be successfully executed so that increased knowledge about the evidence-based public health interventions achieve greater use and impact of the intervention 4

The use of strategies to adopt and integrate evidence-based public health interventions and change practice patterns within specific settings. (Trans-NIH Dissemination and Implementation Program Announcement) The systematic study of how a specific set of activities and designed strategies are used to successfully integrate an evidence-based public health intervention within specific settings (e.g., primary care clinic, community center, school). (CDC Program Announcement)